Glen Park at Long Beach

Allegation investigated: Staff are not following reporting requirements as necessary.

On September 14, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted an initial unannounced complaint visit. Ace Huynh, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation, a collection of documents, and a tour of the facility. A review of Personnel Report LIC 500 (dated 08/12/26), Resident Roster (dated 09/14/26), (R1’s) Identification and Emergency LIn cientIC 601 (dated 07/07/25), Physician’s Report Lic 602A (dated 01/31/25), Medication List (dated 01/31/25), Unusual Incident Report LIC (dated 08/25/26) and other pertinent records associated with this complaint. Interviews conducted with Executive Director and Witness #1 (W1). (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff are not following reporting requirements as necessary. It is alleged that staff did not follow the required reporting requirements concerning Resident #1 (R1). Reports indicate that (R1’s) primary physician or responsible party were not informed of (R1's) inpatient medical stabilization when (R1) was hospitalized on August 26, 2026. There are concerns regarding the lack of communication and documentation about (R1’s) rights related to not allowing the resident to return to the facility. No further detailed information was provided. On September 14, 2026, between 2:30 PM and 3:00 PM, the Department interviewed staff member identified as Executive Director (ED). The Executive Director (ED) denied failing to report any incidents. The (ED) stated that they knew the facility's reporting procedures and understood when to report incidents to the proper authorities. (ED) confirmed that the facility submitted LIC 624 Unusual Incident Report and contacted Community Care Licensing (CCL) when required. (ED) also indicated that (R1's) primary physician was notified by fax on August 24, 2026. Furthermore, Licensing and the Long-Term Ombudsman were informed on August 25, 2026, that (R1) was undergoing an emergency medical evaluation. The responsible party for (R1) was notified by telephone on August 24, 2026, at 7:25 PM according to the facilities telephone charting log. On September 14, 2026, between 2: 32 PM and 2:42 PM, the Department interviewed witness identified as (R1’s) responsible party Witness #1 (W1). (W1) verified that no staff from Glen Park contacted (W1) for (R1’s) emergency hospitalization on August 24, 2026. (W1) stated to have been contacted by primary physician provider and the hospital facility where (R1) was undergoing emergency medical evaluation. (W1) confirmed that (R1) had returned to the facility following (W1's) recent visit. The Department reviewed documentation for reported incident with Unusual Incident Report LIC 624 (dated 08/25/26) occurring within the relevant time frame. The records showed the facility had documented the incident internally and had submitted required reports to CCL when incident met the criteria outlined in Title 22. Facility Internal Reporting Log and Facility’s Telephone Charting Log (dated 08/24/26) verified (R1’s) primary care physician and responsible party were notified. (Evaluation Report continues LIC 9099-C) Further review of (R1’s) Identification and Emergency LIC 601 (dated 07/07/25), Physician’s Report LIC 602A (dated 01/31/25), Medication List (dated 01/31/25). The Department observed that (R1) had returned to the facility and confirmed that (R1’s) included in the facilities Resident Roster (dated 09/14/26). Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. No deficiencies cited. An exit interview was conducted with ACE HUYNH, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Sep 14, 2026 · control 11-AS-20260910133735

Type of visit: Case Management - Annual Continuation

On September 3, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent 1 Year Required visit. LPA met with Executive Director Ace Huynh. LPA explained the purpose of today’s visit. The facility is licensed to serve four (4) ambulatory, 174 non-ambulatory, and 30 bedridden resident age 60 and above. The facility is approved (30) residents on hospice. Currently, the facility has 106 residents with no hospice residents. LPA toured the physical plant. There were no bodies of water or obstructions 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. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #101: #114; #122; #124; #130; #136; #137; #211; #216 #227; #255; #262 in assisted living and #233 #238; #243 and #247 in memory care. The water temperature ranges from 106.9- 115.9 degrees F.; room temperature ranges from 70- 76 degrees F.; call buttons and smoke and carbon monoxide detectors are all in operating condition. LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, as well as sanitizing stations in common areas and restrooms. All mandated inspection control posters, including the Activities Calendar and Food Menu, were posted. (Evaluation Report continues LIC 809-C) DEFICIENCIES: Rooms with no sliding door screens #101; #102; #122; #130; #137. Room #255 wash basin cabinet missing doors. Room #243 toilet not flushing properly Room #206 had medication of Fluticasone and Mupirocin ointment inside the room. Room #122 and #262 had toxic chemical cleaners in their rooms. Deficiencies were cited during this inspection visit. Due to time constraints, LPA was unable to complete the visit and will return at another unannounced time. An exit interview was conducted and a copy of this report was provided to ACE HUYNH. Note: Due to technical difficulties, LPA was unable to generate an electronic inspection tool and instead used a printable/PDF version.the state’s words, verbatim · CDSS document, Sep 3, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a)(b) · Plan of correction due date: Sep 4, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances... items which could pose a danger to residents are in locked storage and are not left unattended... This requirement is not met as evidence by: Based on observation, Licensee failed to adhere to ensure toxic poisonous chemicals in room #122 & #262 substances were not locked in storage and left unattended. This violation possesses an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Licensee must comply with Title 22 Section 87309 and provide a plan on how to ensure toxic chemical substances are kept out of reach of residents in care. Proof of correction, must be submitted by the due date of 10/04/26 to 424-544-1016. Licensee must comply with Title 22 Section 87465 and provide a plan for how to ensure medications are kept out of reach of residents in care. Proof of correction, must be submitted by the due date of 10/04/26 to 424-544-1016.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Sep 4, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications...(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement is not met as evidence by: Based on observation, Licensee failed to adhere to ensure medications are kept out of the hands of residents in room #206 and not left unattended. This violation possesses an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

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

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by Based on observation, the Licensee failed to ensure the facility is in good repair. The room is missing screen doors and cabinet doors. A toilet is not in working condition. This violation poses a potential Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Licensee must comply with Title 22 Section 87303 and repair missing screen doors, cabinet doors, and the toilet that is not flushing properly. Proof of correction, including photos of the repairs, must be submitted by the due date of 10/03/26 to 424-544-1016.

Type of visit: Required - 1 Year

On August 26,2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Executive Director Ace Huynh. LPA explained the purpose of today’s visit. The facility is licensed to serve four (4) ambulatory, 174 non-ambulatory, and 30 bedridden resident age 60 and above. The facility is approved (30) residents on hospice. Currently, the facility has 105 residents with no hospice residents. The two-story commercial building consists of one hundred (100) resident bedrooms, multiple resident bathrooms,(3) common bathrooms, (4) shaded patios, (1) smoking area, dining room, commercial kitchen, staff room, office area, media room, garden area, a laundry, and multiple storage rooms. The facility has a memory care unit with delay egress doors. During the visit LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters, including the Activities Calendar and Food Menu, were posted. An audit of resident's service records for resident #1-#5 (R1-R5) and staff personnel records for staff #1-#5 (S1-S5) were accurate and complete. The facility is current on Community Care Licensing annual fees. Due to time constraints, LPA was unable to complete the visit and will return at another unannounced time. No citations have been issued during this visit. An exit interview has been conducted and a copy of this report has been provided to Executive Director ACE HUYNH.the state’s words, verbatim · CDSS document, Aug 26, 2026

Allegation investigated: Staff mismanaged resident's medication. Staff handle resident in an inappropriate manner. Staff do not ensure resident is treated with dignity and respect.

On August 24, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted an initial unannounced complaint visit. Ace Huynh, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation, a collection of documents, and a tour of the facility. A review of Personnel Report LIC 500 (dated 08/12/26), Resident Roster (dated 07/30/26), Medication Administration Record (dated 07/01/26 through 08/13/26), Admissions Agreement (dated 09/16/25), ID and Emergency Informaiton LIC 601 (dated 09/23/25), and other pertinent records associated with this complaint. Interviews conducted with Resident #1-10, Staff #1-#6 and Witness #1. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff mismanaged resident’s medications. It is alleged that staff mismanaged Resident #1's (R1’s) medications. Reports indicate that (R1) missed a scheduled dose of medication on one occasion. Additional details regarding the circumstances of this incident were not provided. On August 24, 2026, between 09:45 AM and 3:32 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members could not support this claim. Interviews with staff consistently reported that all medications are administered according to physician orders, logged daily, and stored securely. (S1-S5) confirmed their lack of awareness of any incidents involving missed doses, medication errors, or improper handling of (R1’s) medications. On August 24, 2026, between 10:05 AM and 11:38 AM, the Department interviewed residents identified as Resident #2 through Resident #10. Eight (8) out of nine (9) residents could not corroborate this claim. According to reports from (R2-R9), there have been no incidents related to missed doses, medication errors, or improper medication handling. (R1) was unavailable for an interview because the resident passed away in the hospital on August 20, 2026. On August 14, 2026, between 1:10 PM and 01:22 PM, the Department interviewed a witness member identified as (R1’s) responsible party, as Witness #1 (W1). (W1) reported incidents related to (R1’s) care based solely on (R1’s) account. However, (R1) could not provide any specific dates, times, types of medication, or names of those involved. The Department reviewed (R1’s) Medication Administration Records (MAR) and Centrally Stored Medication records for the period of (07/01/26 through 08/13/26. All records were complete, legible, and showed no evidence of missing doses or incorrect administration. Physician orders on file matched the medications listed on the (MAR). No discrepancies were identified between medication labels, logs, or documentation. During the visit on August 13, 2026, the LPA observed that (R1’s) medications were stored in the locked medication cart/room in a manner consistent with Title 22 requirements. (Evaluation Report continues LIC 9099-C) Labels were intact, medications were not expired, and procedures observed during medication pass aligned with facility policy and regulatory standards. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Allegation: Staff handled resident in an inappropriate manner. It is alleged that staff handled Resident #1 (R1) in an improper manner. Reports indicate (R1) was placed in bed forcefully by staff. No further details regarding the circumstances of this incident were provided. On August 24, 2026, between 09:45 AM and 3:32 PM, the Department interviewed staff members identified as Staff #1 through Staff #4 (S1-S5). Four (4) out of the five (5) staff members could not validate this claim. (S1) stated that there have been no incidents of (R1) being handled inappropriately. (S1-S5) denied handling (R1) in any rough, forceful, or inappropriate way. All staff confirmed they used approved techniques to assist residents with transfers, mobility, and daily activities. On August 24, 2026, between 10:05 AM and 11:38 AM, the Department interviewed residents identified as Resident #2 through Resident #10. Nine (9) out of nine (9) residents could not corroborate this claim. None of the individuals from (R2-R10) reported witnessing any inappropriate physical interactions between staff and residents. (R1) was unavailable for an interview because the resident passed away in the hospital on August 20, 2026. On August 14, 2026, from 1:10 PM to 1:22 PM, the Department conducted an interview with a witness identified as the responsible party for (R1), as Witness #1 (W1). (W1) detailed incidents concerning (R1’s) care based solely on (R1’s) description. (W1) could not remember specific dates, times, or names of individuals involved. The Department reviewed personnel files and found current training in Resident Rights, Personal Care, and Safe Transfer Techniques. No incident reports regarding improper physical handling of (R1) were found for the relevant time period. During the visit on August 13, 2026, the LPA observed staff assisting several residents with transfers, ambulation, and routine care. Staff were observed to be gentle, respectful, and consistent with Title 22 regulations and facility policies. No inappropriate handling was observed at any time. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099-C) Allegation: Staff do not ensure resident is treated with dignity and respect. It is alleged that staff failed to ensure that Resident #1 (R1) was treated with dignity and respect. Reports indicate that the resident is not treated with dignity and respect during care. Additional details regarding the circumstances of this incident were not provided. On August 24, 2026, between 09:45 AM and 03:32 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Three (3) out of the five (5) staff members could not support this claim. Interviews with Staff #1 and Staff #4 (S1 and S4) had knowledge of an incident involving (R1) and staff improper behavior as it was reported to them by (R1) and in which (S1) followed up with an internal investigation into the incident. Staff #5 (S5) denied ever speaking rudely to (R1) or ever refusing to provide care services. (S5’s) statements are consistent with statements (S5) had given during the facility's internal investigation. Staff #6 (S6), who had witnessed (S5) speaking offensively to (R1) during an internal investigation, was unavailable for an interview with the Department and did not respond to phone calls. (S1-S5) reported they regularly receive training on resident rights, dignity, privacy, and respectful communication. On August 24, 2026, between 10:05 AM and 11:38 AM, the Department interviewed residents identified as Resident #2 through Resident #10. Nine (9) out of nine (9) residents could not support this claim. All residents interviewed expressed they had not seen any incidents of disrespectful treatment towards themselves or other residents. (R1) was unavailable for an interview because the resident passed away in the hospital on August 20, 2026. On August 14, 2026, from 1:10 PM to 1:22 PM, the Department conducted an interview with a witness identified as the responsible party for (R1), as Witness #1 (W1). (W1) recounted specific events related to (R1’s) care based entirely on (R1’s) account. (W1) was unable to recall particular dates, times, or the names of people involved. The Department reviewed facility training records and confirmed staff had completed current training on resident rights, dignity, and respect. No incident reports or complaints regarding disrespectful treatment of (R1) were found in the facility’s files for the relevant period. (Evaluation Report continues LIC 9099-C) Further review of the facility’s Internal Investigation revealed the facility had responded appropriately. During the visit August 13, 2026, and August 24, 2025, the LPA observed staff engaging with residents during routine care and activities. Staff were observed addressing residents by name, speaking calmly and respectfully, and providing care consistent with regulatory requirements related to dignity, privacy, and personal rights. No interactions were observed that appeared disrespectful or in violation of Title 22 regulations. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. 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 cited. An exit interview was conducted with Catherine Dacara, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Aug 24, 2026 · control 11-AS-20260811160322

Allegation investigated: Staff do not provide a comfortable environment for residents in care

On 08/21/2026 approximately 8:00AM, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced subsequent complaint visit to continue the investigation and deliver findings. LPA met with Administrator Ace Huynh and explained the purpose of the visit. The investigation consisted of the following: The Department conducted interviews with eleven residents (R1-R11) and three staff members, Administrator Ace Huynh (A1), staff (S2-S4). The Department also collected and reviewed facility Staff roster dated 07/30/26 & Personnel roster 08/12/26, Activities calendar date ranges from May to August 2026. The investigation revealed the following: Regarding the allegation, “Staff do not provide a comfortable environment for residents in care,” it is alleged that staff allowed a loud religious activity to occur in or near the dining room, which caused residents to become uncomfortable. Please see report continuation (LIC9099-C) Unsubstantiated Observations revealed the following: The Department observed the dining room and surrounding common areas and did not observe any religious activity or conditions causing discomfort to residents during the visits. Records reviewed revealed the following: The Department reviewed the facility’s May and June 2026 Activity Calendars, which did not document the alleged religious activity in the dining area. Interviews conducted revealed the following: The Department interviewed eleven residents (R1-R11). One of eleven residents (R1) supported the allegation and reported that loud religious singing occurred in the dining room near the entrance. Seven of eleven residents (R2, R3, R5, R6, R7, R8, R9) did not support the allegation. Resident (R3 & R5) recalled a singing group but did not identify the activity as religious and did not find it uncomfortable. Three of eleven residents (R4, R10, R11) either did not recall the event or were not knowledgeable of the occurrence. The Department interviewed four staff members (A1, S2-S4). Administrator Ace Huynh (A1) did not recall the incident being reported. S2 disagreed with the allegation. S3 recalled the event occurring and stated the individuals were visitors associated with a resident. S3 further stated that staff intervened by informing the visitors that the activity could not continue due to the sensitivity of residents in care. S4 recalled the individuals visiting a resident and stated that no concerns regarding residents being uncomfortable were reported to staff at the time. Interviews confirmed religious singing occurred near the dining area; however, most residents did not report discomfort or interference, and the evidence did not show staff knowingly allowed the concern to continue. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation “Staff do not provide a comfortable environment for residents in care” may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. No deficiencies were cited in today’s visit. An exit interview was conducted, and a copy of this Complaint Report was provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 21, 2026 · control 11-AS-20260608113854

Type of visit: Case Management - Deficiencies

On August 13, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit. LPA Dabuet met with Executive Director ACE HUYNH to discuss an incident involving Resident #1 (R1) that occurred on August 7, 2026. The Department received an Unusual Incident Report (LIC 624) on August 7, 2026, regarding an incident that took place at 10:30 AM. It was reported that R1 eloped unsupervised from the community. R1 had been admitted to the community on July 24, 2026, and was diagnosed with a Major Neurocognitive Disorder (NCD). R1 resided on the second floor, which is designated as the "memory care" area. According to Staff #1 (S1) and Staff #2 (S2), while conducting routine checks on residents, they discovered that R1 was not in their room or anywhere on the floor. They immediately contacted the front desk to initiate an elopement alert. Surveillance camera footage confirmed that R1 exited the facility through the front exterior gate without supervision. A door on the second floor, which required a key fob to open, had malfunctioned, allowing R1 to leave the premises via the exterior stairs. R1 was located by law enforcement, who contacted the family, and R1 was returned to the facility on August 8, 2026. Upon return, R1 was reassessed by a Licensed Vocational Nurse (LVN), who found no signs of injury or discomfort. S1 informed the family representative and the physician about the incident. The Department reviewed (R1)'s Medical Assessment LIC 602A (dated 06/16/26) revealed that R1 has a history of "unsafe wandering" and "elopement" which is associated with behaviors in residents diagnosed with (NCD). Further review of camera surveillance footage (dated 08/07/26) verified R1's elopement from the premises. (Evaluation Report continues LIC 809-C) The licensee violates Title 22, Section 87411, Personnel Requirements. California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 809-D). An exit interview was conducted, and a copy of the Evaluation Report and Appeal Rights was provided to Ace ACE HUYNH.the state’s words, verbatim · CDSS document, Aug 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Aug 27, 2026

87411 Personnel Requirements - General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required... This requirement is not met as evidence by: Based on interview, Licensee failed provide necessary supervision services to meet resident needs and eloped from the facility unattended. This violation possesses a potential Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: The Licensee will adhere to the regulations and ensure review of Title 22, Section 87411. The Licensee will provide care staff training to address (NCD) wandering and elopement behaviors—proof of correction, including a sign sheet, to be sent by fax to the El Segundo Regional office at 424-544-1016 by 08/27/26.

Allegation investigated: Staff did not report an incident as necessary.

On 7/24/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Executive Director, Ace Hunyh 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 7/24/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Identification and Emergency Contacts, Physician’s Report, Unusual Incident Report, Internal Incident Report, Emergency Department Discharge Instructions and Discharge Orders. LPA Felisa Shirley conducted a tour of the facility and viewed facility video footage. LPA Shirley interviewed Staff 1 – Staff 7 (S1 – S7), and Resident 1 – Resident 5 (R1-R5). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not report an incident as necessary. It is being alleged that R1 was stabbed in the back with a pen by R3 and staff failed to report the incident. On 7/24/26, LPA Felisa Shirley observed an Unusual Incident Report dated 7/24/26 for an incident involving R1 on 7/18/26. LPA Felisa Shirley also observed and reviewed an Internal Resident Incident Report dated 7/18/26. Per Unusual Incident Report, on 7/18/26 the front desk was notified that R1 had a wound on their back which appeared to be a puncture wound. Upon review of the Internal Resident Incident Report, staff observed blood seeping through R1’s shirt and observed a long blood stain across the back of the shirt. On 7/24/26, LPA Shirley reviewed the surveillance video which contained R1 and R3 sitting at the table in the activities room. R1 was sitting drinking iced tea and R3 had an activity book. The surveillance video covered the time period from 5:30 pm through 7:33 pm and there was no indication of an assault or any involvement by another resident. At 7:33pm, the caregivers made contact with the resident and observed blood on R1’s shirt. LPA Shirley toured the facility on 7/24/26 and inspected R1’s room to locate the shirt R1 was wearing on the day of the incident. Upon examination, no holes or tears were observed in the shirt. LPA interviewed staff 1 – staff 7 (S1 – S7). Of those interviewed 4 out of 7 denied the allegation. Three staff did not know if incident was reported. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 0 out of 5 denied the allegation. Four residents didn’t know if incident was reported and 1 resident did not answer. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not report an incident as necessary,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Executive Director, Ace Huynh.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 11-AS-20260720121155

Allegation investigated: Staff do not ensure resident medication records are properly managed

On 07/16/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent Complaint Visit to the facility listed above. LPA met with Ace Huynh, Administrator, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA conducted a medication review for eight (8) residents. During a subsequent visit on 07/15/2026, LPA interviewed Staff S6 and S7 and conducted a medication review for two (2) residents. During the initial visit conducted on 04/30/2026, LPA inspected the facility, interviewed Staff S1, interviewed Resident R1-R12, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician’s Report (dated 08/04/2025), Appraisal/Needs and Service Plan (dated 04/17/2026), Internal Resident Incident Report (various dates), After Visit Summary (dated 11/19/2025 and 07/08/2025), St. Mary Medical Center – Long Beach Discharge Instruction Document (dated 04/17/2026), Medication Administration Records (MAR) (March 2026 and April 2026), and Memory Care Communication Log (04/17/2026 through 04/29/2026). The investigation revealed the following: Substantiated Allegation: Staff do not ensure medication records are properly managed The allegation alleges that there was no incident report for a resident’s medication that was observed on their bed and not taken. During the facility visit, LPA conducted an audit of ten (10) residents Centrally Stored Medications using the electronic Medication Administration Record (eMAR). During the review, LPA observed the following medications not signed off as taken or refused for Resident R1, R13-R21: >Resient R1 -Divalproex Sod ER 500mg > not signed off on MAR 07/03/2026, no comments -Donepezil HCL 5 MG Tables > not signed off on MAR 07/03/2026, no comments -Mirtazapine 15mg > not signed off on MAR 07/03/2026, no comments -Mirtazapine 7.5mg > not signed off on MAR 07/03/2026, no comments -Atrovastain 20mg > not signed off on MAR 07/03/2026, no comments -Busprione HCL 10mg > PM not signed off on MAR 07/02/2026, 07/05/2026, and 07/11/2026, no comments -Quietapine Fumarate 25mg > PM not signed off on MAR on 07/03/2026, no comments. >Resident R13 -Eliquis 5mg > not signed off AM on MAR 07/08/2026 and 07/10/2026, no comments -Escitalopram 5mg > not signed off on MAR 07/08/2026 and 07/10/2026, no comments -Potassium CL ER 20 Meq > not signed off on MAR 07/08/2026 and 07/10/2026, no comments -Folic Acid 1mg> not signed off on MAR 07/08/2026 and 07/10/2026, no comments -Hydralazine 50mg > not signed off on AM MAR 07/08/2026 and 07/10/2026, no comments -Metoprolol Taritrate 25mg> not signed off on AM MAR 07/08/2026 and 07/10/2026, no comments -Vitamin B-1 100mg> not signed off on MAR 07/08/2026 and 07/10/2026, no comments -Vitamin B12 500mcg > not signed off on AM MAR 07/08/2026 and 07/10/2026, no comments >Resident R14 -Asprin EC 81 mg > not signed off on AM MAR 07/08/2026, no comments -Docusate Sodium 100mg > not signed off on AM MAR 07/08/2026, no comments -Fluticasone Prop 50 mcg > not signed off on AM MAR 07/08/2026, no comments. -Lactulose 10 gm/15ml > not signed off on AM MAR 07/08/2026, no comments. -Pantoprazole SOD DR 40mg > not signed off on AM MAR 07/11/2026 and 07/12/2026, no comments. -Potassium CL ER 20 MEQ > not signed off on AM MAR 07/08/2026, no comments. -Quetiapine Fumarate 50mg > not signed off on PM MAR 07/08/2026, no comments. -Refresh Tears 0.5% drops 1 OP > not signed off on AM MAR 07/08/2026, no comments. -Resperidone 0.5 MG > Not signed off on AM MAR 07/08/2026, no comments >Resident R16 -Amlodipine Besylate 5 MG> not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Ammonium Lactate 12% Cream> not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Asprin EC 81 MG > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Clopidogrel 75 MG > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Escitalopram 10 MG > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Famotidine 20 MG > not signed off on AM and PM MAR for 07/07/2026 and not signed off on AM 07/10/2026, no comments. -Geri-Mucil Powder 1 PO > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Glucosamine Daily Complex T 1 PO > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Januvia 100 MG - not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Metformin 500MG > not signed off on AM and PM MAR 07/07/2026 and not signed off on AM 07/10/2026, no comments. -Sitagliptin Phos 100 MG > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Tamsulosin 0.4 MG > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. >Resident R17 -Aripiprazoles 5 MG > 07/11/2026 pill in packet, not signed on MAR, and no comment. 07/12/2026 pill in packet, not signed on MAR, and no comment. 07/13/2026 removed from packet, not signed off on MAR, and no comment. 07/14/2026 removed from packet, not signed off on MAR, and no comment. -Hydrocodone-Acet 5-325 > Not signed off on eMAR for 07/08/2026 and 07/11/2026 -Lidocaine 4% Patch > Not signed off on MAR for 07/11/2026. No Comment. -Pantoprazole SOD DR 40 MG > Not signed off on 07/11/2026 and 07/12/2026. -Vitamin C 1,000 MG > Not signed off on MAR on 07/11/2026, No comment. -Vitamin D3 50 MG > Not signed off on MAR on 07/11/2026, No comment. > Resident R18 -Oxybutynin 5 MG - Not signed off on 07/11/2026 12pm. No comments. -Pantoprazole SOD DR 40 MG > Not signed off on AM 07/11/2026 and 07/12/2026. No comments. -Vitamin D3 2000 IU 50 MG >Not signed off on AM 07/11/2026. > Resident R19 -Levothyroxine 50 MCG > Not signed off on AM 07/11/2026. No comments. > Resident R20 - Aspirin 81 MG > Not signed off on AM 07/10/2026. No comments. -Clopidogrel 75 MG > Not signed off on AM 07/10/2026. No comments. -Famotidine 20 MG > Not signed off on AM 07/10/2026. No comments. -Metoprolol Tartirate 50 MG > Not signed off on AM 07/10/2026. No comments. - Naltrexone 50 MG > Not signed off on AM 07/11/2026 and 07/12/2026. No comments. -Quetiapine Fumarate 100 MG > Not signed off on AM 07/10/2026. No comments. -Vitamin B-12 1,000 Unit> Not signed off on AM 07/10/2026. No comments. -Vitamin D3 5,000 Unit > Not signed off on AM 07/10/2026. No comments. > Resident R21 -Atorvastatin 40 MG > Not signed off on PM 07/01/2026, 07/02/2026, and 07/03/2026. No comments. -Divalproex SOD DR 125 mg > Not signed off on PM 07/02/2026, 07/05/2026, and 07/11/2026. No comments. -Donepepezil HCL 5 MG > Not signed off on PM 07/3/2026. No comments. -Memantine HCL 5 MG > Not signed off on PM 07/02/2026, 07/05/2026, and 07/11/2026. No comments. -Quetiapine Fumarate 100 MG > Not signed off on PM 07/03/2026. No comments. -Senna 8.6 MG > Not signed off on PM 07/02/2026, 07/05/2026, and 07/11/2026. No comments. During interviews with Staff S1-S7, were asked if staff keep accurate records of residents medications and doses taken, seven (7) out of seven (7) stated yes, staff keep accurate records of residents medications taken. During interview's with Residents R1-R12, were asked if they feel staff properly manage their medication records, twelve (12) out of twelve (12) stated yes, they believe staff properly manage their medication records. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Brenna Randolph, Business Office Manager, and a copy of this report and the Appeals Rights were provided.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 11-AS-20260421155314

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87505(a) · Plan of correction due date: Jul 30, 2026

87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Based on observations, interviews, and record review Staff failed to ensure medications were documented as administered or refused for R1, R13, R14, R16-R21, This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: Administrator will develop a plan to ensure that medication administration records are checked frequently to avoid discrepancies. Administrator will submit plan to LPA by POC due date.

Allegation investigated: Staff do not ensure reporting requirements are being followed Staff did not ensure resident was provided medical care

On 07/14/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent Complaint Visit to the facility listed above. LPA met with Ace Huynh, Administrator, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today's visit, LPA interviewed Staff S6 and S7 and conducted a medication review for two (2) residents. During the initial visit conducted on 04/30/2026, LPA inspected the facility, interviewed Staff S1, interviewed Resident R1-R12, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician’s Report (dated 08/04/2025), Appraisal/Needs and Service Plan (dated 04/17/2026), Internal Resident Incident Report (various dates), After Visit Summary (dated 11/19/2025 and 07/08/2025), St. Mary Medical Center – Long Beach Discharge Instruction Document (dated 04/17/2026), Medication Administration Records (MAR) (March 2026 and April 2026), and Memory Care Communication Log (04/17/2026 through 04/29/2026). The investigation revealed the following: Substantiated Allegation: Staff do not ensure reporting requirements are being followed The allegation alleges it was not reported when a resident’s medication was not taken and when a resident was observed with feces in their mouth. During record review, LPA received and reviewed two Internal Resident Incident Reports, one is dated 04/13/2026 at 3:20am that indicates R1 was observed with feces in their mouth. Staff attempted to assist R1 and R1 was combative and went back to sleep. Staff attempted to assist R1 again 10 minutes later and R1 was still combative and went back to sleep. When AM shift arrived, Staff tried to assist with brushing teeth and R1 was combative. LPA observed in the Contact Made section under Physician was indicated “no,” and under the Responsible Party it was not indicated whether they were contacted. The second Internal Resident Incident Report is dated 04/13/2026 at 3:15am, S2 was informed R1 was observed with feces in their mouth and was asked if R1 should be sent out. S2 informed Staff that R1 could be sent out for altered mental status but may be returned right away if R1 has a diagnosis of dementia. Under Action Taken indicates nurse to follow up with Primary Care Physician (PCP) and family. LPA observed in the Contact Made section there was no indication if the Physician or Responsible Party were notified. Staff were unable to provide documentation that the Physician or Responsible Party were notified. Additionally, LPA received and reviewed St. Mary Medical Center – Long Beach Discharge Instruction Document dated 04/17/2026, indicates R1 was examined due to abdominal pain and acute chest pain during respiration. LPA observed on the eMAR that R1 refused medications on 04/02/2026 and 04/13/2026. LPA did not observe any notes or indication that the POA or Physician was notified of the medication refusals. Additionally, during records review and LPA observed the following: R1 has a POA, according to a document titled Power of Attorney for California (dated on 05/11/2024). This POA is also mentioned on the LIC 601 has the person responsible for final affairs, payment for care and legal guardian if any and this is also indicated on LIC 603 that POA is the person who manages R1’s finances. During a file review, LPA reviewed the Unusual Incident/Injury Reports faxed to the department, LPA did not observe any reports regarding R1 having feces in their mouth on 04/13/2026 or regarding being transferred to the Emergency Room on 04/17/2026. During interviews with Staff S1-S7, were asked if staff meet the reporting requirements, informing the residents responsible party, physician, and/or Community Care Licensing (CCL) of unusual incidents and/or injury’s, seven (7) out of seven (7) stated yes incidents are reported to the responsible party or power of attorney, the physician, and CCL. During interviews with Residents R1-R12, were asked if they feel staff meet reporting requirements, informing responsible party or physician, twelve (12) out of twelve (12) stated they feel staff meet reporting requirements. During an interview with a resident’s family member W1, was asked if the facility stated the POA was not made aware of the incident until they visit the facility on 04/15/2026. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. Allegation: Staff do not ensure resident was provided medical care The allegation alleges that a resident was not sent to the hospital to be evaluated after not eating meals and being observed with feces in their mouth. During record review, LPA received and reviewed two Internal Resident Incident Reports, one is dated 04/13/2026 at 3:20am that indicates R1 was observed with feces in their mouth. Staff attempted to assist R1 and R1 was combative and went back to sleep. Staff attempted to assist R1 again 10 minutes later and R1 was still combative and went back to sleep. When AM shift arrived, Staff tried to assist with brushing teeth and R1 was combative. The second Internal Resident Incident Report is dated 04/13/2026 at 3:15am, S2 was informed R1 was observed with feces in their mouth and if R1 should be sent out. S2 informed Staff that R1 could be sent out for altered mental status but may be returned right away if R1 has a diagnosis of dementia. Under Action Taken indicates S2 to follow up with Primary Care Physician (PCP) and family. LPA observed in the Contact Made section there was no indication if the Physician or Responsible Party were notified. Additionally, LPA received and reviewed St. Mary Medical Center – Long Beach Discharge Instruction Document (dated 04/17/2026) that indicates R1 was examined due to abdominal pain and acute chest pain during respiration. During interviews with Staff S1-S7, were asked if residents receive medical care when needed, seven (7) out of seven (7) stated resident receive medical care when needed. During interviews with Residents R1-R12, were asked if staff ensure they receive medical care when needed, twelve (12) out of twelve (12) stated yes they receive medical care when needed. During an interview with a resident’s family member W1, stated the POA was not made aware of the incident until they visited the facility on 04/15/2026 and were told by a nurse they were not going to send R1 out to the hospital due to their given health. R1 was later seen at the hospital on 04/17/2026 for abdominal pain and acute chest pain during respiration. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Ace Huyhn, Executive Director, and a copy of this report and the Appeals Rights were provided.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 11-AS-20260421155314

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jul 29, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met based on record review, interviews, and observations, there was no incident reports submitted to CCL for the incidents of R1 on 4/13/2026 or of R1's Emergency Room visit on 04/17/2026, which poses a heath and safety risk.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Staff retraining regrading reporting incidents to CCL and Responsible party was conducted in June 2026. The Administrator will email the staff training log to LPA at Wendy.Gibbs@dss.ca.gov by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(5) · Plan of correction due date: Jul 29, 2026

87411 Personnel Requirements – General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement was not met based on an incident of R1 who was observed with feces in their mouth on 04/13/2026 and was not evaluated by a medical professional on 04/17/2026 due to abdominal pain.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Administrator will retrain staff on documenting communication with the Primary Care Physician and Responsible Party of resdients regarding incident that occur. Administrator will email the staff training log to LPA at Wendy.Gibbs@dss.ca.gov by POC due date.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Facility is in disrepair

On 07/14/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent Complaint Visit to the facility listed above. LPA met with Ace Huynh, Administrator, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today's visit, LPA interviewed Staff S6 and S7. During the initial visit conducted on 04/30/2026, LPA inspected the facility, interviewed Staff S1, interviewed Resident R1-R12, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician’s Report (dated 08/04/2025), Appraisal/Needs and Service Plan (dated 04/17/2026), Internal Resident Incident Report (various dates), After Visit Summary (dated 11/19/2025 and 07/08/2025), Medication Administration Records (March 2026 and April 2026), Memory Care Communication Log (04/17/2026 through 04/29/2026), Maintenance Request (01/28/2025 through 04/30/2026), and Maintenance & Equipment Request Form (various dates). The investigation revealed the following: Substantiated Allegation: Facility is in disrepair. The allegation alleges that in a resident’s room the shower head is not in working condition and spays outside of the shower getting the floor wet and the handle on the closet in the room is broken. During the facility inspection LPA observed the handle on the closet door in room 245 was broken with the broken piece lying on the window ledge next to the closet. Additionally, LPA and Staff turned on the shower in room 245 and it sprayed outside of the shower. During record review, LPA received and reviewed the Maintenance and Equipment Request Forms for repairs dated 04/19/2026 for room 101, 02/26/2026 for room 104, 02/23/2026 for room 118, 02/02/2026 for room 227, and 01/24/2026 room 101. Additionally, LPA received and reviewed Maintenance Request that lists the following repair description and repairs dated 01/03/2026 for window screens in the memory care, 01/23/2026 for the AC in memory care, 04/28/2026 for new blinds in room 120, and 04/30/2026 new room key for new resident move in. During interviews with Staff S1-S7, were asked if any part of the facility is in disrepair, five (5) out of seven (7) stated no, the facility is not in disrepair. Two (2) out of seven (7) stated there are items that need repaired including the closet handle and shower in room 245 and a ceiling tile that came down in the activity room. During interviews with Residents R1-R12, were asked if they felt the facility is in disrepair, twelve (12) out of twelve (12) stated no, the facility is not in disrepair During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Ace Huyhn, Executive Director, and a copy of this report and the Appeals Rights were provided. Allegation: Staff are falsifying resident records The allegation alleges that a resident’s family was given an incident report indicating staff observed a resident eating feces and when speaking to the Primary Care Physician they were notified it was reported that it was observed in the resident’s teeth during oral care. During record review, LPA received and reviewed two Internal Resident Incident Reports, one is dated 04/13/2026 at 3:20am that indicates R1 was observed with feces in their mouth. Staff attempted to assist R1 and R1 was combative and went back to sleep. Staff attempted to assist R1 again 10 minutes later and R1 was still combative and went back to sleep. When AM shift arrived, Staff tried to assist with brushing teeth and R1 was combative. There was no indication on the report if the residents Physician or Responsible Party were notified. The second Internal Resident Incident Report is dated 04/13/2026 at 3:15am, S2 was informed R1 was observed with feces in their mouth and if R1 should be sent out. S2 informed Staff that R1 could be sent out for altered mental status but may be returned right away if R1 has a diagnosis of dementia. Under Action Taken indicates S2 to follow up with Primary Care Physician (PCP) and family. LPA observed in the Contact Made section there was no indication if the Physician or Responsible Party were notified. During interviews with Staff S1-S7, were asked if they have observed staff falsify resident’s records, seven (7) out of seven (7) stated no, they have not observed staff falsify records. During interviews with Residents R1-R12, were asked if they have any concerns regarding staff falsifying records, twelve (12) out of twelve (12) stated no, they have no concerns regarding staff falsifying records. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) 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(s) is/are unsubstantiated. An exit interview was conducted with Ace Huyhn, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 11-AS-20260424164701

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87303(a) · Plan of correction due date: Jul 29, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met based on interviews and observations, LPA observed on 04/30/2026, in room 245 the handle on the closet door was broken and the shower head spayed outside the shower, which poses a health and safety riskthe state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: During a visit on 06/02/2026, LPA observed the handle and shower head were replaced. Administrator

Allegation investigated: Resident call light is in disrepair.

On July 08, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted an initial unannounced complaint visit. Ace Huynh, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation, a collection of documents, and a tour of the facility. A review of Personnel Report LIC 500 (dated 06/02/26), Resident Roster (dated 007/02/26), Faciltiy Visitor Log (dated 06/01/26 - 06/30/26), Maintenance Request Report (dated 03/1/26 - 07/07/26), Resident #1 (R1's) Medical Assessment for Residential Care Facilities LIC 602A (dated 05/01/26), Appraisal/Needs and Services Plan LiC 625 (dated 06/03/26), Incident Report LIC 624 (dated 06/02/26 & 06/04/26) and other pertinent records associated with this complaint. Interviews conducted with Resident #1-5, Staff #1-#3 and Witness #1. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: ALLEGATION: Resident call light is in disrepair. It is alleged that the call light for Resident #1 (R1) is in disrepair. For the past month, the call light has not been functioning properly on weekends. Although it has been fixed each week, it continues to work inconsistently. It is important to note that (R1) is at high risk of falling and requires a functioning call light for safety. No further details have been provided. On July 8, 2026, between 09:50 AM and 11:30 AM, the Department interviewed resident members identified as Resident #1 through Resident #5 (R1-R5). Four (4) out of five (5) could not support this claim. (R2-R5) reported no issues or concerns regarding their call lights. They stated that when maintenance is needed, the response and repair time is timely. (R1) stated that the call light is operational. Although it was down a couple of times, it has been repaired and is now working. (R1) mentioned that it has been functioning well for over a week and a half. (R2), who shares a room with (R1), stated that (R2) has never experienced any issues with (R2’s) call light system and that it served as a useful option for (R1) when (R1’s) call light was inoperable. However, (R2) noted that (R1) tends to pull the cord horizontally, which can cause the entire call box system to come off the wall. (R2) explained that the proper way to use the system is to pull the cord downward to avoid dislodging it. On July 08, 2026, between 09:30 AM and 3:35 PM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of three (3) staff members could not support this claim. (S1–S3) all asserted that Resident #1 (R1) has a functional call light system. (S1) indicated that (S1) became aware of the issue on July 2, 2026, when (S2) received a call about (R1's) call light system being dislodged from the wall and inoperable. (S2) reported that (S2) performed minor repairs on June 19, 2026, to (R1's) call light system, followed by a subsequent service on June 30, 2026, when the call light was found broken. There might have been one time before June 19, 2026, when it was dispatched on the walkie talkie as an urgent request and might have not been logged on the Maintenance Request Report. Services were completed on the same day. Additionally, (S2) claimed that no other service orders were placed apart from those two occasions. (S3) was on duty on June 7, 14, 21, and 28, 2026, when concerns were raised about (R1's) call light system functioning properly. Although it was being tested only, it was never reported as non-operational, and no maintenance order for repairs was required. If the situation calls for it, (S3) will promptly place an order for repairs to ensure everything is in top condition. On July 6, 2026, between 8:14 AM and 8:40 AM, the Department conducted an interview with witness #1 (W1). (W1) noticed that the call box was malfunctioning around June 3-4, 2026, after (R1) had pulled it off the wall while seeking assistance. On June 7,2026, (W1) found the call box hanging off the wall again and reported it to the front desk, which informed them that repairs were in progress. (W1) repeatedly observed the call box hanging off the wall and reported it each time. By June 28, 2026, the call mechanism had been tampered with and was no longer usable. The Department inspected room #132 (R1's room) and evaluated the call light system. The wall-mounted system was found to be functioning properly. A care staff member responded within 2 minutes after the call light was activated. Further inspection of the call light system in room #132 (R2) confirmed it was operable as well. In addition, the call light systems in the following rooms were inspected and tested: #101, #104, #134, #137, #139, #141, #142, #206, #208, #213, #217, #228, and #229. All 30 call light systems were found to be in working condition. A review of the Facility Visitor Log Report (dated 06/01/26 to 06/30/26), revealed inaccuracies in the reporting of visit dates from (W1). Additionally, a review of the Facility Maintenance Request Report for the same period confirmed that services were performed on (R1's) call light system on June 19, 2026, and June 30, 2026. The analysis showed that of (68) work orders, (60) were completed within 24 hours, resulting in an 88.24% completion rate. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above 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 cited. An exit interview was conducted with Ace Huynh, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 11-AS-20260630170230

Type of visit: Case Management - Incident

On July 07, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit to the facility following an incident reported by the facility that occurred on June 21, 2026. During the visit, the LPA met with Ace Huynh, Executive Director, to explain the purpose of the visit. The El Segundo Regional Office Adult and Senior Care received an Unusual Incident Report (LIC 624) on June 27, 2026, stating that Resident #1 (R1) had been given the incorrect medication. On June 21, 2026, at approximately 5 PM, the medication technician mistakenly administered in error to (R1) Buspirone, Hydrocodone, Metformin, and Metoprolol to (R1) in error. The Department found that the facility was not in compliance with Title 22 Regulations and issued citations as follows: 87465(c)(2) Incidental Medical and Dental Care Services. The investigation revealed that the facility failed to comply with Title 22 regulations. The LPA reviewed (R1’s) Physician's Report (LIC 602A) (dated 12/27/24), Appraisal/Needs and Services Plan LIC 625 (dated 06/13/26), and Medication List (dated 07/08/26), which identified that (R1) needs assistance with medication administration and Buspirone, Hydrocodone, Metformin, and Metoprolol are not prescribed by (R1's) physician. Based on interviews, observations, and record reviews, the licensee was found in violation of the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies have been issued, and an exit interview was conducted with Ace Huynh, Executive Director. A copy of this report is provided, along with the appeal rights.the state’s words, verbatim · CDSS document, Jul 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jul 9, 2026

87465)(c)(2) Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need .. facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on the records review, staff administered (R1) Buspirone, Hydrocodone, Metformin, and Metoprolol in error. The facility reported a medication not prescribed to (R1). This violation poses/posed an immediate risk to persons in care.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: Licensee shall provide medication administration retraining. This training shall be provided by pharmacy and/or registered nurse. Submit proof of training by POC due.07/09/26.

Allegation investigated: Staff are not safeguarding residents medications.

On 07/07/26 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Co-Executive Director Anita Csukardi as the purpose of today’s visit was explained. The investigation consisted of the following: On 07/07/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1-3 (R1-R3) Emergency ID form, pre-appraisal,Physicians reports, needs and service plans, medication list, and Medication Administration Records (MAR) for the months of June 2026-July 2026. On 07/07/26 from 10:00am- 11:31am LPA conducted a review of medications for residents #1-7 (R1-R7). On 07/07/26 from 1pm- 1:45pm LPA conducted interviews with resident #1-10 (R1-R10), and from interviews with staff #1-4 (s1-S4). The investigation revealed the following: Allegation: Staff are not safeguarding residents medications. Substantiated It is alleged that residents’ medication goes missing daily with no explanation. On 07/07/26 LPA conducted interviews with R1-R10 regarding the allegation above. 7 of the 10 residents denied the allegation above and reported having no concerns with the staff who handle their medication(s). Additionally, 6 or 10 resident reported that they have never been told that their medication are unavailable. 1 of the 10 residents interviewed reported that there medications have been unavailable but reports it was due to pharmacy availability. 3 of the 10 residents interviewed reported being unaware if they take medications while currently receiving care at the facility. On 07/07/26 LPA conducted interviews with On 07/07/26 from 10:00am- 11:31am LPA conducted a records review of the June 2026 and July 2026 medications administration records (MARs) for R1-R7. During the records review LPA observed that for July 2026 there were 16 medication documentation errors that affected 4 residents. The review showed missing initials for medications assigned to R1- Famotidine 20mg 8am- documented as refused but still in the pack for July 4th, 2026 Famotidine 20mg 4pm- documented as refused but are not in the bubble pack for July 1st-3rd 2026, Fluoxetine HCL 20mg- July 3rd, 2026 and July 7th, 2026 documented as refused but not in the bubble pack, July 6th, 2026 documented as given, then documented in the back that resident refused. LPA observed the following for R2, Carbamazepine 8am am- July 2nd, 2026 documented given but in the bubble pack, Levetiracetam 8am July 2nd 2026 documented given but in the bubble pack, Tamsulosin 8am July 2nd, 2026 documented given but in the bubble pack. LPA observed the following for R4, Amitriptyline HCL 100mg 8 pm July 1st, 2026 documented as given but in the bubble pack, Atorvastatin 40 mg 8pm July 1st, 2026 documented as given but in the bubble pack Senna 8.6 mg 8pm July 1st, 2026 documented as given but in the bubble pack. LPA observed the following for R5 Besylate 2.5 mg 8am July 2nd, 2026 documented given but in the bubble pack, Benztropine MES 1pm 8am July 2nd, 2026 documented given but in the bubble pack, Benztropine MES 1pm 4 pm July 2nd, 2026 not signed out and not in the bubble pack, Divalproex DOS 500 mg 10pm out of bubble pack on 07/1/26, 07/3/26, 07/4/26 and on 07/5/26 but not signed out, Folic Acid 1mg 8am July 2nd, 2026 not documentation but inside bubble pack, Metformin 1000 mg 8am July 2nd, 2026 signed out but in the bubble pack, Metformin 1000 mg 4 pm July 2nd, 2026 not signed out and not in the bubble pack. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. Exit interview provided, appeal rights explained, and a copy of this report was provided. It is alleged that facility staff play mind games with the residents by manipulating them. On 07/07/26 LPA conducted interviews with R1-R10 regarding the allegation above. 10 of the 10 residents interviewed denied the allegation above and reported feeling respected by the facility staff. On 07/07/26 LPA conducted interviews with S1-S4 regarding the allegation above. 4 of 4 staff interviewed denied the allegation above, and reported having good interactions with residents in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 11-AS-20260629143423

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6)(A-F) · Plan of correction due date: Jul 21, 2026

(h)The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained...(A-F) records for centrally stored medications...based on records review the Department identified that for July 2026 there were 16 medication documentation errors that affected 4 residents, indicating medications were not documented as required which poses a potential health and safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Executive Director will retrain all medication staff on MAR documentation requirements in order to get into compliance with title 22 regulation. A weekly MAR review will be implemented to ensure all entries are completed correctly with signatures and correct dates tht match. LPA to receive proof by POC due that the med room staff was retrained. Training materials, staff sign in sheet, and a documented from Executive Director self certifying the review and understandment of the regulation being cited. Lizeth.villegas@dss.ca.gov

Allegation investigated: Facility staff did not meet residents’ care needs, resulting in resident obtaining multiple UTI’s Resident sustained multiple bruises due to staff neglect. Facility staff did not ensure that residents have clean linen. Facility staff did not provide adequate laundry service Facility is not providing adequate food service resulting in resident weight loss. Facility staff did not respond to resident's call button in a timely manner.

On 07/07/2026 at 08:45am, the department made an unannounced visit at this facility to conduct an subsequent visit to reveal the investigation findings for the allegations above. During today’s visit, the department met with Catherine Dacara (Assistant Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 04/01/2026, the department interviewed Administrator (A1), Staff (S1 - S7) Residents (R1- R10), between the hours of 09:27am - 2:33pm. LPA requested copies of Staff Roster (dated 03/19/2026), Resident Roster (dated 03/25/2026), Resident 1 (R1): LIC 601: Identification & Emergency Information (date 10/30/2024); LIC 602: Physician Report for Residential Care Facilities for the Elderly (dated 08/04/2025), LIC 603: Preplacement Appraisal Information (dated 10/14/2024); LIC 625: Needs & Service Appraisal (dated 02/12/2026), Admission Agreement (dated 10/31/2024) Medication Administration Record (MAR) (dated January 2026 - March 2026) Internal Resident Incident Report (dated 01/21/2026, 11/23/2025, 10/11/2025, & 07/08/2025), Weight Record (March 2026) Power of Attorney (dated 05/11/2024), Resident Laundry Schedule for March 2026 and Spring 4 Week Food Menu Cycle. Unsubstantiated The investigation revealed the following: Allegation: Facility staff did not meet resident’s care needs, resulting in resident obtaining multiple UTIs. It was alleged that for several months, a resident had not been provided with adequate hygiene and incontinence care. A resident was reportedly found soiled on multiple occasions, not changed. It was further alleged that a resident developed multiple urinary tract infections due to untimely hygiene care. On 04/01/2026 between the hours of 9:27am – 9:50am, the Department interviewed Administrator (A1) in regards to the allegation. A1 denied the allegation and stated being unaware of any UTIs occurring while the resident was in care. A1 reported that a physician visited the resident the prior week but did not leave notes or orders. A1 stated the facility’s protocol for UTI prevention includes encouraging hydration, contacting the physician, and following any orders provided. A1 stated that residents receiving incontinence care are changed regularly in the morning, noon, night, and overnight, or upon request, with documentation maintained in ADL logs. A1 stated no incident reports or nursing notes were completed because no physician orders for labs or treatment were issued. On 04/01/2026, between 10:00am -11:50am, LPA interviewed seven (7) staff in regards to the allegation. 3 out of 7 staff denied the allegation. 2 out of 7 staff confirmed the allegation and expressed observing odor and pain. 2 out of 7 staff did not confirm nor deny that allegation of one(1) who mentioned only being aware of R1's UTI during the resident last hospital visit. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents in regards to the allegation. 7 of 10 residents denied the allegation and expressed no concerns with hygiene or care needs. 3 of 10 resident did not confirm nor deny the allegation and reported sometimes waiting for assistance. On 05/18/2026, between the hours of 3:00pm - 4:00pm, the Department conducted a record review and observed the LIC 602A Medical Assessment documented a “recent UTI – resolved” prior to admission, with notation that nitrofurantoin had been completed and no urinary symptoms were present at the time of assessment. The Department reviewed the resident’s Medication Administration Records (MARs) for all months in care and found no physician orders, MAR entries, or medication administration related to UTI treatment, antibiotics, or diagnostic testing such as urinalysis or urine culture. The Department reviewed all physician orders on file and found no orders for laboratory testing, diagnostic evaluation, or treatment related to UTIs. The Department reviewed the resident’s ADL logs, which documented routine incontinence care but did not contain entries indicating missed care, delayed care, or concerns related to urinary symptoms. The Department reviewed the Needs and Services Plan, which documented scheduled toileting every 2–3 hours and as needed, hydration encouragement, and incontinence care requirements. The Department reviewed all incident reports, and found no documentation of UTIs, suspected UTIs, changes in condition related to urinary symptoms, or communication with the authorized representative regarding UTIs. No documentation was found indicating multiple UTIs or unmet hygiene care needs. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Resident sustained multiple bruises due to staff neglect. It was alleged that a resident was observed with bruising on the forearm and hand that staff could not explain. It was further alleged that the bruising may have resulted from rough handling or neglect during care. On 04/01/2026 between the hours of 9:27am - 9:50am, the Department interviewed A1 in regards to the allegation. A1 denied the allegation and stated not being aware of any bruising, no incident reports were completed, and no concerns were brought to A1's attention. A1 stated that per protocol, the LVN assesses bruising and reports findings to the physician. On 04/01/2026, between 10:00am -11:50am, the Department interviewed seven (7) staff. 6 out 7 staff denied the allegation and reported no rough handling or observed inappropriate care. 1 out of 7 staff did not confirm nor deny that allegation, yet S2 reported seeing a mark on the resident’s arm but did not know the cause. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents. 9 out of 10 residents denied being handled roughly or observing rough handling. 1 out of 10 residents did not confirm nor deny the allegation but reported staff were rough during cleaning of their private area. On 05/18/2026, between the hours of 3:00pm - 4:00pm, the Department conducted a record review and observed the following: no incident reports documented bruising, discoloration, skin tears, or unexplained marks. The Department reviewed the LIC 602A Medical Assessment, which documented a history of skin breakdown but did not identify bruising or unexplained injuries. The Department reviewed communication logs and found no documentation of staff reporting bruising, unexplained injuries, or neglect related to skin integrity. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Facility staff did not ensure that residents have clean linen. It was alleged that the resident’s bedding was left soiled and not changed in a timely manner. On 04/01/2026 between 9:27am - 9:50am, the Department interviewed A1 in regards to the allegation. A1 denied the allegation and stated not being aware of any issues regarding soiled bedding. A1 stated linens are changed daily and immediately if soiled. On 04/01/2026, between 10:00am -11:50am, the Department interviewed seven (7) staff. 2 out of 7 staff confirmed the allegation and stated finding soiled bedding at times but states it changed immediately. 5 out of 7 staff denied the allegation and reported no delays in linen changes. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents. 1 out of 10 resident confirmed the allegation and reported that bedding was not changed promptly sometimes. 9 out of 10 residents denied the allegation and had no concerns with linen changes. On 05/18/2026, between the hours of 3:00pm - 4:00pm, the Department conducted a records review and observed the following: on page 2 of the Admission Agreement and Basic Services (signed on 10/30/2024) states that the facility provides clean bed and bath linens weekly or more often if needed. Upon further review, no incident reports, no communication logs, and no internal notes were found with concerns regarding soiled bedding, missed linen changes, or lack of clean linens. No documentation was found indicating feces on bedding, urine on sheets, or extended periods without clean linens for R1. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Facility staff did not provide adequate laundry service. It was alleged that the resident’s clothing was not washed regularly and remained soiled for extended periods. On 04/01/2026 between 9:27am - 9:50am, the Department interviewed A1 in regards to the allegation. A1 denied the allegation and stated not being aware of any concerns regarding unwashed clothing. A1 stated laundry is washed daily, with caregivers providing additional laundry support on Sundays. On 04/01/2026, between 10:00am - 11:50am, the Department interviewed seven (7) staff in regards to the allegation 7 out of 7 staff denied the allegation and mentioned that laundry is completed on assigned days and heavily soiled items are washed immediately. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents in regards to the allegation. 9 out of 10 residents denied with no concerns with laundry service. 1 out 10 residents was unaware of the allegation and stated they don't because they travel a lot . On 05/18/2026, between the hours of 3:00pm - 4:00pm, the Department conducted a records reviewed and observe Resident's Laundry Service for the month of March indicates R1's laundry day of the week was on Mondays. The LIC 500 Personnel Report, which listed designated (2) laundry staff who are assigned specifically to provide laundry services. The Department reviewed communication logs and incident reports and found no documentation of concerns regarding unwashed clothing, delays in laundry service, or extended periods without clean garments. No documentation was found indicating inadequate laundry service. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Facility is not providing adequate food service resulting in resident weight loss. It was alleged that a resident experienced weight loss due to inadequate food services. It was reported that meals were not consistently consumed and that staff did not ensure adequate food intake. On 04/01/2026 between 9:27am - 9:50am, the Department interview A1 regarding the allegation. A1 denied the allegation and stated there was no documented weight loss and no special diet per LIC 602. A1 stated no concerns were raised by the family and no physician or dietitian was consulted. On 04/01/2026, between 10:00am - 11:50am, the Department interviewed seven (7) staff in regards to the allegation. 6 out of 7 staff denied the allegation. 1 out of 7 staff did not confirm nor deny the allegation and reported the resident sometimes does not finish meals but stated concerns are reported to the nurse. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents in regards to the allegation. 2 out of 10 resident confirmed the allegation, of which one resident mention weight loss, while the other resident mentioned not receiving enough food and missing meals. 7 out 10 residents denied the allegation and had no concerns with food service. Of the 8 residents who denied the allegation ; 1 resident mentioned losing weight but did not attribute it to food service. 1 out of 10 resident did not confirm nor deny the allegation but mentioned sometimes not receiving enough food. On 05/18/2026, between the hours of 3:00pm - 4:00pm, the Department conducted a records review and observed the LIC 625 Appraisal/Needs & Service Plan documents R1 is on a NAS diet with thin liquids but according to the LIC 602A Physician's Report for RCFE documented that the resident was not on a special diet and required “No Added Salt” with thin liquids. The Department reviewed the March 2026 weight log, which documented three consecutive refusals (“Refused x3”) for scheduled weigh-ins by R1. No weight loss was documented. On 07/07/2026 between the hours of 12:30pm - 12:45pm, the Department reviewed the facility's four-week menu cycle utilized during Spring 2025. Although the menus are labeled "Spring 2022" and "Spring 2023," facility Administrator indicated these menus were the menus in use during Spring 2025. The menus reflected planned daily breakfast, lunch, dinner, and evening snacks, including a variety of proteins, fruits, vegetables, grains, dairy products, and beverages. Breakfast meals included items such as eggs, oatmeal, pancakes, waffles, French toast, breakfast meats, toast, cereal, fruit juice, coffee, tea, and milk. Lunch and dinner menus included a variety of entrees consisting of chicken, turkey, beef, pork, fish, tuna, and pasta dishes, accompanied by vegetables, rice, potatoes, beans, salads, soups, bread, fresh fruit, and desserts. Evening snacks included items such as yogurt, pudding, muffins, granola bars, fruit, crackers, cookies, ice cream, and nutritional beverages Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation : Facility staff did not respond to resident’s call button in a timely manner. It was alleged that staff failed to respond promptly when the resident activated the call button and left without prompt assistance when using the call bell, with delays reported up to 30 minutes. On 04/01/2026 between 9:27am - 9:50am, the Department interview A1 regarding the allegation. A1 denied the allegation and stated not being aware of any delays and ensure staff responds right away. A1 stated no response logs are maintained. On 04/01/2026, between 10:00am - 11:50am, the Department interviewed seven (7) staff in regards to the allegation. 6 out of 7 staff denied the allegation. 1 out of 7 staff did not confirm nor deny the allegation & reported that call light delays occur when caregivers are assisting other residents. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents in regards to the allegation. 5 out of 10 confirmed the allegation & reported delayed call light response with R2 mentioning waiting two hours at one time. 4 out of 10 residents denied and stated they do not use the call button. 1 out 10 residents did not confirm nor deny the allegation but mentioned a time period of 10 -15 minutes wait. On 04/01/2026 at 2:34pm, the Department conducted a call light inspection in room 245. At 2:41pm, facility staff entered room 245 to respond to the activated call light, resulting in a total response time of 7 minutes. On 07/07/2026 between 2:02pm – 2:23pm, the Department continued conducting call light inspections and observed the following: at 2:02pm, the call light was activated in room 137 and answered at 2:06pm, resulting in a four-minute response time. At 2:08pm, the call light was activated in room 115. At 2:09pm, two (2) staff walked by and did not acknowledge the call light. The call light was answered at 2:10pm by another staff, resulting in a two-minute response time. At 2:11pm, the call light was activated in room 130. At 2:13pm, two staff walked by and did not acknowledge the call light. At 2:14pm, a third staff walked by and did not address the call light. Between 2:15pm – 2:21pm, two additional staff walked by and did not address the call light. Between 2:11pm – 2:21pm, the call light in room 130 remained unanswered, resulting in a ten-minute period with no staff response. At 2:22pm, a staff informed a caregiver that the resident in room 102 needed a diaper change. The caregiver stated they were attending to two other residents and asked the staff to notify someone at the front desk. At 2:23pm, another caregiver entered room 102 with diapers to assist the resident with the diaper change, resulting in a one-minute response time. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Catherine Dacara (Assistant Administrator) and copy of this report was provided. Allegation : Facility staff did not provide communication with authorized representative. It was alleged that the facility failed to communicate with the authorized representative regarding the resident’s care and condition. On 04/01/2026 between 9:27am - 9:50am, the Department interview A1 regarding the allegation. A1 denied the allegation and stated not being aware of any concerns. A1 stated multiple staff communicate with families as needed. On 04/01/2026, between 10:00am - 11:50am, the Department interviewed seven (7) staff in regards to the allegation. 7 out of 7 staff denied the allegation and stated they would refer the representative to the Administrator, med tech, or front desk. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents in regards to the allegation. 8 of out 10 residents denied the allegation and expressed no concerns with communication. Several residents independently manage their own communication or do not have family. 2 out of 10 residents did not confirm nor deny the allegation and mentioned having no family (R8) and or does not communicate with their family (R4). On 05/18/2026, between the hours of 3:00pm - 4:00pm, the Department conducted a records review and observed the following: R1 has a POA, according to a document titled Power of Attorney for California (dated on 05/11/2024). This POA is also mentioned on the LIC 601 has the person responsible for final affairs, payment for care and legal guardian if any and this is also indicated on LIC 603 that POA is the person who manages R1’s finances. On 07/07/2026 between 11:45am – 1:00pm, the Department conducted further review of four (4) internal resident incident reports dated (2) on 07/08/2025, 11/23/2025, and 01/21/2026. The incident report dated 07/08/2025 documented that R1 was sent to the hospital and the written narrative stated that the POA was notified; however, the “Responsible Party” section reflected “No” for contact made. The incident report dated 07/08/2025 documented R1’s return from the hospital and indicated that discharge paperwork was scanned to GPDocs, the pharmacy, and the former office desk manager, and that the POA was notified; however, the “Responsible Party” section again reflected “No” for contact made. The incident reports dated on 10/11/2025 of an unwitnessed fall, on 11/23/2025 R1 screaming and shaking and on 01/21/2026 documented a witnessed fall in which 911 was called; however, the “Responsible Party” section reflected “No” for contact made. Based on the 4 incident reports, the Department observed that “No” was consistently checked for contact made to the responsible party, indicating that the authorized representative was not contacted at the time of each incident. The Department did not observe supplemental documentation indicating that communication occurred outside of the incident reports. Based on observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Catherine Dacara (Assistant Administrator) and a copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 11-AS-20260327155037

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Jul 21, 2026

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: (8) To have their representatives regularly informed by the licensee of activities related to care or services including ongoing evaluations... This requirement was not met as incident reports dated 07/08/2025, 10/11/2025, 11/23/2025, and 01/21/2026 showed “No” contact made with R1’s authorized representative, with no documentation of communication. This poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: The Administrator shall retrain staff on required notification procedures for authorized representatives by ensuring responsible parties are notified of all incidents and requests, with documentation completed accordingly. The facility shall submit proof of training to the Department via email at Zina.Brown@dss.ca.gov by the POC due date.

Allegation investigated: Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. Staff does not ensure resident's hygienic care needs are met. Staff does not ensure resident's incontinence care needs are met. Staff did not allow resident back to facility after hospital stay.

*This report supersedes the report dated 04/24/2026 to add additional information and interviews.* On 07/1/2026, at 9:15am, the department conducted a subsequent complaint visit to the facility and was greeted by Ace Huynh, Executive Director. The department explained the purpose of this visit was to amend the prior complaint with additional information and interviews. The investigation consisted of the following: On 04/01/2026, the department conducted an initial complaint visit to gather facility files. On 04/24/2026 from 11:00am-2:00pm, the department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4), residents (R2-R10). R1 was not available for interview because they are no longer at the facility and has cognitive issues. On 06/08/2026 the department interviewed witness (W1); resident (R1s) representative. The department received the following documents: Report Continued on LIC909-C Unsubstantiated Staff Roster (Dated: 03/19/2026), Resident Roster (Dated: 03/25/2026), Identification & Emergency Information (Dated: 02/02/2026), Physician Report (Dated: 12/08/2025), Preplacement Appraisal Information (Dated 02/02/2026), Needs & Service Appraisal (Dated: 04/01/2026), Admission Agreement (Dated 02/02/2026), Shower Schedule (Last Updated 03/06/2026), Shower Log (for March 2026) and Internal Resident Incident Reports (Dated: 03/12/2026, 03/23/2026 & 03/25/2026), and Medication Administration Record (Dated: February 2026 - March 2026) from the facility. The investigation revealed the following: Allegation #1-Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. The details of the complaint alleged that resident (R1) had two unwitnessed falls, with no injuries in the facility. It was reported that the staff did not provide adequate supervision for the resident. On 04/24/2026 from 11:00am-2:00pm, the department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4), residents (R2-R10), and on 06/08/2026 the department interviewed witness (W1) regarding the allegation. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. 4 of 4 staff denied the allegation that Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. All staff stated that they do provide adequate supervision for the residents in the facility. Staff also stated that there is a call button in each resident’s room that they can push if they need assistance or are having trouble walking. They further stated that the residents are checked on frequently throughout the day and night and to their knowledge (R1) never had a fall in the facility. The department interviewed residents (R2-R10) about the allegation and 8 of 10 residents that were interviewed stated that they believe the staff does provide adequate care and supervision for the residents in the facility. Those residents further stated that they are satisfied with the care and supervision and feel safe living in the facility. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. The department interviewed witness (W1), and they stated that the staff did not monitor the resident correctly and felt that they wouldn’t have fallen if they were monitored better. The department reviewed Internal Resident Incident Reports (Dated: 03/12/2026, 03/23/2026 & 03/25/2026) and observed that the incident reports were not fall related. There is no documentation that (R1) had any falls. The department reviewed the Staff Roster (Dated: 03/19/2026) and observed that the facility has sufficient staff to provide adequate supervision for the residents. The department also reviewed the Preplacement Appraisal Information (Dated 02/02/2026) and observed that (R1) was able to walk without any physical assistance and does not utilize assistive devices for mobility, despite having a cane available. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report Continued on LIC9099-C Allegation #2- Staff does not ensure resident's hygienic care needs are met. The details of the complaint alleged that the facility staff did not ensure the residents’ (R1) hygiene care needs were met. It was reported that hygiene requests from the family were not addressed. On 04/24/2026 from 11:00am-2:00pm, the department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4), residents (R2-R10), and on 06/08/2026 the department interviewed witness (W1) regarding the allegations. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. 3 of 4 staff denied the allegation that Staff does not ensure resident's hygienic care needs are met. The majority of the staff stated that the residents’ hygienic care needs were being met. Staff further stated that (R1) was able to care for their own hygiene needs with little assistance from the staff but needed reminders from the staff. Staff stated that they reminded (R1) often and tried to assist (R1) but (R1) would get agitated and scream for them to stop. While 1 staff stated that the resident did require some assistance and would often refuse and get agitated if they tried to assist them. The department interviewed residents (R2-R10) about the allegation and 9 of 10 residents that were interviewed stated that the facility staff does ensure that their hygiene needs are met but added that they are primarily independent and care for their own needs. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. The department interviewed witness (W1), and they stated that the facility staff did not make sure that (R1s) hygiene (shower/grooming) needs were met as requested. The department reviewed the Needs & Service Appraisal (Dated: 04/01/2026) and observed that (R1) needed assistance with bathing and grooming but was able to care for their toileting needs by themselves without assistance. The department reviewed the Shower Schedule (Last Updated 03/06/2026) and Shower Log (for March 2026) and observed that (R1) was on a schedule but some days it was documented that (R1) refused to shower and refused assistance. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that Staff does not ensure resident's hygienic care needs are met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report Continued On LIC9099-C Allegation #3- Staff does not ensure resident's incontinence care needs are met. The details of the complaint alleged that the facility staff did not ensure that resident (R1) incontinent care needs were met. It was reported that (R1) had redness in their groin area which they suggested was suggestive of infrequent brief changes. On 04/24/2026 from 11:00am-2:00pm, the department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4), residents (R2-R10), on 06/08/2026 the department interviewed witness (W1) regarding the allegation. On 7/1/26 the department reinterviewed staff about the allegation. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. 3 of 4 staff denied the allegation that Staff does not ensure resident's incontinence care needs are met. The majority of the staff stated that the residents’ needs were being met. While 1 staff said they needed some assistance sometime but could generally care for their own toileting needs. All staff stated they had no knowledge of any redness in (R1s) groin area. All staff stated that residents who need assistance with incontinence care is conducted every two hours or as needed depending on the resident’s needs. All staff stated that (R1) did not need incontinent care. The department interviewed residents (R2-R10) about the allegation and 9 of 10 residents that were interviewed stated that the staff does ensure that their care needs are met. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. The department interviewed witness (W1), and they stated that the facility staff did not make sure that (R1) incontinence care needs were being met. W1 stated that R1 was not changed often and had dried feces in their adult briefs and believed their groin area was red because of infrequent brief changes. The department reviewed the Needs & Service Appraisal (Dated: 04/01/2026), Physician Report (Dated: 12/08/2025), and Preplacement Appraisal Information (Dated 02/02/2026) and observed that the resident was able to care for their toileting needs by themselves without assistance. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that Staff does not ensure resident's incontinence care needs are met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report Continued on LIC9099-C Allegation #4- Staff did not allow resident back to facility after hospital stay. The details of the complaint alleged that the facility did not allow resident back after hospital stay. It was reported that the family member of the resident did not want to return the resident to the facility because they didn’t think the resident was properly cared for. On 04/24/2026 from 11:00am-2:00pm, the department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4), residents (R2-R10), and on 06/08/2026 the department interviewed witness (W1) regarding the allegations. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. 4 of 4 staff denied the allegation that Staff did not allow resident back to facility after hospital stay. Staff (S1) stated that the family member of the resident came on 03/24/2026 to take the resident to the hospital for evaluation and never brought the resident back to the facility. S1 also stated on that day, the family member removed all of the residents’ belongings from the facility. S1 further stated that there wasn’t a valid reason that the resident could not return to the facility, and no one said otherwise. S2-S4 stated that they had no knowledge of a reason that the resident would not be allowed to return to the facility. The department did not find any documentation or communication that would have denied the resident from returning to the facility. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. The department interviewed witness (W1), and they stated that the facility did not refuse to allow R1 back. However, they felt that R1 would be safer in a different facility and chose to take R1 elsewhere. Based on interviews conducted, there is insufficient evidence to support the allegation that Staff did not allow resident back to facility after hospital stay. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued for this complaint investigation. An exit interview was conducted with Ace Huynh, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Jul 1, 2026 · control 11-AS-20260325144642

Type of visit: Case Management - Incident

On June 15, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit to the facility following an incident reported by the facility that occurred on June 6, 2026. During the visit, the LPA met with Anita Csukardi & Ace Huynh, Executive Directors to explain the purpose of the inspection. The El Segundo Regional Office Adult and Senior Care received an Unusual Incident Report (LIC 624) on June 8, 2026, stating that Resident #1 (R1) had been given the wrong medication. On June 6, 2026, at 4 PM, the medication technician mistakenly verified only (R1's) last name without confirming the correct resident. Consequently, (R1) was administered medications intended for another resident with the same last name. As a result, both Metformin and Senna were given to (R1) in error, leading to hospitalization in the emergency room. The Department found that the facility was not in compliance with Title 22 Regulations and issued citations as follows: 87465(c)(2) Incidental Medical and Dental Care Services. The investigation revealed that the facility failed to comply with Title 22 regulations. The LPA reviewed (R1’s) Physicians Report (LIC 602A) (dated 07/27/23) and Medication List (dated 06/15/26), which confirmed that (R1) was not prescribed Metformin by (R1's) physician. Based on interviews, observations, and record reviews, the licensee was found in violation of the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies have been issued, and an exit interview was conducted with Ace Huynh, Executive Director. A copy of this report is provided, along with the appeal rights.the state’s words, verbatim · CDSS document, Jun 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465)(c)(2) · Plan of correction due date: Jun 16, 2026

87465)(c)(2) Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on the records review, facility staff did not verify the medication record and administered medication Metform that was not prescribed to (R1). The facility reported a medication error: administering the wrong medications intended for another resident with the same last name. This violation poses/posed an immediate risk to persons in care.the state’s words, verbatim · CDSS document, Jun 15, 2026

Plan of correction: Licensee shall provide medication administration in-service training to all staff that dispense medications. This training shall be provided by pharmacy and/or registered nurse. Submit proof of training by POC due.06/16/26. Citation was cleared during the visit. Medication training took place on 06/10/26 with a registered nurse.

Allegation investigated: Facility did not maintain a safe and healthful environment for the resident.

This report supersedes the report created on 03/18/2026. An additional report will be provided addressing the remaining allegations investigated. The findings regarding the loud television and resulting sleep disruption remain unchanged. On 06/09/2026, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced complaint visit. LPA met with Administrator Catherine Dacara. The investigation consisted of the following: On 03/18/2026, LPA Anguiano interviewed fourteen (14) residents (R1–R14) and five (5) staff members (S1–S5), conducted observations, and collected records. Records obtained included internal incident reports for R1 and R2, an LIC 500 dated 03/12/2026, staff roster, resident roster dated 03/05/2026, and an internal resident incident report for R5 with documentation of a house rules reminder provided. LPA also reviewed four (4) resident files, including admission agreements, physician’s reports, and appraisal/reappraisal documents. The investigation revealed the following: Please see report continuation on (LIC9099-C) Substantiated Regarding the allegation, “Facility did not maintain a safe and healthful environment for the resident,” it was alleged that a resident was subjected to ongoing noise disturbances due to a roommate’s loud television at night, resulting in sleep disruption. Records review revealed internal incident reports dated 03/12/2026 and 03/13/2026 documenting concerns regarding loud television use and roommate conflict between R1 and R2. Documentation indicated that R1 reported concerns regarding television volume and difficulty sleeping. Records also indicated that staff provided reminders to R2 regarding house rules, including lowering television volume and use of headphones at night. However, the facility did not provide additional requested documentation, including behavior logs, complaint logs, or other records demonstrating ongoing monitoring, follow-up actions, or effective resolution of the roommate conflict. Resident interviews revealed that R1 reported concerns regarding loud television volume at night and disruption of sleep. Staff interviews revealed ongoing roommate conflict between R1 and R2 involving television volume, different sleep schedules, and sleep disruption. Staff further reported that incident reports were completed, the issue was brought to administration, and staff attempted verbal interventions including reminders, counseling, mediation, and review of house rules. S1 reported addressing the concern by counseling the resident, reviewing house rules, and offering a room change. However, both residents declined relocation and staff reported the concern remained ongoing at the time of the investigation. Observations revealed that residents were observed in their rooms and common areas, and the facility appeared calm during the visit. Based on interviews conducted, observations made, and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation that the facility did not maintain a safe and healthful environment for the resident due to ongoing noise disturbance and sleep disruption is Substantiated. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.1(a)(2), Personal Rights of Residents in All Facilities. A citation is being issued on the attached (LIC9099-D). An exit interview was conducted with the Administrator. A copy of this report and appeal rights were provided to the Administrator. The investigation revealed the following: Regarding the allegation that a resident attempted to run over another resident with a wheelchair, interviews conducted with residents and staff did not corroborate the allegation. Staff interviewed denied knowledge of physical aggression or wheelchair aggression between R1 and R2. S1 stated this concern had not been previously reported. Records reviewed did not contain incident reports, behavior logs, or other documentation supporting the allegation. During the visit, LPA did not observe physical aggression between residents. Regarding the allegation that a resident yelled at another resident, interviews conducted with residents and staff did not corroborate the allegation. Staff interviewed denied knowledge of yelling between R1 and R2. S1 stated this concern had not been previously reported. Records reviewed did not contain incident reports, behavior logs, or other documentation supporting the allegation. During the visit, LPA did not observe yelling or active conflict between residents. Regarding the allegation that a resident used abusive language toward another resident, interviews conducted with residents and staff did not corroborate the allegation. Staff interviewed denied knowledge of abusive language between R1 and R2. S1 stated this concern had not been previously reported. Records reviewed did not contain incident reports, behavior logs, or other documentation supporting the allegation. During the visit, LPA did not observe abusive language or active conflict between residents. Based on interviews conducted, observations made, and records reviewed, although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the allegations are Unsubstantiated. No deficiencies were cited regarding these allegations. An exit interview was conducted with the Administrator. A copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 9, 2026 · control 11-AS-20260311163742

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 10, 2026

87468.1 Personal Rights of Residents in All Facilities(a)...in all residential care facilities for the elderly...all of the following personal rights:(2)To be accorded safe...accommodations...This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee failed to ensure R1’s personal rights were protected. R1 experienced repeated sleep disruption due to R2’s loud television. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 9, 2026

Plan of correction: Licensee agreed to find a better room for R1 in order to help R1's personal rights by due date and email LPA: jose.anguiano@dss.ca.gov

Allegation investigated: Staff did not distribute residents' medications as prescribed Staff do not provide a comfortable environment for residents in care

On 06/04/26 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. California Department of Social Services (CDSS) was met by staff one, Ace Huynh - Administrator (S1), and the purpose of the visit was explained. CDSS was assisted by Davila Alvarez (S2) and toured the facility. The investigation consisted of the following: Between 9:00AM and 1:00PM CDSS interviewed ten (10) out of one-hundred and nine (109) residents (R1-R10) and four (4) out of fifty-five (55) staff (S1-S4). CDSS collected documents listed as follows: Resident roster (Dated: 06/03/26), Staff roster (Dated: 06/02/26), Admission Agreement of resident one (R1) (Dated: 02/08/22), medical transport of resident 11 (R11) and medications administration record (MAR) of R1 and R12 for the month of May, 2026 (05/2026). The investigation revealed the following: Regarding the allegation “Staff did not distribute residents' medications as prescribed”, it is being alleged that on 5/25/2026, the facility was short staffed and that medications were not delivered to all residents in care. Report continues, please see LIC9099-C. Unsubstantiated Record reviews revealed the following: During the month of May (05/2026) CDSS reviewed two (2) MARs and there were zero (0) discrepancies observed. Interviews revealed the following: Nine (9) out of ten (10) (R2-R10) residents and all four staff (S1-S4) have denied the allegation has taken place. 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. Regarding the allegation “Staff do not provide a comfortable environment for residents in care”, it is being alleged that another resident speaks too loudly on a daily basis and staff have spoken to this resident, yet the volume of their voice remains loud. Record reviews have revealed that, within house rules, the grievance procedures are listed. Interviews revealed the following: Six (6) out of ten (10) (R4-R8 and R10) residents and all four staff (S1-S4) have denied the allegation has taken place. 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. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with staff one, Ace Huynh, and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 11-AS-20260529151706

Allegation investigated: Facility staff mismanage residents’ medications

**This report supersedes the report delivered on 05/13/2026 to include additional information to the findings** On 06/03/2026 at 8:00am, the department conducted an subsequent visit to deliver the investigation findings at this facility for the allegation listed above. During today’s visit, the department met with Catherine Dacara (Assistant Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 04/07/2026 between the hours of 8:40am - 1:33 pm, the department interviewed Administrator (A1), Staff (S1 - S5), Residents (R1 - R10). The department also requested and obtained the following documents: Staff Roster (dated 03/19/2026), Resident Roster (dated 04/06/2026), Employee Schedule (dated 03/29/2026 - 04/04/2026), Visitor Log (dated 04/02/2026),2 Resident Records for R1 & R2 which include: See LIC 9099-C Substantiated LIC 601: Identification & Emergency Information (R1 dated 03/09/2026 & R2 dated 02/26/2025), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (R1 dated 08/21/2025 & R2 dated 02/07/2025), LIC 603: Preplacement Appraisal Information (R1 dated 08/27/2025 & R2 dated 02/07/2025), Admission Agreement (R1 dated 09/19/2025 & R2 dated 02/28/2025, R1's New Resident Account Set Up (dated 09/19/2025), R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) . The investigation revealed the following: Allegation: Facility staff mismanage residents’ medications. It was alleged that residents’ medications were not administered as prescribed and that documentation was incomplete. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated medtechs assist with self-administered medications when LVNs are unavailable. A1 reported she was not aware of any missed doses or medication errors. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Four (4) out of five (5) staff denied the allegation. One (1) staff was unaware. Staff reported they were not aware of missed doses and stated they notify the med-tech or charge nurse if unable to administer medications. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed ten (10) residents regarding the allegation. One (1) out of ten (10) residents confirmed the allegation. One (1) out of ten (10) was unsure of the allegation. Eight (8) out of ten (10) denied the allegation. Of the one (1) resident who confirmed the allegation, the resident reported missed doses. Of the one (1) resident who was unsure mentioned being not sure of their medication management. On 05/13/2026 between 10:00am – 11:00am, the Department conducted a records review of the April and May 2026 Medication Administration Records (MARs) and identified 42 undocumented medication administrations affecting eight (8) residents. The review showed missing initials for medications assigned to R1, including 6 missed doses of Carvedilol, 3 of Duloxetine, 14 of Furosemide, and 9 of Gabapentin on various dates in April 2026; R2 had 2 missed doses of Sacubitril/Valsartan, 2 of Magnesium Oxide, 2 of Vitamin C, and 1 multivitamin dose between April 10–18, 2026; R3 had 2 missed doses of AmoxClav, 1 of Olanzapine, and 1 Lidocaine patch between April 6–15, 2026; R4 had 2 missed doses of Polyethylene Glycol, 3 of Amlodipine, and 2 of Atorvastatin between April 12–20, 2026; R5 had 1 missed dose each of Benazepril, Eliquis, and Refresh Tears on April 9, 13, and 17, 2026; R6 had 2 missed doses of Divalproex, 2 of Vitamin D3, 3 of Docusate Sodium, 4 of Famotidine, 1 of Omega-3 Ethyl Esters, and 1 of Buspirone between April 5–22, 2026; R7 had 20 missed doses of Lantus Solostar, 3 of Metformin, and 2 of Xiidra throughout April 2026; and R8 had 2 missed doses of Levetiracetam and 1 missed dose each of Lisinopril, Sertraline, Acetazolamide, Bisacodyl, Ipratropium-Albuterol, Isosorbide Dinitrate, Jardiance, and Triamcinolone between April 7–25, 2026. The Department also observed nine (9) medications remaining inside bubble packs despite being initialed as administered, with no documentation explaining the discrepancies. Based on the Department's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Catherine Dacara (Assistant Administrator) a copy of this report was provided with appeal rights. LIC 601: Identification & Emergency Information (R1 dated 03/09/2026 & R2 dated 02/26/2025), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (R1 dated 08/21/2025 & R2 dated 02/07/2025), LIC 603: Preplacement Appraisal Information (R1 dated 08/27/2025 & R2 dated 02/07/2025), Admission Agreement (R1 dated 09/19/2025 & R2 dated 02/28/2025, R1's New Resident Account Set Up (dated 09/19/2025), R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) . The Investigation revealed the following: Allegation: Facility staff do not ensure that residents’ toileting needs are met. It was alleged that residents were not receiving timely assistance with toileting and incontinence care due to chronic understaffing, resulting in delays in responding to care needs and insufficient break coverage. On 04/07/2026 between the hours of 8:40am - 8:52am, the Department interviewed A1 in regards to the allegation. A1 denied the allegation, stated not being informed of any resident left soiled or any staff refusing assistance due to being on break. A1 explained that the facility uses a break schedule to ensure coverage and stated not being present during the reported incident and did not receive follow-up information. On 04/07/2026 between the hours of 11:55am - 1:33pm, the Department interviewed 5 staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they had not observed a resident being left soiled, had not refused assistance due to being on break, and stated that another caregiver is assigned to provide coverage when a staff member is on break. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents was aware of the allegation. Nine (9) out of ten (10) residents denied the allegation. Residents reported they independently manage toileting or receive timely assistance. One resident reported a single instance where staff stated they were on break in regards to the delay in responding to care needs. On 05/13/2026 between the hours of 10:00am - 11:00am, the Department conducted a records review of resident assessments and facility documentation and did not observe any records indicating unmet toileting needs or delays in incontinence care. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Facility staff did not treat residents with dignity and respect. It was alleged that staff entered rooms without knocking, spoke rudely to residents, and refused to provide their names. On 04/07/2026 between 8:40am -8:52am, the Department interviewed the Administrator (A1) regarding the allegation. A1 denied the allegation and mentioned not being informed of staff entering rooms without knocking, speaking rudely to residents, or refusing to provide their names. A1 stated staff are expected to knock before entering and identify themselves when asked, and no complaints of disrespectful conduct had been reported. On 06/03/2026 between 9:24am - 9:42am, the Department re-interviewed A1 to obtain additional information in regards to the allegation. A1 denied receiving any reports of staff entering rooms without knocking, speaking rudely to residents or visitors, refusing to provide their names, or making inappropriate statements. A1 stated staff are trained to uphold resident Personal Rights, including respectful communication and proper room entry procedures. A1 reported that R1 approached her the day after 04/02/2026 to apologize for R1's visitor’s behavior such as being rude towards the staff. A1 stated she spoke with the involved staff (S4), reviewed expectations regarding respectful communication, and reinforced de-escalation procedures. A1 reported no residents had expressed concerns about staff conduct or indicated a desire to move out due to staff behavior. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they knock before entering resident rooms, do not speak to residents in a rude manner, and provide their names when requested. Staff stated they were not aware of any incidents involving rude tone or refusal to identify themselves. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. Two (2) of ten (10) residents confirmed the allegation. Eight (8) of ten (10) residents denied the allegation. Two residents reported incidents involving rude tone or failure to knock; the remaining residents reported staff knock before entering and treat them respectfully. On 05/13/2026 between the hours of 10:00am – 11:00am, the Department conducted a records review of facility policies, resident rights documentation, and internal records and did not observe any documentation indicating staff failed to treat residents with dignity or respect. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Facility staff do not ensure residents’ medical needs are being met. It was alleged that residents were not receiving ordered physical therapy or medical services. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated not being aware of any resident failing to receive ordered physical therapy or medical services. A1 stated the facility follows up with therapy providers when services are missed and had not received reports of unmet medical needs. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Four (4) out of five (5) staff denied the allegation. One (1) out of five (5) staff was unaware of the allegation. Staff reported they had not observed residents missing medical services and stated they notify the LVN or med-tech when residents report concerns. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents confirmed the allegation. Nine (9) of ten (10) residents denied the allegation. One resident reported not receiving physical therapy; other residents reported receiving medical services as ordered or stated delays were due to insurance authorization rather than facility action. On 05/13/2026 between the hours of 10:00am – 11:00am, the Department conducted a records review of LIC 602s, LIC 603s, and medical documentation and did not observe any records indicating missed medical services or lack of follow up by the facility. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff do not ensure food served is of good quality. It was alleged that the food served to residents was of poor quality and did not meet nutritional needs, and that inadequate staffing and oversight contributed to inconsistent meal preparation and insufficient attention to dietary requirements. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated menus are created monthly and reviewed for nutritional adequacy. A1 reported not receiving complaints regarding food quality. On 04/07/2026 between the hours of 11:55am – 1:33 pm, the Department interviewed five (5) staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they had not received complaints regarding food quality and stated meals are prepared according to posted menus. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents confirmed the allegation. Nine (9) of ten (10) residents denied the allegation. One resident reported dissatisfaction with food quality; other residents reported meals were satisfactory. On 05/13/2026 between the hours of 10:00am – 11:00am, the Department conducted a records review of the facility’s posted Spring 2026 menus for Weeks 1, 3, and 4. The Department observed that the menus were dated, organized, and reflected balanced meals including proteins, vegetables, starches, fruits, and desserts. Breakfast menus included hot cereals, eggs, pancakes, and juice options. Lunch and dinner menus included soups, salads, meats, vegetables, and desserts. The Department observed that the menus aligned with the facility’s Admission Agreement requirement to provide three nutritious meals daily and accommodate special diets. No documentation was found indicating that meals served failed to meet nutritional standards or that residents were served food inconsistent with posted menus or dietary requirements. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Catherine Dacara and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 3, 2026 · control 11-AS-20260403094947

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 4, 2026

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: The licensee shall assist residents with self-administered medication as needed Based on observation and record review, the Department identified eight (8) residents and nine (9) medications remaining in bubble packs despite being initialed as administered, posing a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2026

Plan of correction: The Administrator will complete an immediate medication audit & ensure all medications are administered & documented correctly. Also Administrator will provide proof of scheduled in-service training from a contracted pharmacy on proper administration of medication & proper MAR documentation... for all staff who handle meds. Proof of the completed medication audit in detail and scheduled date and time for the in-service training with contracted pharmacy on proper medication administration by the POC due date to LPA Brown at Zina.Brown@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6)(A–F) · Plan of correction due date: Jun 24, 2026

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring a record of centrally stored prescription medications for each resident is maintained ...(A-F) records for centrally stored medication... Based on record review, the Department identified 42 undocumented medication administrations affecting eight (8) residents, indicating medications were not documented as required, which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2026

Plan of correction: The Administrator will retrain all medication staff on MAR documentation requirements under 87465(h)(6)(A–F). A weekly MAR review will be implemented to ensure all entries are complete, accurate & must be signed & dated daily. The administrator will submit proof of completed retraining for... MAR documentation requirements & weekly MAR review entries are conducted & must be reviewed by being signed & dated for confirmation of review being completed by the POC due date and email proof to LPA Brown at Zina.Brown@dss.ca.gov

Allegation investigated: Staff do not ensure that resident's transportation needs are being met

***Please note that this amended Complaint Investigation Report LIC9099 and LIC9099-C dated June 25, 2026, will supersede the original LIC9099 dated June 3, 2026, clarification.*** On Wednesday, June 3, 2026, Licensing Program Analyst (LPA) Pamela Bunker conducted an initial visit to gather information regarding the above allegation. LPA met with Ace Huynh, Executive Director, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On June 3, 2026, the following documents were reviewed and obtained as part of the investigation: Personnel Report (dated 06/02/26), Resident Roster (dated 03/02/26), Admission Agreement (dated 01/23/26), Identification and Emergency Information (dated 02/17/26), Physician’s Report (dated 07/30/25), Medical Assessment (dated 12/31/25), Medication Administration Records (MARs) (06/01/26 -Present), Resident Appraisal & Needs and Services Plan (dated 12/31/25), Functional Capability Assessment (dated 12/31/25), Preplacement Appraisal Information (dated 12/31/25), Personal Rights (dated 01/23/26), Consent Forms (dated 01/23/26), Personal Property and Valuable (dated 01/30/26). See continued LIC9099-C page 2. Unsubstantiated Continued LIC9099-C page 2. The investigation revealed the following: Allegation: Staff do not ensure that residents' transportation needs are being met. On 06/03/2026, between 10:00 a.m. and 3:30 p.m., the Department interviewed Staff #1 through Staff #3 (S1–S3). All three staff members (3 out of 3) stated that the facility ensures residents' transportation needs are met. Staff reported that residents may schedule transportation services through the front desk receptionists for use of the facility van, and staff also assist residents in arranging transportation through Access Services and CalVA Car. 3 out of 3 staff members stated that residents are required to sign up in advance for transportation to medical appointments. Staff explained that once transportation requests are submitted, the front desk notifies administration, and nursing staff are also informed when transportation is needed for medical appointments to ensure proper coordination of care. All three staff members stated that residents are not denied transportation services and denied the allegation that the facility fails to meet residents' transportation needs. On 06/03/2026, between 1:00 p.m. and 3:30 p.m., and on 06/25/2026, between 11:00 a.m. and 12:00 p.m., the Department interviewed Residents #1 through #10 (R1–R10) regarding the above allegation. 9 out of 10 residents interviewed stated that staff ensure their transportation needs are met and reported no issues obtaining transportation to medical appointments or other scheduled destinations. 9 out of 10 residents stated that transportation services are available when requested and that staff assist them as needed. 1 out of 10 residents stated that staff is currently assisting them with obtaining transportation services through Access Services and LA Care to help meet their transportation needs. The resident did not express any concerns regarding staff’s efforts and acknowledged that staff are actively working to coordinate the necessary services. 10 out of 10 residents stated that staff follow their individual needs and service plans, and their care needs are being met. 9 out of 10 residents stated that they have not experienced any problems related to transportation. 9 out of 10 residents interviewed denied the allegation that staff fail to ensure residents’ transportation needs are being met. See continued LIC9099-C page 3. Continued LIC9099-C page 3 The Department reviewed the resident’s Physician’s Report (dated 07/30/25), Medical Assessment (dated 12/31/25), Resident Appraisal/Needs and Services Plan (dated 12/31/25), Functional Capability Assessment (dated 12/31/25), and Pre-placement Appraisal Information (dated 12/31/25). There was no indication that the resident had been seen by physical therapy (PT). Documentation reflects that the resident had no scheduled PT appointments. Based on interviews, available evidence, observations, information received, and records reviewed, there was not sufficient evidence to support the allegation. Although the allegation may have occurred or may be valid, there is not a preponderance of evidence to prove that 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 Ace Huynh, Executive Director. No deficiencies were cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Jun 3, 2026 · control 11-AS-20260526112802

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

Allegation investigated: Facility staff are not assisting resident with obtaining healthcare

On 06/02/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint visit to the facility listed above. LPA met with Ace Huynh, Administrator, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation revealed the following: During today’s visit, LPA interviewed Staff S4-S7 and delivered findings. During a subsequent visit conducted on 04/30/2026, LPA inspected the facility, interviewed Staff S3, interviewed Residents R1-R12, and received and reviewed Internal Resident Incident Reports, Besht Wellness Group Progress Notes (dated 10/27/2025, 12/15/2026, 12/18/2025 . During an initial visit conducted on 03/05/2026, LPA interviewed Staff S1 and S2 and received documents. The following documents were received and reviewed: Staff Roster, Resident Roster, Physician’s Report (dated 03/27/2026), Needs and Service Plan (dated 02/15/2026), Physician’s Orders, and Admission Agreement (dated 04/04/2025). The investigation revealed the following: Unsubstantiated Allegation: Facility staff are not assisting resident with obtaining health care The allegation alleges that a resident wants physical therapy, a new wheelchair, and a medical procedure done and she has not received it. During record review, LPA received and reviewed the Admission Agreement (dated 04/03/2025) that lists under Basic Service the following, On page 1, number 3 states “Notification to resident’s family, physician, and other appropriate person/agency of resident’s needs. And on page 2, number 6 states “Plan, arrange and/or provide for transportation to medical and dental appointments within a 7-mile radius of facility." Physician’s Report for Residential Care Facilities for the Elderly (dated 03/27/2025) that indicates R1 has a Motor Impairment/Paralysis that causes hemiplegia and hemiparesis. Additionally, LPA received and reviewed Progress Notes from Besht Wellness (dated 12/18/2025) that under Plan lists the following: Referral to home health physical and occupational therapy for ongoing rehabilitation needs. Order for durable medial equipment: replacement or repair of motorized wheelchair. Referral to obstetrics and gynecology for intrauterine device replacement as previously requested. LPA observed an order for home health for physical therapy/occupational therapy on 10/28/25 and 12/18/25. During the facility visit, LPA observed R1 utilizing an electric wheelchair. R1 stated that it was working fine During interviews with Staff S1-S7, were asked if there is staff who assist residents with arranging medical appointments or procedures, seven (7) out of seven (7) stated if a resident requires assistance making a doctor’s appointment, staff in the medication room or the front desk are able to assist. Additionally, Staff S1- S7 were asked if staff assist residents with acquiring assistive devices or outside services, seven (7) out of seven (7) stated if there is an order from the doctor, they will assist with acquiring it or if the resident or family request we can notify their physician to see about getting an order. During interviews with Residents R1-R12, were asked if staff assist them with arranging medical appointments or procedures, twelve (12) out of twelve (12) stated yes, staff are there to assist them with arranging appointments and transportation, if needed. Additionally, Residents R1-R12 were asked if staff assist them with receiving outside services and/or acquiring assistive devices, twelve (12) out of twelve (12) stated yes, staff are there to assist with receiving outside services and/or acquiring assistive devices, if need. During an interview with R1, they specified the issue has been with their physician and have since gotten a new doctor. 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 did or did not occur, therefore the allegation is/are unsubstantiated. LPA did not observe or cite any deficiencies. An exit interview was conducted with Administrator, Ace Huynh, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 11-AS-20260226154701

Allegation investigated: The facility did not ensure that resident was provided with comfortable, safe, and sanitary living accommodations.

On 05/29/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with the Executive Director, Ace Huynh and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 05/20/2026, an interview was conducted. On 05/22/2026, interviews were conducted and records were reviewed. Interviews conducted consisted of Witness 1 (W1), Staff 1 (S1) to Staff 6 (S6) and Resident 2 (R2) to Resident 9 (R9). Facility records were reviewed which consisted of Personnel Report dated 05/01/2026 and Resident Roster. Resident 1’s (R1) records were reviewed which consisted of Admission Agreement, Physicians Report dated 4/24/2023, Appraisal/Needs And Services Plan (ANS) dated 01/30/2025, Friendly Reminder letter dated 02/20/2025, five (5) Internal Resident Incident Reports ranging from 01/27/2025 to 02/17/2026. On 05/29/2026, R1’s room was toured. Substantiated Investigation revealed the following: Allegation: “The facility did not ensure that resident was provided with comfortable, safe, and sanitary living accommodations.” It is being alleged that staff allowed R1’s belongings and unsanitary items to accumulate in resident’s room. On 05/22/2026 at around 9:30 AM, R1’s room was toured and the following was observed: the room floor was filled with miscellaneous items such as boxes, picture frames, bags of stuff, bags of food supplies, toys, art supplies, house hold supplies, there is a medical bed with a half bed rail, large black bags filled, wheelchair, microwave, toiletries, and other items. It was difficult to maneuver around the bedroom; there was a small narrow path that led to the bed; it was not possible to open the bedroom window because the floor was covered with miscellaneous items (as mentioned above). R1’s bathroom was toured and the following was observed: the bathroom bathtub/shower was filled with clothing items and other miscellaneous supplies. The shower curtain rod was used as a closet rod that holds about forty-seven (47) hangers with long sleeve t-shirts, sweaters, sweatpants, etc. The bathroom sink was filled with dirty dishes. Vermin droppings and dead vermin were observed in the bathroom. On 05/29/2026, R1’s room was toured and two (2) kitchen knives were observed out. (Several pictures of R1’s room were taken and video footage). Interviews conducted with W1 revealed the following: W1 agreed with the allegation. W1 explained that the facility has not addressed R1’s hoarding; furthermore, W1 states that they have witnessed one (1) to four (4) portable urinal bottles filled with urine at one time on several occasions. Interviews conducted with R2 to R9 revealed the following: Five (5) out of eight (8) residents agreed with the allegation. Residents indicated that R1 was a “pack rat,” “hoarder,” and they had observed cups filled with urine. Three (3) out of eight (8) residents could not corroborate towards the allegation (residents had not seen R1’s room). Interviews conducted with Staff 1 (S1) to Staff 6 (S6) revealed the following: Six (6) out of six (6) staff agreed that R1 has a hoarding problem which makes it difficult for R1 to remove items from their room. Staff indicated that R1 uses a wheelchair, is a large person, and were unsure how R1 maneuvered in their room. Furthermore, staff indicated that it was difficult to work inside R1’s room due to it being difficult to ambulate in the room. Moreover, staff indicated that they had observed portable urinals filled with urine. Additionally, staff indicated that R1 was unable to shower in their bathroom because it was filled with clothing items. Staff indicated since the date they began working in the facility R1’s room has been like this (filled with boxes, art supplies, etc.). Staff were unaware if Unusual Incident Reports and Adult Protective Services (APS SOC341) reports were submitted to the department. Staff were unaware if there was a specific detailed plan in place to decrease the number of items R1 had. R1’s records reviewed revealed the following: Admission Agreement was not signed nor dated by R1 nor facility staff but stated that date of Admission was 04/25/17; on page 11 under “9. Clutter No hoarding or clutter is allowed in the units. Blocking the walkways, exit areas, and air/heat unit is a safety hazard.”; R1 is “Self-Responsible.” Physicians Report dated 04/24/2023 (report not signed by R1), stated that R1 needs assistance with bathing, grooming, toileting needs, and is non-ambulatory due to both mental and physical condition. Internal Resident Incident Report dated 01/27/2025, stated that the facility contacted R1’s family about R1 being a fall risk and room being a fire hazard; family indicated they are aware of R1’s “hoarding in the past.” Appraisal/Needs And Services Plan (ANS) dated 01/30/2025 was not signed by R1 nor facility staff; document stated that R1 required assistance with Activities of Daily Living (ADLs); it stated that on 01/08/2025, “staff reported that the resident’s room had become excessively cluttered, making it difficult to move around safely. The resident also reported seeing roaches in the room.”; under “Physical/Health” it stated “Environmental/Safety Needs” “Provide a constant supervision and assistance maintaining a clean, safe, and uncluttered living space” and “all staff” will be involved daily. Internal Resident Incident Report dated 02/06/2025, indicated that R1 was hospitalized and not in the facility. Friendly Reminder letter dated 02/20/2025, stated that R1 was not complying with the facilities House Rules and/or policies, referenced House Rule 9, and stated that R1 had until 03/20/2025 to clear out the room; the letter went on to explain that “The room is extremely cluttered. This poses a fire risk and makes it difficult for our staff to assist R1”; furthermore, it indicated failure to resolve will lead to the beginning of eviction proceedings. Internal Resident Incident Report dated 03/11/2025, described R1’s room as a fire hazard. Internal Resident Incident Report dated 03/22/2025, indicated that R1’s room still needs to be de-cluttered. Internal Resident Incident Report dated 02/17/2026, indicated that R1 went to the hospital. Substantiated: Based on observations, interviews and record reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Ace Huynh.the state’s words, verbatim · CDSS document, May 29, 2026 · control 11-AS-20260519135515

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 30, 2026

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 is not met as evidence by: Based on observations, interviews, and record review, the licensee did not comply with the section cited above, in not ensuring that R1's room was free of excessive items, vermin, and vermin droppings. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 29, 2026

Plan of correction: The Executive Director has agreed to create a plan with R1 to maintain R1’s room free of clutter, human waste, and vermin. A plan to maintain R1’s room and bathroom free of clutter, human waste, and vermin will be emailed to Socorro.Leandro@dss.ca.gov. Progress of R1's room will be submitted to the Department on a weekly basis up until 07/03/2026. Pictures of R1's room/bathroom along with an Unusual Incident/Injury Report (UIR) will be faxed to the Departments at 424-544-1016.

Type of visit: Case Management - Deficiencies

On 05/29/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit. The purpose of this visit is to deliver deficiencies observed on 05/22/2026 during a complaint investigation visit control number 11-AS-20260519135515. LPA met with the Executive Director, Ace Huynh and the purpose of the visit was explained. LPA was granted entry to the facility. Deficiencies observed on 05/22/2026 were as follows: · The facility did not submit Unusual Incident/Injury Reports (UIRs) for Resident 1(R1). o Internal Resident Incident Report dated 02/06/2025, indicated that R1 was hospitalized and not in the facility. o Friendly Reminder letter dated 02/20/2025, stated that R1 was not complying with the facilities House Rules and/or policies and stated that R1 had until 03/20/2025 to clear out the room; the letter went on to explain that “The room is extremely cluttered. This poses a fire risk and makes it difficult for our staff to assist R1”; furthermore, it indicated failure to resolve will lead to the beginning of eviction proceedings. o Internal Resident Incident Report dated 03/11/2025, described R1’s room as a fire hazard. o Internal Resident Incident Report dated 03/22/2025, indicated that R1’s room still needs to be de-cluttered. o Internal Resident Incident Report dated 02/17/2026, indicated that R1 went to the hospital and was diagnosed with shingles. · The facility did not have a yearly Appraisal and Needs Services Plan [ANS) also known as a reappraisal] for R1. o R1’s ANS dated 01/30/2025 was not signed by R1 nor facility staff. o The facility did not have an ANS for R1 for the year 2026. · The facility did not have a yearly updated Physicians Report (e.g. annual medical routine visit) for R1. o R1’s Physicians Report was dated 04/24/2023. o There was no documentation explaining as to why R1 did not receive an annual medical routine visit for 2024, 2025, nor 2026. Deficiencies are being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds. 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 Executive Director, Ace Huynh.the state’s words, verbatim · CDSS document, May 29, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 19, 2026

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidence by: Based on record review, the licensee did not comply with the section cited above in not submitting Unusual Incident to the department for incidents with Resident 1 on 2/20/2025, 3/20/2025, 3/11/2025, 3/22/2025, and 2/17/2025. This posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2026

Plan of correction: The Executive Director has agreed to retrain staff on Reporting Requirements. Email trainings to Socorro.Leandro@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Jun 16, 2026

Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidence by: Based on record review, the licensee did not comply with the section cited above in not having a yearly reappraisal for Resident 1 (R1). This posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2026

Plan of correction: The Executive Director has agreed to create an updated reappraisal with R1 and email updated reappraisal to Socorro.Leandro@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(h)(1-3) · Plan of correction due date: Jun 16, 2026

Reappraisals (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. (2) Documentation of a resident's refusal to receive an annual routine visit, or if applicable, their representative's refusal on their behalf, shall be added to the resident's record. (3) If a resident refuses to receive an annual routine visit, or if applicable, their representative refuses an annual routine visit on their behalf, but later agrees to one, documentation of the annual routine visit shall be added to the resident’s record. This requirement is not met as evidence by: Based on record review, the licensee did not comply with the section cited above in not having a documented annual medical routine visit for R1. This posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2026

Plan of correction: On 5/29/2026, the Executive Director provided LPA with an updated physician's report for R1.

Allegation investigated: Staff mismanaged resident medication

**This report supersedes the report delivered on 12/17/2025 to include additional information to the findings** On 05/20/2026 at 08:55am, the Department conducted a subsequent visit at this facility to deliver the complaint findings for the allegations above. During today’s visit, the Department met with Catherine Dacara (Asssistant Administrator) and the purpose of the visit was explained. The investigation consisted of the following: On 11/13/2025, the Department conducted interviews with Administrator (A1), Staff (S1-S10) & Residents (R1 - R10) between the hours of 8:29am - 2:30pm. The Department also requested and received the following documents: Staff Roster (dated 11/07/2025), Resident Roster (dated 11/01/2025), Resident #1's personnel record such as LIC 503 Pre-Placement Appraisal (dated 09/28/2022), LIC 602: Physician Report (dated 07/27/2023), Admission Agreement (dated 08/01/2024) & Dietary Preference (dated 10/25/2022), Fall Menu Week 3 (10/2025 & 11/ 2025), staff training & Medication Administration Record for R1 - R10 (for 10/2025 - 11/2025) . Substantiated The investigation revealed the following: Allegation: Staff mismanaged resident medication It was alleged that for the last 3 months a resident medications have been passed out late. On 11/13/2025 between the hours of 11:12am - 11:22am, the Department interviewed A1 who denied the allegation and stated the facility uses a medication cart for medtech to administer the medication to the residents. A1 also stated the facility just suspended two (2) medtech for lack of performance and Technical Support Program (TSP) provided by the Department of Social Service Community Care Licensing came to the facility about two weeks ago to assist with medication training. On 11/13/2025, between 9:15am - 1:21 pm, , the Department interviewed 9 staff regarding the allegation. 2 of 9 staff confirmed the allegation and stated due to short staff and or stopping to help assist another resident there have been challenges with timely medication administration. 2 of 9 staff denied the allegation and stated not rushing to administrator medication quickly to avoid making a mistake while another staff stated it's hasn't been any challenges with timely medication administration. 5 of 9 staff were unaware and or have no knowledge of the allegation due to their assigned job roles such a receptionist, caregiver, and activities director. On 11/13/2025, between 8:29am- 2:00pm, LPA interviewed 10 residents: 4 of 10 residents confirmed and stated by R1 that medication were for 3 months while other residents such as R3, R7 and R9 stated their medication being given late or missed once before. 3 of 10 residents denied and stated never experienced receiving their medication being given late nor missed. 3 of 10 residents did not confirm nor deny the allegation due to R6 stating no comment while R8 stated not remembering and R10 have not having any knowledge of their medication being give late or missed. On 11/19/2025, between the hours of 9am - 11am, LPA conducted medication review for 10 residents (R1 - R10) and observed the following: Medication Administration Record (MAR) for November 2025 indicated the medtechs administered medication by initial & timestamp. However medication is still observed to be in the bubble for Resident 1 (R1) 8pm Pregabalin 150mg on 11/1, 11/04, 11//11 and 11/18, Resident 1 (R1) 6:30am Pantoprazole SD DR 40 on 11/01 , Resident 5 (R5) 8pm Rosuvastatin Calcium 10 MG on 11/09, Resident 5 (R5) 6:30am Pantoprazole SD DR 40 MG on 11/01 and Resident 9 (R9) 8pm Atorvastatin 40 MG on 11/13, 11/14 and 11/15 Based on the Departments observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights. The investigation revealed the following: Allegation: Facility does not have a certified Administrator It was alleged that the facility does not have a certified Administrator since Michael Mendoza. On 11/13/2025 between the hours of 11:12am - 11:22am, the Department interviewed A1 who stated Melissa Flores is currently acting as the facility Administrator and is not sure how long she's been in the position. A1 stated she has a Administrator certification. On 11/13/2025, between 9:15am - 1:21 pm, the Department interviewed 9 staff regarding the allegation. 9 of 9 staff denied the allegation and stated Jennifer Rivas has been acting as the facility Administrator for a couple months. On 11/13/2025, between 8:29am- 2:00pm, the Department interviewed 10 residents regarding the allegation. 1 of 10 resident denied the allegation and stated Jennifer Rivas is the current Administrator of the facility. 9 of 10 are unaware of the allegation. On 11/17/2025, between the hours of 2:20pm - 2:30pm, the Department conducted a records review and observed the following: The previous Administrator for the facility was Michael Mendoza. Upon the departure of Michael Mendoza, the facility had Melissa Flores acting as the Administrator who held a Administrator Certification effective 08/11/2023 - 08/11/2025. On 11/7/2025, the Department received an email from Jennifer Rivas who provided her Proof of Completion for Certification Program for 740 - Residential Care Facility for the Elderly effective as of 02/23/2024 - 02/23/2026. Unfounded: This agency has investigated the complaint alleging (for the allegation above). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. Exit interview conducted with Catherine Dacara (Assistant Administrator) and a copy of this report was provided. The investigation revealed the following: Allegation: Staff do not ensure resident diapering needs are met It was alleged that residents are not getting their diapers changed in a timely manner. On 11/13/2025 between the hours of 11:12am - 11:22am, the Department interviewed A1 denied the allegation and stated staff conduct rounds to ensure resident who need diaper changes are assigned promptly. On 11/13/2025, between 9:15am - 1:21 pm, the Department interviewed 9 staff regarding the allegation. 7 of 9 staff denied the allegation and stated upon the call light going off, caregiver are radio over the walkie-talkies to assist the residents and also resident are changed every 2-3 hours or upon the residents’ request. 2 of 9 staff did not confirm nor deny the allegation but stated at time sometimes when the facility is short staff it does affect how quickly the resident receive diapering care needs. On 11/13/2025, between 8:29am- 2:00pm, the Department interviewed 10 residents regarding the allegation. 2 of 10 residents denied the allegation and stated that they are in fact incontinent but expressed the staff check and change them, once in the morning and once in the night or 3 times in the afternoon and 2 times in the middle of the night. 7 of 10 residents did not confirm nor deny and state that they are not wearing diapers because they are not incontinent 1 of 10 residents had no knowledge of the allegation and stated no comment at the time of the interview. On 12/16/2025, between 1:30pm -2:30pm, the Department conducted a records review and observed the following: The facility has 35 incontinent residents. According to incontinence logs for September through November 2025, 33 residents received incontinence care, including bowel movements, toileting, supervised toileting for safety, showers, wet or dry briefs, or care was refused. Care was documented at various times throughout the day and night, ranging from overnight (NOC) to hourly intervals between 1:00am and 11:00pm Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff are not adequately trained. It was alleged that there are many staff members who are not trained. On 11/13/2025, between the hours of 11:12am - 11:22am, LPA interviewed A1, who denied the allegation and stated that in-service training for staff is conducted once a month, and this month's training will address fall risk. On11/13/2025 between 9:15am - 1:21pm, the Department interviewed 9 staff regarding the allegation. 9 of 9 staff denied the allegation and stated they receive in-service training on a regular basis. On 11/13/2025, between 8:20am - 2:00pm, the Department 10 residents: 8 of 10 residents denied the allegation and stated the staff know what they are doing when helping residents and have not noticed a difference between newer staff and those who currently work or formerly worked at the facility. 2 of 10 residents did not confirm nor deny the allegation; R6 stated "no comment," while R8 stated doesn't think much about it because they don't know which staff are new and that does not involve them. On 12/16/2025, between 8:35am - 11:15am, the Department conducted a records review and observed that the facility conducted twenty-nine (29) in-service trainings between January 28, 2025 and September 29, 2025. Each training included a sign-in sheet acknowledging staff participation and understanding of the material presented. Topics covered during these training included new employee orientation; sexual harassment (1 hour); workplace violence (1 hour); injury and illness prevention; bloodborne pathogens (30 minutes); missing resident response procedures; dementia and memory care practices (5 hours); activities of daily living and personal care; medication administration; infection control (3 hours); residents’ rights and mandated reporting; fall and elopement safety; housekeeping and food safety practices; activity programming; customer service (3 hours); and applicable facility policies and procedures. On 05/18/2026, between 11:00am -12:00pm, the Department conducted an additional records review (requested training on multiple dates such as 04/03, 04/17, 05/13) of personnel files for A1 and S1–S10 which included training certificates, medication training documentation, shadow training logs, and facility in-service sign-in sheets. The review revealed that all eleven (11) staff had completed the required New Employee 20-Hour Training, with completion dates ranging from 2021–2025. Nine (9) staff had current Sexual Harassment Prevention Training, and six (6) staff completed Workplace Violence Prevention Training in 2024–2025. Four (4) staff completed the 8-hour Medication Technician Training, and three (3) staff completed the full Basic Medication Training Course supported by 16-hour medication shadow-training logs documenting instruction in medication ordering, storage, documentation, medication passing, refusal procedures, and communication. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff do not ensure that resident's with special dietary needs are adequately fed It was alleged that residents who require a special diet are not accommodated. On 11/13/2025 between the hours of 11:12am - 11:22am, the Department interviewed A1 denied the allegation and stated that residents with special diets or food allergies are identified on a list created by the front desk, which is posted in the kitchen. A1 also stated that if a resident cannot eat what is being served, an alternative menu is offered. However, if the resident does not want anything from the alternative menu, the facility will ask the resident what they prefer and will try to accommodate their request as much as possible. Between 9:15am - 1:21 pm, the Department interviewed 10 staff: 10 of 10 staff denied the allegation and stated the facility has documentation such a binder on file and the whiteboard located in the kitchen which list the residents special diets and food allergies. Staff also states the facility has other options such as sandwich, chicken, yogurt , Jello, rice pudding and fruit as alternative food. Between 8:29am - 2:00pm, the Department interviewed 10 residents: 1 of 10 residents confirmed the allegation and stated the facility does not handle their dietary preferences at all with no healthy alternative options provided as a result of purchasing their own food for the last two years. 8 of 10 residents denied the allegation and stated not asking for something specific and did not experience being served food they couldn't eat. 1 of 10 resident did not confirm nor deny the allegation and stated being allergic but the facility doesn't give them avocados. However one time the resident was served veal and can't eat veal. On 11/26/2026 between the hours of 11:16am - 11:25am, the Department conducted a record review a observed the following: Resident 1 (R1) LIC 602A Physicians Report for Residential Care Facilities for the Elderly (RCFE) - (dated 07/27/2023 page 3 of 6 states under the physical health status e. special diet is checked no. Also, the GPLB Resident Summary Sheet (spreadsheet), stated that the facility requested Resident 1 (R1) Physician Report on 08/19/2025. Resident 1 (R1) provided a Rx from Vannarith So, MD Internal Medicine (dated 12/21/2023) states patient (R1) is lactose intolerance, intolerance to bell pepper and allergic to bleach. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Catherine Dacara (Assistant Administrator) and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 20, 2026 · control 11-AS-20251104162513

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 3, 2026

Incidental Medical & Dental Care (a) A plan for incidental medical care shall be developed by each facility. The plan shall encourage routine medical care & assist in obtaining care, by compliance with..: (4) the licensee shall assist residents with self-administered medication as needed This requirement was not met as evidenced by interviews, observations, and record review showing medications for R1, R5, and R9 were not administered as prescribed. However, LPA observed medications not given but signed out, posing a health and safety risk to residents.the state’s words, verbatim · CDSS document, May 20, 2026

Plan of correction: The Administrator will have a licensed Pharmacist provide additional medication training for all the medtech and the LVN will conduct daily audits for Medication Administration for the next 30 days. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

Allegation investigated: Facility staff mismanage residents’ medications.

On 05/13/2026 at 8:15am, the Department conducted an subsequent visit to deliver the investigation findings at this facility for the allegation listed above. During today’s visit, the department met with Catherine Dacara (Assistant Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 04/07/2026 between the hours of 8:40am - 1:33pm, the Department interviewed Administrator (A1), Staff (S1 - S5), Residents (R1 - R10). The department also requested and obtained the following documents: Staff Roster (dated 03/19/2026), Resident Roster (dated 04/06/2026), Employee Schedule (dated 03/29/2026 - 04/04/2026), Visitor Log (dated 04/02/2026),2 Resident Records for R1 & R2 which include: LIC 601: Identification & Emergency Information (R1 dated 03/09/2026 & R2 dated 02/26/2025), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (R1 dated 08/21/2025 & R2 dated 02/07/2025), LIC 603: Preplacement Appraisal Information (R1 dated 08/27/2025 & R2 dated 02/07/2025), Admission Agreement (R1 dated 09/19/2025 & R2 dated 02/28/2025, R1's New Resident Account Set Up (dated 09/19/2025) . .Report continues on LIC 9099-C Substantiated R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) . The investigation revealed the following: Allegation: Facility staff mismanage residents’ medications. It was alleged that residents’ medications were not administered as prescribed and that documentation was incomplete. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated med-techs assist with self-administered medications when LVNs are unavailable. A1 reported not being aware of any missed doses or medication errors. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Four (4) out of five (5) staff denied the allegation. One (1) staff was unaware. Staff reported they were not aware of missed doses and stated they notify the med-tech or charge nurse if unable to administer medications. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents confirmed the allegation. One (1) out ten (1) resident was unsure of the allegation. Eight (8) out of ten (10) denied the allegation. One resident reported missed doses; another resident was unsure of their medication management. On 05/13/2026 between the hours of 10:10am – 11:00am, the Department conducted a records review of the April and May 2026 Medication Administration Records (MARs) and observed multiple missing staff initials indicating undocumented medication administration for several residents. The Department also observed medications remaining inside bubble packs despite being initialed as administered. Missing initials were noted for daily medications which include, diabetic medications, antihypertensives, anticoagulants, and ophthalmic treatments. These discrepancies were observed for multiple residents on multiple dates, and no documentation was found to explain the missing initials or unadministered medications. Based on the Department's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights. R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) . The Investigation revealed the following Allegation: Facility staff do not ensure that residents’ toileting needs are met. It was alleged that residents were not receiving timely assistance with toileting and incontinence care due to chronic understaffing, resulting in delays in responding to care needs and insufficient break coverage. On 04/07/2026 between the hours of 8:40am - 8:52am, the Department interviewed A1 in regards to the allegation. A1 denied the allegation, stated not being informed of any resident left soiled or any staff refusing assistance due to being on break. A1 explained that the facility uses a break schedule to ensure coverage and stated not being present during the reported incident and did not receive follow-up information. On 04/07/2026 between the hours of 11:55am - 1:33pm, the Department interviewed 5 staff regarding the allegation. five (5) staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they had not observed a resident left soiled, had not refused assistance due to being on break, and stated that another caregiver is assigned to provide coverage when a staff member is on break. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents was aware of the allegation. Nine (9) out of ten (10) residents denied the allegation. Residents reported they independently manage toileting or receive timely assistance. One resident reported a single instance where staff stated they were on break in regards to the delay in responding to care needs. On 05/13/2026 between the hours of 10am - 11am, the Department conducted a records review of resident assessments and facility documentation and did not observe any records indicating unmet toileting needs or delays in incontinence care. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Facility staff did not treat residents with dignity and respect. It was alleged that staff entered rooms without knocking, spoke rudely to residents, and refused to provide their names. On 04/07/2026 between the hours of 8:40am – 8:52am the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated not being informed of any staff entering rooms without knocking, speaking rudely to residents, or refusing to provide their names. A1 stated staff are required to knock before entering rooms and provide their names when asked, and A1 did not receive any complaints regarding disrespectful conduct. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they knock before entering resident rooms, do not speak to residents in a rude manner, and provide their names when requested. Staff stated they were not aware of any incidents involving rude tone or refusal to identify themselves. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. Two (2) of ten (10) residents confirmed the allegation. Eight (8) of ten (10) residents denied the allegation. Two residents reported incidents involving rude tone or failure to knock; the remaining residents reported staff knock before entering and treat them respectfully. On 05/13/2026 between the hours of 10:00 AM – 11:00 AM, the Department conducted a records review of facility policies, resident rights documentation, and internal records and did not observe any documentation indicating staff failed to treat residents with dignity or respect. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Facility staff do not ensure residents’ medical needs are being met. It was alleged that residents were not receiving ordered physical therapy or medical services. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated not being aware of any resident failing to receive ordered physical therapy or medical services. A1 stated the facility follows up with therapy providers when services are missed and had not received reports of unmet medical needs. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Four (4) out of five (5) staff denied the allegation. One (1) out of five (5) staff was unaware of the allegation. Staff reported they had not observed residents missing medical services and stated they notify the LVN or med-tech when residents report concerns. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents confirmed the allegation. Nine (9) of ten (10) residents denied the allegation. One resident reported not receiving physical therapy; other residents reported receiving medical services as ordered or stated delays were due to insurance authorization rather than facility action. On 05/13/2026 between the hours of 10:00am – 11:00am, the Department conducted a records review of LIC 602s, LIC 603s, and medical documentation and did not observe any records indicating missed medical services or lack of follow up by the facility. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff do not ensure food served is of good quality. It was alleged that the food served to residents was of poor quality and did not meet nutritional needs, and that inadequate staffing and oversight contributed to inconsistent meal preparation and insufficient attention to dietary requirements. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated menus are created monthly and reviewed for nutritional adequacy. A1 reported not receiving complaints regarding food quality. On 04/07/2026 between the hours of 11:55am – 1:33 pm, the Department interviewed five (5) staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they had not received complaints regarding food quality and stated meals are prepared according to posted menus. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents confirmed the allegation. Nine (9) of ten (10) residents denied the allegation. One resident reported dissatisfaction with food quality; other residents reported meals were satisfactory. On 05/13/2026 between the hours of 10:00am – 11:00am, the Department conducted a records review of the facility’s posted Spring 2026 menus for Weeks 1, 3, and 4. The Department observed that the menus were dated, organized, and reflected balanced meals including proteins, vegetables, starches, fruits, and desserts. Breakfast menus included hot cereals, eggs, pancakes, and juice options. Lunch and dinner menus included soups, salads, meats, vegetables, and desserts. The Department observed that the menus aligned with the facility’s Admission Agreement requirement to provide three nutritious meals daily and accommodate special diets. No documentation was found indicating that meals served failed to meet nutritional standards or that residents were served food inconsistent with posted menus or dietary requirements. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Catherine Dacara and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 13, 2026 · control 11-AS-20260403094947

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 6, 2026

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: The licensee shall assist residents with self-administered medication as needed Based on observation and record review: The Department observed medications remaining inside bubble packs despite being initialed as administered and or not being initialed on the MAR which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: The Administrator will arrange an in‑service medication‑management training with the facility’s contracted pharmacy for all medication‑assisting staff. Training will include proper MAR documentation and ensuring medications are initialed at the time of administration. The Administrator will submit proof of completed pharmacy in-service training to the Department by the due date.

Allegation investigated: Staff does not treat resident with dignity or respect. Staff does not accord resident privacy in the restroom.

On May 13, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted an initial unannounced complaint visit. Catherine Dacara, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegations mentioned above. The investigation included interviews, inspection of the facility, and a collection of documents. A review of Personnel Report LIC 500 (dated 05/01/26), Register of Faciltiy Residents Roster (dated 04/06/26), Admission Agreement, (dated 08/01/24), Identification and Emergency Information (dated 09/18/24), Physicians Report LIC 602A (dated 04/10/26), Resident Appraisal LIC 603A (dated 05/30/22) and other pertinent records associated with this complaint. Interviews conducted with Resident #1 - #10 (R1-R10), and Staff #1- #7 (S1-S7) and an inspection of (R1's) room #220. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff does not treat resident with dignity or respect. Allegation #2: Staff does not accord resident privacy in the restroom. The complaint alleges that the staff does not treat Resident #1 (R1) with the dignity, respect, and privacy (R1) deserve while in care. Reports indicate that staff members, specifically Staff #5 (S5) and Staff #6 (S6), harassed (R1) by yelling profanities at them in front of other residents during an incident. Furthermore, there are concerns about (R1's) privacy being violated by Staff #7 (S7), who entered (R1's) room while (R1) was in the bathroom, failing to provide adequate privacy. It has also been reported that (S7) spoke harshly about (R1) in (S7's) native language. These concerns have been brought to the management's attention, but no action has been taken to address the behavior. No additional details regarding this matter are provided. Resident #1 (R1) was admitted to Glen Park in Long Beach on October 25, 2022, based on the facility’s Admissions Agreement (dated 08/01/24). (R1) is responsible for self-admission to this facility. On May 11, 2026, and May 12, 2026, between 11:20 AM and 03:40 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Nine (9) out of the ten (10) residents could not support both claims. (R2-R10) were complimentary of all staff, including Staff #5 (S5), Staff #6 (S6), and Staff #7 (S7). All of them stated that they are treated with dignity and respect; no employee has ever addressed them disrespectfully. Furthermore, the staff honors residents' privacy by announcing their arrival before entering a resident's room and will only enter with the resident's permission. (R1) had concerns about how (S5), (S6), and (S7) addressed (R1) during recent incidents on March 28, 2026, and April 15, 2026. In both occurrences, (R1)’s rights were breached when (S5), (S6), and (S7) displayed disrespectful behavior and used offensive language while making derogatory remarks about (R1). (R1) claims that these concerns were raised with management, but notes that no action has been taken. On May 11, 2026, May 12, 2026, and May 13, 2026, between 09:45 AM and 3:59 PM, the Department interviewed staff members identified as Staff #1 through Staff #7 (S1-S7). Seven (7) out of seven (7) staff members could not validate this claim. Staff #5 (S5), Staff #6 (S6), and Staff #7(S7) all denied the allegations of violating (R1’s) rights, asserting that they never made any derogatory remarks to (R1). (Evaluation Report continues LIC 9099-C) They indicated that (R1) has exceptionally high expectations and is resistant to receiving guidance from any staff. This often leads to a shift from positive interactions to negative ones. Staff #7 (S7) specifically stated that the claim regarding (R1) intruding on privacy rights is false; the incident never occurred. Staff #3 (S3) indicated that management has implemented proactive steps regarding the incidents that occurred on March 28, 2026, and April 15, 2026. An internal inquiry was conducted, including analysis of surveillance footage from March 28, 2026. The inquiry found insufficient evidence to ascertain whether the staff had infringed on (R1’s) rights. A review of (R1’s) Admission Agreement (dated 08/01/24), Physicians Report LIC 602A (dated 07/27/23), and Resident Appraisal LIC 603A (dated 03/10/26), and Personal Rights LIC 613 (dated 08/01/24) revealed (R1's) medical diagnosis profoundly impacts (R1’s) thought processes and belief system, intricately shaping (R1) perspective and understanding. Further review of Internal Staff Incident Report (dated 03/30/26), Internal Resident Incident Repot (dated 03/28/26 and 04/15/26) confirmed that the facility had conduced internal investigation on both incidents. Additional review of (R1’s) Medication Orders (dated 05/12/26) (R1) is prescribed (18) medications and (9) out of the (18) have side effects of inducing manic symptoms, depression, fatigue, and disturbance (ref National Institute of Health). During the visit on May 11, 2026 through May 13, 2026, the Department identified that the facility promotes the rights and safety of its residents. Posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. Based on the information gathered, there is not enough evidence to support the allegations mentioned above. 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. Exit interview conducted with Executive Director CATHERINE DACARA, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 13, 2026 · control 11-AS-20260504125345

Type of visit: Case Management - Deficiencies

On 05/13/2025 at 8;15am, the Department conducted an unannounced Case Management Deficiencies visit. During at 8:30 AM, the Department met with Catherine Dacara (Assistant Administrator) and explain the purpose of the visit. On 04/03/2026, upon the Department issuing a Technical Violation for 87465(a)(4) with a due date of 04/17/2026, the Department also requested that the facility submit employee training records from hire date to present by the end of the week of 04/03/2026 in relation to Complaint Control #11-AS-20251104162513. On 04/17/2026 at 5:55 PM, the Department received an email from the facility’s Assistant Administrator containing a PDF attachment titled Allegiance Valley Pharmacy Audited and Reviewed Medication Management Program Training dated 04/15/2026. On 05/11/2026 at 8:00am via email and on 05/13/2026 at 8:30am in person, the Department requested for staff training records from hire date to present related to Complaint Control #11-AS-20251104162513. The facility did not provide the requested documentation until 12:00 PM. Upon review, the training records submitted reflected training years 2021–2026, but did not include training records from previous employers for staff listed on the LIC 811, as requested As a result, according to the California Code of Regulations (Title 22, Division 6, Chapter 8) the facility did not comply with Title 22, Section 87412(f)(1), which states: All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. The facility failed to make provide personnel training records upon request in a timely manner An exit interview was conducted with Assistant Administrator Catherine Dacara. A copy of this report with appeal right were provided.the state’s words, verbatim · CDSS document, May 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(f)(1) · Plan of correction due date: May 13, 2026

Personnel Records: All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. . .information is otherwise readily available in another document or format. Based on observation and record review, the facility did not provide staff training upon request in a timely manner for staff from hire date to present. This posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: Facility will submit all staff training records for the employees listed on the LIC811 from Complaint Control #11-AS-20251104162513. and submit the plan of correction by due date and email proof to LPA Brown at Zina.Brown@dss.ca.gov

Allegation investigated: Staff withheld resident's funds.

On May 12, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted a subsequent unannounced complaint visit. Anita Csukardi, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, inspection of the facility, and a collection of documents. A review of Personnel Report LIC 500 (dated 05/01/26), Register of Faciltiy Residents Roster (dated 04/06/26), Admission Agreement, (dated 06/30/26), Identification and Emergency Information (dated 02/17/26), Medical Assessment LIC 602A (dated 12/30/25), Resident Appraisal LIC 603A (dated 12/31/25) and other pertinent records associated with this complaint. Interviews conducted with Resident#1 through #10 (R1-R10), Staff #1 through Staff #3 (S1-S3) and Witness #1 (W1). (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff withheld resident's funds. The complaint alleges that the staff is withholding funds from Resident #1 (R1). It is reported that (R1) has a trust fund account intended for a family member, but the administrator has denied (R1) access to those funds. No additional details regarding this matter are provided. Resident #1 (R1) was admitted to Glen Park in Long Beach on January 22, 2026, based on the facility’s Admissions Agreement (dated 01/23/26). (R1) is responsible for self-admission to this facility. On May 11, 2026, between 11:20 AM and 01:00 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Nine (9) out of the ten (10) residents could not support this claim. Four (4) of the ten (10) are independent and can manage their own finances. Three (3) of the ten (10) have other family members handling their finances, while two (2) out of the ten (10) cannot manage their finances themselves. (R1) claimed to have an $11,000 trust fund that the facility is withholding. However, (R1) had no information or documentation regarding this trust fund. (R1) was unaware of the trust fund's origin and could not provide further details. The only information (R1) had was that there was a trust fund, and (R1) wanted to grant access to these funds to a family member. (R1) did not have legal documentation arranged that holds and manages assets—such as money, stocks, or real estate—for a beneficiary on behalf of a grantor, managed by a trustee. On May 11, 2026, between 09:45 AM and 01:30 PM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Two (2) out of (3) three staff members reported that (R1) has personal funds being managed by the facility. (S1) indicated that Glen Park serves as the payee for (R1’s) Supplemental Security Income (SSI). Basic services are paid directly to Glen Park, and any remaining funds are deposited into (R1’s) resident's account. Both (S1) and (S2) stated that since (R1) is self-responsible and does not have the power of attorney or conservator managing (R1’s) finances, Glen Park functions as the payee for (R1’s) (SSI). (S1) and (S2) stated that they informed (R1) that (R1) needed to complete a facility form to withdraw funds and for accounting tracking. This information may have led to (R1's) current misunderstanding of the situation. However, (S1-S3) were unaware of any issues regarding (R1's) lack of understanding of the process. (Evaluation Report continue LIC 9099-C) (S1) stated that the facility is not being defiant or refusing to provide (R1) with access to personal funds. The funds established by the facility are for any leftover money from (R1’s) (SSI) and Personal and Incidental (P&I) expenses, a term that (R1) does not understand. The management informed (R1) that a process exists: the Check Request form and the Payable Distribution Letter must be completed to distribute funds. On May 11, 2026, between 12:00 PM and 12:15 PM, the Department interviewed a family member identified as Witness #1 (W1). (W1) stated that (W1) was not aware of any trust account in the name of (R1). Furthermore, W1 mentioned that when family members passed away over 30 years ago, there was no trust account for (R1) that (W1) was aware of. A review of (R1’s) Admission Agreement (dated June 30, 2026), Identification and Emergency Information (dated 02/17/26), Medical Assessment LIC 602A (dated 12/30/25), and Resident Appraisal LIC 603A (dated 12/31/25) revealed that (R1) is self responsible but cannot manage their own financial resources. A copy of (R1’s) Record of Resident’s Safeguarded Cash Resources LIC 405 (dated 05/12/26) detailed the date, description, initial deposit, withdrawal, balance, signature, and transaction number, confirming that (R1) has a trust account with a positive balance. Further review of the facility's Check Request form (dated 05/12/26) and Payable Distribution Letter confirmed that the facility has a process in place that must be followed to access (R1's) finances. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above 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 with Anita Csukardi, and copies of the reports were provided.the state’s words, verbatim · CDSS document, May 12, 2026 · control 11-AS-20260507123904

Allegation investigated: Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. Staff does not ensure resident's hygienic care needs are met. Staff does not ensure resident's incontinence care needs are met. Staff did not allow resident back to facility after hospital stay.

On 04/24/2026, at 11:00am, the department conducted a subsequent complaint visit to the facility and was greeted by Ace Huynh, Executive Director, and Cathrine Dacara, Assistant Administrator. The department explained the purpose of this visit was to gather information about the complaint, interview staff and residents, and deliver findings for the allegations mentioned above. The investigation consisted of the following: On 04/01/2026, the department conducted an initial complaint visit to gather facility files. On 04/24/2026 from 11:00am-2:00pm, the department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4) and residents (R1-R10). The department received the following documents: Staff Roster (Dated: 03/19/2026), Resident Roster (Dated: 03/25/2026), Identification & Emergency Information (Dated: 02/02/2026), Physician Report (Dated: 12/08/2025), Preplacement Appraisal Information (Dated 02/02/2026), Needs & Service Appraisal (Dated: 04/01/2026), Admission Agreement (Dated 02/02/2026), Shower Schedule (Last Updated 03/06/2026), Shower Log (for March 2026) and Internal Resident Incident Reports (Dated: 03/12/2026, 03/23/2026 & 03/25/2026).... Report Continued On LIC9099-C Unsubstantiated On 4/24/2026, from 11:00am-2:00pm, the department interviewed staff (S1-S4) regarding the allegation. 4 of 4 staff denied the allegation that Staff did not allow resident back to facility after hospital stay. Staff (S1) stated that the family member of the resident came on 03/24/2026 to take the resident to the hospital for evaluation and never brought the resident back to the facility. S1 also stated on that day, the family member removed all of the residents’ belongings from the facility. S1 further stated that there wasn’t a valid reason that the resident could not return to the facility, and no one said otherwise. S2-S4 stated that they had no knowledge of a reason that the resident would not be allowed to return to the facility. Based on interviews conducted, there is insufficient evidence to support the allegation that Staff did not allow resident back to facility after hospital stay. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued for this complaint investigation. An exit interview was conducted with Ace Huynh, Executive Director, and a hard copy of this Complaint Investigation Report was provided. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that the facility staff does ensure that their hygiene needs are met but added that they are primarily independent and care for their own needs. The department reviewed the Needs & Service Appraisal (Dated: 04/01/2026), Physician Report (Dated: 12/08/2025), and Shower Log (for March 2026) and observed that the resident was able to bathe, dress, groom, and care for their toileting needs by themselves without assistance. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that Staff does not ensure resident's hygienic care needs are met. 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 #3- Staff does not ensure resident's incontinence care needs are met. The details of the complaint alleged that the facility staff did not ensure the residents’ incontinent care needs were met. On 4/24/2026, from 11:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that Staff does not ensure resident's incontinence care needs are met. All staff stated that the residents’ needs were being met. 3 of 4 staff denied the resident needed incontinence care while 1 staff said they needed some assistance sometime but could generally care for their own toileting needs. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that the staff does ensure that their care needs are being met. The department reviewed the Needs & Service Appraisal (Dated: 04/01/2026), and Physician Report (Dated: 12/08/2025) and observed that the resident was able to care for their toileting needs by themselves without assistance. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that Staff does not ensure resident's incontinence care needs are met. 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 #4- Staff did not allow resident back to facility after hospital stay. The details of the complaint alleged that the facility did not allow resident back after hospital stay. It was reported that the family member of the resident did not want to return the resident to the facility because they didn’t think the resident was properly cared for. Report Continued On LIC9099-C and Medication Administration Record (Dated: February 2026 - March 2026) from the facility. The investigation revealed the following: Allegation #1- Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. The details of the complaint alleged that the resident had two unwitnessed falls, with no injuries in the facility. It was reported that the staff did not provide adequate supervision for the resident. On 4/24/2026, from 11:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. All staff stated that they do provide adequate supervision for the residents in the facility. Staff also stated that there is a call button in each resident’s room that they can push if they need assistance or are having trouble walking. They further stated that the residents are checked on frequently throughout the day and night. The department interviewed residents (R1-R10) about the allegation and 8 of 10 residents that were interviewed stated that they believe the staff does provide adequate care and supervision for the residents in the facility. Those residents further stated that they are satisfied with the care and supervision and feel safe living in the facility. The department reviewed Internal Resident Incident Reports (Dated: 03/12/2026, 03/23/2026 & 03/25/2026) and Staff Roster (Dated: 03/19/2026) and observed that the incidents were documented and reported and that the facility has sufficient staff to provide adequate supervision to the residents. The department also reviewed the Physician Report (Dated: 12/08/2025) and observed the resident had no motor impairments or paralysis. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. 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 #2- Staff does not ensure resident's hygienic care needs are met. The details of the complaint alleged that the facility staff did not ensure the residents’ hygiene care needs were met. On 4/24/2026, from 11:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 3 of 4 staff denied the allegation that Staff does not ensure resident's hygienic care needs are met. The majority of the staff stated that the residents’ hygienic care needs were being met. Staff further stated that the resident was able to care for their own hygiene needs with little assistance from the staff. While 1 staff stated that the resident did require some assistance and would often refuse and get agitated if they tried to assist them. Report Continued On LIC9099-Cthe state’s words, verbatim · CDSS document, Apr 24, 2026 · control 11-AS-20260325144642

Allegation investigated: Facility illegally evicted a resident in care.

On 4/23/2026, at 9:30am, the department conducted an initial complaint visit to the facility and was greeted by Ace Huynh, Executive Director, and Cathrine Dacara, Assistant Administrator. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff and resident, and deliver findings regarding the allegation mentioned above. The investigation consisted of the following: The department investigated the allegation mentioned in this complaint and conducted interviews with staff (S1-S3) and witness (W1). The department received the following documents: Resident Roster (Date: 03/02/2026), Staff Roster (Dated: 04/22/2026), ID Emergency Information (Dated: 04/25/2024), Physician’s Report (Dated: 04/30/2025), Admission Agreement (Dated: 04/25/2024), and Resident Appraisal (Dated: 04/25/2024) from the facility. The investigation revealed the following: Allegation- Facility illegally evicted a resident in care. Report Continued On LIC9099-C Unsubstantiated The details of the complaint alleged that the resident went to the hospital and that the facility would not allow the resident to return due to the resident needing to use a Continuous Positive Airway Pressure (CPAP) machine used for Chronic Obstructive Pulmonary Disease (COPD). It was reported that the facility is evicting the resident and discriminating against the resident because of the diagnosis. On 4/23/26, from 9:30am-12:00pm, the department interviewed staff (S1-S3) and witness (W1) regarding the allegation. 3 of 3 staff denied the allegation that the Facility illegally evicted a resident in care. All staff stated that the facility has not issued an eviction notice nor is the resident being evicted. They all state that the resident went into the hospital because they were having breathing problems. While at the hospital the resident was prescribed a Bilevel Positive Airway Pressure (BIPAP) machine which assists with breathing by delivering, via a mask, higher air pressure during inhalation and lower pressure during exhalation. S2 stated that according to the residents’ Physicians Report they can’t manage their own medication, treatment, or equipment and that is why they have not accepted the resident back. S2 stated that once the resident no longer needs the equipment they are welcomed to come back to the facility. The department interviewed witness (W1) about the allegation and (W1) stated that they were informed that the resident would not be able to come back to the facility while they were using the BIPAP machine because their Physicians report stated they could not manage the machine on their own. The department asked if the resident or (W1) has received an eviction notice written or verbal, they stated they have not. The department reviewed the Physician’s Report (Dated: 04/30/2025) and observed that the report states the patient cannot manage their own treatment, medication, or equipment (page 2 Physicians Report). The department reviewed the facility records for the resident and did not observe an eviction notice or eviction notes for the resident. Based on interviews and records that were reviewed, there is insufficient evidence to support the allegation that the Facility illegally evicted a resident in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were found and no citations were issued for this complaint investigation. An exit interview was conducted with Ace Huynh, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Apr 24, 2026 · control 11-AS-20260416134102

Allegation investigated: Staff does not prevent resident from smoking inside the facility.

*This report does not supersede the previous report dated 10/24/2025 but is used to clarify findings*. On 04/23/2026 at approximately 01:40 PM Licensing Program Analyst (LPA) Troy Watson made a subsequent unannounced visit to deliver findings to the facility listed above. LPA Watson was greeted by the Assistant Administrator, Catherine Dacara, and explained the purpose of the visit. LPA was granted entry into the facility. The investigation consisted of the following:On 10/24/2025 between 08:01 AM – 04:56 PM the department requested, obtained, and reviewed the following documents: Resident Roster (10/08/25), Staff Roster (10/01/25), Smoking Policy (01/18/23), Staff Schedule (10/19/25 – 10/25/25), Unusual Incident Report (10/09/25 – 10/10/25) CONTINUED ON LIC9099-C Unsubstantiated Psychiatric Emergency Team Assessment (10/10/25), and Placement for Evaluation and Treatment documentation (10/10/25). On 10/24/2025 between 08:01 AM – 04:56 PM the department conducted interviews with Staff #1 – #5 (S1–S5) and Resident #2 – #11 (R2–R11). An attempt to interview Resident #1 (R1) was made, but the resident was no longer at the facility and could not be contacted. LPA Watson toured the facility with the Assistant Administrator, Catherine Dacara, and found the facility clean and in good repair. The investigation revealed the following: Allegation: Staff do not prevent residents from smoking inside the facility. It was alleged that staff failed to prevent residents from smoking inside the facility, resulting in R1 reportedly igniting their shirt while smoking in their bedroom, creating a fire hazard and risk of injury. On 10/24/2025 between 08:01 AM – 04:56 PM LPA Watson interviewed Staff #1 – #5 (S1–S5). Out of those interviewed, 5 out of 5 staff denied the above allegation. On 10/24/2025 LPA Watson interviewed Residents #2 – #11 (R2–R11). Out of those interviewed, 10 out of 10 denied the above allegation. On 10/24/2025 between 08:01 AM – 04:56 PM the department conducted an interview with the Assistant Administrator, Catherine Dacara (S1), and they were asked the question: does staff prevent residents from smoking inside the facility? S1 answered that residents and staff are not permitted to smoke inside the facility, and that a designated smoking patio outside the facility is provided for this purpose. The facility enforces its posted house rules prohibiting smoking on the premises, and staff assist residents by holding their cigarettes to ensure compliance and safety. LPA Watson reviewed the Smoking Policy records, and it showed on pg. 1, section 8, under Procedures that “There will be designated times for supervised smoking set by the administration.” A review of the Unusual Incident Report dated 10/09/25 – 10/10/25 revealed that R1 was witnessed on 10/09/25 at approximately 7:00 AM trying to set his shirt on fire using a lighter and attempted to put it out with a broom, causing heavy smoke inside his room. Further review of the Unusual Incident Report also showed that R1 told staff fireworks were shot into his room and caused the smoke, but there was no evidence or proof of fireworks being recovered from that incident. The Department reviewed R1’s file and did not find any other similar incidents. CONTINUED ON LIC9099-C Based on record reviews, staff and client interviews, and observations, there is insufficient evidence to support the allegation: “Staff do not prevent residents from smoking inside the facility.” 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 the Assistant Administrator, Catherine Dacara, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 11-AS-20251017130143

Allegation investigated: Staff does not prevent resident from smoking inside the facility.

*This report does not supersede the previous report dated 10/24/2025 but is used to clarify findings. * On 02/11/2026 at approximately 1:02 PM Licensing Program Analyst (LPA) Troy Watson made a subsequent unannounced visit to the facility listed above. LPA Watson was greeted by the Assistant Administrator Catherine Dacara and explained the purpose of the visit. LPA was granted entry into the facility. The investigation consisted of the following: On 10/24/2025 between 08:01 AM – 04:56 PM the department requested, obtained, and reviewed the following documents: Resident Roster (10/08/25), Staff Roster (10/01/25), Smoking Policy (01/18/23), Staff Schedule (10/19/25 – 10/25/25), Unusual Incident Report (10/09/25 – 10/10/25), CONTINUED IN LIC9099-C Unsubstantiated Psychiatric Emergency Team Assessment (10/10/25), and Placement for Evaluation and Treatment documentation (10/10/25). On 10/24/2025 between 08:01 AM – 04:56 PM the department conducted interviews with Staff #1 – #5 (S1–S5) and Resident #2 – #11 (R2–R11). An attempt to interview Resident #1 (R1) was made, but the resident was no longer at the facility and could not be contacted. LPA Watson toured the facility with the Assistant Administrator, Catherine Dacara, and found the facility clean and in good repair. The investigation revealed the following: Allegation: Staff do not prevent residents from smoking inside the facility. It was alleged that staff failed to prevent residents from smoking inside the facility, resulting in R1 reportedly igniting their shirt while smoking in their bedroom, creating a fire hazard and risk of injury. On 10/24/2025 between 08:01 AM – 04:56 PM LPA Watson interviewed Staff #1 – #5 (S1–S5). Of those interviewed, 5 out of 5 staff denied the above allegation. On 10/24/2025 LPA Watson interviewed Residents #2 – #11 (R2–R11). Of those interviewed, 10 out of 10 denied the above allegation. On 10/24/2025 between 08:01 AM – 04:56 PM the department conducted an interview with the Assistant Administrator, Catherine Dacara (S1) and they were asked the question, does staff prevent residents from smoking inside the facility? S1 answered that residents and staff are not permitted to smoke inside the facility, and that a designated smoking patio outside the facility is provided for this purpose. The facility enforces its posted house rules prohibiting smoking on the premises, and staff assist residents by holding their cigarettes to ensure compliance and safety. LPA Watson reviewed the Smoking Policy records, and it showed on pg. 1, section 8, under Procedures that “There will be designated times for supervised smoking set by the administration.” A review of the Unusual Incident Report dated 10/09/25 – 10/10/25 revealed that R1 was witnessed on 10/09/25 at approximately 7:00 AM trying to set his shirt on fire using a lighter and attempted to put it out with a broom, causing heavy smoke inside his room. Further review of the Unusual Incident Report also showed that R1 told staff fireworks shot into his room and caused the smoke, but there was no evidence or proof of fireworks being recovered from that incident. The Department reviewed R1;s file and did not find any other similar incidents. CONTINUED ON LIC9099-C Based on record reviews, staff and client interviews, and observations, there is insufficient evidence to support the allegation: “Staff do not prevent residents from smoking inside the facility.” 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 the Assistant Administrator, Catherine Dacara and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 11-AS-20251017130143

Type of visit: Case Management - Incident

On 04/03/2025 at 9:10 am, the Department conducted an unannounced case management incident visit. The department met with Catherine Dacara (Administrator) and Ace Huynh (Executive Director) and explained the purpose of the visit. On 03/20/2026 at 3:58 pm., On Duty Office of the Day LPA Gibbs received a telephone call from Administrator Catherine Dacara, who reported that medications were missing from the facility’s medication room and noted a Medtech is suspected of involvement. LPA Gibbs requested that an incident report be faxed to the Department. The department received the LIC 624 Unusual Incident/Injury Report (dated 03/13/2026) on March 20, 2026 at 10:05pm. On 04/03/2026 between the hours of 9:25am - 9:30am, the Department reviewed a copy of the LIC 624 Unusual Incident/Injury Report (dated 03/13/2026) which states the following at around 2:16pm, the Staff 1 (S1) who is a LVN received a text message from Staff 2 (S2) who is a medtech mentioned PRN Oxycodone is missing for Resident 1 (R1). When S1 spoke with Staff 3 (S3) who is also a medtech from the previous shift, mentioned to S1 that medicine was placed in the NARC box. R1 was informed along with Welbe Pace. On 04/03/2026 between the hours of 10:45am - 11:41am, the department conducted a medication review for 7 residents & observed the following: the department did not discover any missing medication. Due to insufficient information available at this time, the case management incidents needs further investigation. An exit interview was conducted with Catherine Dacara (Administrator) and a copy of this report with a technical violation was provided.the state’s words, verbatim · CDSS document, Apr 3, 2026

Allegation investigated: Facility did not maintain a safe and healthful environment for the resident.

On 03/18/2026, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced complaint visit. LPA met with Administrator Catherine Dacara. The investigation consisted of the following: On 03/18/2026, LPA Anguiano interviewed 14 residents (R1–R14) and 5 staff (S1–S5), conducted observations, and collected records. Records obtained included internal incident reports for R1 and R2, an LIC 500 dated 03/12/2026, staff roster, resident roster dated 03/05/2026, and an internal resident incident report for R5 with documentation of a house rules reminder provided. LPA also reviewed four resident files (S1–S4), including admission agreements, physician’s reports, and appraisal/reappraisal documents. The investigation revealed the following: Observations revealed that residents were observed in their rooms and common areas, and the facility appeared calm, with most residents engaging appropriately. Please see (LIC9099-C) for report continuation. Substantiated No active conflict was observed at the time of the visit. Records review revealed the following: Records for R1 indicate a diagnosis of end-stage renal failure requiring ongoing dialysis treatment and that R1 requires assistance with activities of daily living and supervision, including night supervision. Records for R2 indicate physical impairment requiring assistance with activities of daily living. LPA reviewed internal incident reports dated 03/12/2026 and 03/13/2026 documenting complaints regarding loud television use and roommate conflict between R1 and R2. Documentation indicates that R1 reported an inability to sleep due to the volume of the television, and staff provided reminders to R2 regarding house rules, including lowering the volume and using headphones at night. However, the facility did not provide additional requested documentation, including behavior logs, complaint logs, or records demonstrating ongoing monitoring, follow-up actions, or resolution of the roommate conflict. Records reviewed support the allegation, as the documentation confirms the reported concern and demonstrates that interventions were limited to reminders, without evidence of effective resolution, despite the resident’s medical condition requiring adequate rest and supervision. Regarding the allegation, “Facility did not maintain a safe and healthful environment for the resident,” it is being alleged that a resident was subjected to ongoing roommate conflict, including noise disturbances, lack of shared space access, and disruption of sleep, and that staff failed to ensure effective resolution of the situation. Interviews conducted revealed the following: Four residents (R1–R4) reported concerns supporting the allegation, while 10 out of 14 residents reported no concerns. Residents who reported concerns described ongoing roommate conflict involving loud television use at night, lack of respect, and misuse of shared space, as well as feeling unsafe due to roommate conflict and experiencing ongoing issues involving noise, hygiene concerns, and unresolved conflict lasting approximately six months. Interviews with 5 staff (S1–S5) supported the allegation, as staff confirmed that the roommate conflict between R1 and R2 has been ongoing for several months. Staff reported that R1 requires rest due to dialysis treatment, while R2 maintains a conflicting sleep schedule and uses the television at a high volume. Staff further reported that incident reports were completed and the issue was brought to administration, and that staff attempted verbal interventions such as reminders and mediation. S1 reported addressing the concern by counseling the resident, reviewing house rules, and offering a room change; however, both residents declined relocation, and the issue remained ongoing at the time of the investigation. Additional statements indicated that R1 may have difficulty reporting concerns due to language barriers. Please see (LIC9099-C) for report continuation. Based on the evidence gathered, interviews conducted, observations, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation “Facility did not maintain a safe and healthful environment for the resident” is found to be substantiated. The facility identified the roommate conflict and implemented initial interventions; however, those actions were not effective, and the issue continued to impact the resident’s health and well-being. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87307(d)(2). A citation is being issued on the attached (LIC 9099D). An exit interview was conducted, and a copy of this report, along with appeal rights, was provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 11-AS-20260311163742

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Apr 1, 2026

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Based on interviews, observations, and records review, the licensee failed to ensure a safe and healthful environment for R1, as the resident was subjected to ongoing roommate conflict, including noise disturbances and disruption of sleep, despite having a medical condition requiring dialysis and rest. Staff were aware of the issue for several months and completed incident reports; however, the facility failed to implement timely and effective corrective action to resolve the situation. This violation poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: PLAN OF CORRECTION (POC): Licensee agrees to submit a Plan of Correction to LPA Jose Anguiano by due date and emailed to: Jose.Anguiano@dss.ca.gov

Allegation investigated: Staff does not treat residents with dignity and respect. Staff do not accord resident privacy. Staff unable to communicate with resident due to language barrier.

On 03/09/2026 at 8:40am, Licensing Program Analyst (LPA) Zina Brown conducted an subsequent visit at this facility to deliver the complaint investigation findings for the allegations above. During today’s visit, LPA met with Wendy Wheeler (Retirement Counselor) and explained the purpose of the visit. The investigation consisted of the following: On 02/19/2026 at 8:21am, Licensing Program Analysts (LPA) Zina Brown conducted interviews with Administrator (A1), Staff (S1-S10) & Residents (R1-R10), between the hours of 8:31am - 1:00pm and requested the following documentation: Staff Roster (dated 01/26/2026), Resident Roster (dated 02/18/2026) , Resident 1's (R1), records such as Admission Agreement (dated 10/15/2019) LIC 601: Identification & Emergency Information (not dated), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (not dated) , LIC 603: Preplacement Appraisal Information (dated 10/03/2019), and Medication Administration Record (December 2025). Unsubstantiated The investigation consisted of the following: Allegation: Staff does not treat residents with dignity and respect It was alleged that facility staff does not treat residents with dignity and respect. During breakfast time one of the younger staff workers spoke to the resident in a disrespectful manner. On 02/19/2026 between the hours of 8:31am - 8:42am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and indicated that the facility has not recently received any complaints regarding how staff speak to residents. A1 stated having no knowledge of any incidents where staff spoke to residents in a disrespectful manner. A1 mentioned if a staff member speaks disrespectfully to a resident, the facility would first arrange for a 1-on-1 meeting with staff, second talk to the resident to listen to their concern, third provide training to all staff, fourth take disciplinary action, and fifth remove the staff from that unit as a change of face. On 02/19/2026 between the hours of 9:26am - 11:43am, LPA conducted 5 staff interviews regarding the allegation. 5 of 5 staff denied the allegation and indicated they have not received complaints from residents or their families about how staff speak to residents, are not aware of any incidents where staff spoke to residents in a disrespectful manner, and would report such incidents to the Administrator and complete an incident report. On 02/19/2026 between the hours of 12:28pm - 2:30pm, LPA conducted 10 resident interviews regarding the allegation. 3 of 10 residents confirmed the allegation and indicated staff do not speak to them nicely all the time, staff have spoken to them in a rude or disrespectful way a few times or every once in a blue moon or staff do not treat them with respect all the time, and they have witnessed or heard staff speak rudely to other residents. Of the 3 residents who confirmed the allegation ; 1 of the residents indicated they have seen staff speak rudely to other residents. 7 of 10 residents denied the allegation and indicated staff speak to them nicely, no staff member has ever spoken to them in a rude or disrespectful way, staff treat them with respect, and they have not seen staff speak rudely to other residents. On 02/27/2026, between the hours of 2:25pm - 2:30pm, The Department had not received nor had on file any LIC 624 Unusual Incident/Injury Report, nor any reports or notes that alleged a staff spoke to a resident in a disrespectful manner. Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff do not accord resident privacy It was alleged that facility staff do not accord residents privacy. A staff worker came into the resident's room without knocking, used their key, and walked right in. On 02/19/2026 between the hours of 8:31am - 8:42am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and disclosed the facility's policy about entering residents' rooms requires staff to knock before entering, identify themselves, asking for permission first, and explain the purpose of entering the room. If the resident doesn't want staff to enter, then staff has to respect that. A1 stated always knocks before entering a resident's room all the time and identifying herself. A1 indicated never receiving any complaints about staff entering residents' rooms without knocking. A1 mentioned staff has received training on respecting residents' privacy. On 02/19/2026 between the hours of 9:26am -11:43am, LPA conducted 5 staff interviews regarding the allegation. 1 of 5 staff confirmed the allegation and disclosed entering a resident's room without knocking first which resident have made complaints about. 4 of 5 staff denied the allegation and indicated the facility's policy about entering residents' rooms is to always knock first before going in, they knock before entering a resident's room, they have not entered a resident's room without knocking first, and they have received training on respecting residents' privacy. On 02/19/2026 between the hours of 12:28pm - 2:30pm, LPA conducted 10 resident interviews regarding the allegation. 4 of 10 residents confirmed the allegation and indicated staff do not knock on their door before coming into their room or only occasionally, staff have walked into their room without knocking, and they do not feel they have privacy in their room. Of the four (4) residents who confirmed the allegation, one (1) resident reported having to place a 160 pound chair against their door and cover themselves with a sheet or towel because staff entered the room without knocking, while the resident was disrobed at that time. Another resident stated that staff had to create a sign for their door because staff would otherwise walk in without announcing themselves. 2 of 10 residents did not confirm nor deny the allegation and stated they don't know if staff knock on their door before coming into their room or if staff have walked into their room without knocking. 4 of 10 residents denied the allegation and indicated staff knock on their door before coming into their room most of the time or always, staff have not walked into their room without knocking, and they feel they have privacy in their room. On 02/27/2026, between the hours of 2:25pm - 2:30pm, LPA conducted a records review & observed the following:The Department had not received nor had on file any LIC 624 Unusual Incident/Injury Report, nor any reports or notes related to a staff member entering a residents room without knocking before walking into the residents room. Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff unable to communicate with resident due to language barrier It was alleged that facility staff is unable to communicate with the resident due to a language barrier. A staff worker has a hard time understanding the resident because the staff speaks their language a lot. When the resident complained to the staff worker, the staff worker told the resident that they did not understand the resident and that the resident needs to write theirs concerns on paper which staff would look into it. On 02/19/2026 between the hours of 8:31am - 8:42am, LPA interviewed A1 regarding the allegation. A1 was aware of the allegation and mentioned at times the facility has had difficulty understanding or communicating with specific residents. A1 disclosed if a resident speaks to staff and they don't understand them, staff call the receptionist to have another staff who can interpret and at the same time use the Google Translator app. A1 stated residents have complained that staff don't understand them, and when that happens, A1 sends a request for another staff to translate. A1 mentioned training has been provided on how to communicate with residents who speak different languages. On 02/19/2026 between the hours of 9:26am -11:43am, LPA conducted 5 staff interviews regarding the allegation. 5 of 5 staff denied and stated that they have receive training on how to communicate with residents who speak different languages. However, all staff indicated if a resident speaks to them and they don't understand, they get assistance from another caregiver who speaks the same language as the resident or inform the Administrator. Staff noted residents have not complained that they don't understand them. Staff disclosed some residents are difficult to understand due to dementia but not due to language barriers. On 02/19/2026 between the hours of 12:28pm - 2:30pm, LPA conducted 10 resident interviews regarding the allegation. 3 of 10 residents confirmed the allegation and indicated they have had trouble getting staff to understand what they need or want. Of the 3 residents who confirmed the allegation, 1 resident stated staff have an foreign accents such as Spanish, West Indies, British, or Creole with staff answering questions with part English mixed with another language, and they don't understand staff most of the time. This same resident also mentioned nothing gets done if the staff doesn't understand. Since staff members doesn't understand, it results in yelling or displays of authority—yet the Administrator refuses to address these underlying communication problems .1 of 10 resident did not confirm nor deny the allegation and noted they have had trouble getting staff to understand what they need or want, but also indicated they make sure they are understood. 6 of 10 residents denied the allegation and indicated they have not had trouble getting staff to understand what they need or want. The resident also mentioned no staff member has told them they don't understand them and staff understand them when they ask for help and or have witness staff finding solutions. Report continues on LIC 9099-C On 02/27/2026, between the hours of 2:25pm - 2:30pm, the LPA conducted a records review and observed the following: The Department had not received nor had on file any LIC 624 Unusual Incident/Injury Report, nor any reports or notes related to the alleged language barriers between the resident and staff. Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Wendy Wheeler (Retirement Counselor) and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 9, 2026 · control 11-AS-20260210101503

Allegation investigated: Staff did not ensure resident medication was taken as prescribed

On 03/04/2026 around 12:00 PM, Licensing Program Analyst (LPA) Jose Anguiano conducted an subsequent unannounced complaint visit. LPA met with Administrator Catherine Decara. The investigation consisted of the following: On 01/22/2026, during the visit, LPA interviewed 11 residents (R1–R11) and 8 staff members (S1–S8). LPA collected the staff roster for the week of 01/18/2026 to 01/24/2026, the resident roster dated 01/20/2026, and Medication Administration Records (MARs) for two residents (R1–R2) for November 2025, December 2025, and January 2026. LPA also reviewed the facility’s Plan of Operation and Personnel Policies. On 03/04/2026, LPA collected a sample medication/treatment administration record for March 2026 for R2 and the MARs for December 2025 and January 2026 for R1. Investigation revealed the following: Regarding the allegation “Staff did not ensure resident medication was taken as prescribed,” it is being alleged that Resident (R1) time-sensitive medications were consistently administered later than prescribed. Please see report continuation on LIC9099-C Substantiated Interviews Conducted revealed: Staff (1-6) confirmed the facility’s medication scanner was functioning properly from January 2026 to present date. R1 stated that routine medications are often not administered on time. Staff (S1–S6) confirmed that MAR entries include the medication name, dosage, administration time, and staff initials, stamped at the time of administration. Observations: LPA observed a demonstration by five staff members (S1–S5) of the medication scanner scanning a sample resident medication. The printed timestamp accurately reflected the time, date, and medication description at the time the sample was conducted. Records Review: MARs for R1 from December 2025 and January 2026 indicate multiple routine medications were administered 1–2 hours after the prescribed time. The scanner demonstration confirmed equipment is operational, eliminating equipment malfunction as a justification for late administration as previously stated. Based on the evidence gathered, interviews conducted, observations, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation is SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, §87465, Incidental Medical and Dental Care. A citation is being issued on the attached LIC-9099D. An exit interview, a copy of this report, and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 4, 2026 · control 11-AS-20260114115021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 11, 2026

87465 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: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by Based on observation, records, and interviews, the facility failed to ensure that routine, time-sensitive medications for Resident R1 were administered at the prescribed times. This violation poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 4, 2026

Plan of correction: Administrator agreed to send LPA a plan of correction on due date. jose.anguiano@dss.ca.gov

Allegation investigated: Resident is not provided with proper housekeeping services

On 02/25/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegation. LPA met with Marketing Director and the purpose of the visit was explained. LPA spoke with Administrator Assistant Catherine Espino Dacara over the phone. Investigation consisted of the following: On 02/25/2025, LPA obtained Personnel Report (01/20/2026), Register of Residents, and GPLB Housekeeping Daily Task List. LPA interviewed Residents #1 - #9, Staff #1 - #4, #7 - #9 and observed Residents’ bedrooms. Note: LPA left a voicemail for Staff #5 - #6. Investigation revealed the following: Regarding the allegation, “Resident is not provided with proper housekeeping services,” it is being alleged Resident #1 (R1) room has only been cleaned once in February 2026. Record review of Facility Program and Admission Agreement revealed residents will receive cleaning of resident’s room. Continue to LIC9099-C. Unsubstantiated Review of Personnel Report revealed four housekeepers of which two – four housekeepers are working on the same day. Review of facility housekeeping daily task lists revealed staff are to restock towels, toilet paper and take out trash, daily. It also revealed staff are to sweep under the bed, mop, and vacuum floors including the bathroom, dust, disinfect, clean toilets and sinks, and check for pest control. The facility is divided into three zones and R1 lives in zone two. Seven out of eight resident interviews (R1 – R7, R9) indicated housekeeping services are provided daily or every other day. Seven out of seven staff interviews (S1 – S4, S7 - S9) indicated housekeeping services are provided daily or every other day. S2, S4, and S9 indicated R1 does not like S2 to clean R1’s room. S7 indicated R1 likes particular people to clean R1’s room. S1/The Administrator Assistant indicated another housekeeper will clean R1’s room when S2 is working in zone two. S1 indicated R1 will complain that no one has cleaned R1’s room even after S1 sent a staff member or S3 to the room. LPA observed resident rooms (219 - 222, 226 – 228) to be clean and observed housekeepers cleaning. LPA observed R1’s room to be clean. Regarding the allegation, “Resident is not provided with proper housekeeping services,” based on record reviews, interviews, and observations, 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 deficiencies cited. An exit interview was conducted and a copy of this report was provided to Administrator Assistant Catherine Espino Dacara.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 11-AS-20260219120149

Allegation investigated: Staff leave residents behind locked doors. Staff are not qualified to care and supervise residents.

On 02/25/2026, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegations. LPA met with Administrator Assistant Catherine Dacara and the purpose of the visit was explained. Investigation consisted of the following: On 12/31/2025, LPA obtained Personnel Report (12/09/25), Register of Residents (12/19/25), and Staff Schedule (12/21/25 – 01/03/26). On 01/08/26, LPA interviewed Staff #1 – 3, 5, 6, 7, received emergency contact for residents in memory care, and toured the facility. On 02/23/26, LPA interviewed Witnesses 1, 3, 4, and 6 over the phone. On 02/25/26, LPA interviewed Staff #8 - #9 and Witness #11. Note: LPA left a voicemail for Staff #4 and Witnesses 2, 5, 7 – 10. Investigation revealed the following: Regarding the allegation, “Staff leave residents behind locked doors,” it is being alleged memory care residents are locked behind door with only one employee... Continue to LIC9099-C. Unsubstantiated after midnight and during the day to provide care and supervision. It is also alleged that staff does not have enough supplies to perform their jobs and there isn’t any front desk coverage after midnight for emergency personnel entrance and for families to reach memory care residents. Record review of Fire Inspection allows for the facility to have locked doors in the memory care unit. Review of staff schedule (12/21/25 - 12/27/25) revealed one staff worked in memory care during the PM and NOC shift on 12/21/25, 12/27/25. One staff worked in memory care on 12/22/25 (2:30 PM - 11:00 PM). One staff worked in memory care on 12/23/25 - 01/02/26 (11:00 PM - 7:30 AM). Review of staff schedule (12/28/25 – 01/03/26) revealed one staff worked in memory care during the PM and NOC shift on 12/28/25 - 12/29/25, 01/03/26. One staff worked in memory care on 12/30/25 - 01/02/26 (11:00 PM - 7:30 AM). Two out of three staff interviews (S1, S3, S6) indicated there are two staff working in memory care and rounds are conducted every two hours or less. S5 and S7 indicated working with another staff member in zone one (assisted living on the first floor). S1 indicated there are eleven residents in memory care (zone three). S6 indicated most residents are sleep around 8:00pm. Five out of five staff interviews (S1, S3, S5 - S7) indicated there is enough supplies for caregivers. Five out of five staff interviews (S1, S3, S5 – S7) indicated someone works at the front desk after midnight who is able to grant access to emergency personnel and transfer phone calls from families to memory care. S8 indicated there is always a caregiver working the front desk overnight and use radios to inform of incoming phone calls. Three out of three Memory Care Emergency Contact (W3 - W4, W6) indicated care and supervision is provided to residents in memory care. Four out of four Memory Care Emergency Contact (W1, W3-W4, W6) indicated they have not tried to call the facility after 10pm. On 01/08/26 (9:40 AM – 10:00 AM), LPA toured and observed a locked door device that requires a key scan to enter the Memory Care Unit. The area also included an aiphone that rings to the front desk. Memory Care has a phone in the common room and in the office. The phone in the common room was tested and the front desk answered. While at the front desk, LPA and staff tested memory care's radio and a caregiver responded. LPA also observed the Paging System at the front desk. Staff was able to make an announcement that went throughout the building. LPA also observed supplies for the caregivers to access them. No deficiencies cited. Continue to LIC9099-C. Regarding the allegation, “Staff are not qualified to care and supervise residents,” it is alleged the facility’s nurse was fired and the position is being covered by an unqualified employee. Interview with Administrator Assistant indicated the facility has contracts with three nurse agencies and a Licensed Vocational Nurse (LVN) is in the facility from 6:00 AM – 5:00 PM. S6 indicated there are two LVNs on staff and a third-party nurse comes out. Three out of three staff interviews (S2 – S3, S6) indicated residents receive visits from the LVNs. S9 indicated S9 worked with that third-party agency before getting hired at the facility. S9 is primarily responsible for residents’ insulin injections, attending to falls, taking vitals, and assessing residents with changes of conditions. Interview with third-party agency (Witness #11) indicated they provided professional services (LVNs, RNs, MedTech, and Caregivers) to the Licensee in December 2025. Regarding the allegation, “Staff are not qualified to care and supervise residents” based on 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 deficiencies cited. An exit interview was conducted and a copy of this report was provided to the Administrator Assistant Catherine Dacara.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 11-AS-20251223135226

Allegation investigated: Staff do not ensure resident's personal hygiene needs are being met.

On 02/23/2026 at 8:35am, Licensing Program Analyst (LPA) Zina Brown conducted an subsequent investigation complaint visit at this facility to deliver the findings for the allegation above. During today’s visit, LPA met with Catherine Dacara (Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 02/19/2026, Licensing Program Analysts (LPA) Zina Brown conducted interviews with Administrator (A1), Staff (S1-S5) & Residents (R1-R10), between the hours of 8:42am - 2:11pm and requested the following documentation: Staff Roster (dated 01/26/2026), Resident Roster (dated 02/18/2026), Staff Schedule(02/08/2026 - 02/21/2026), Resident 1's (R1) records such as Admission Agreement (dated 07/04/2025), LIC 601: Identification & Emergency Information (dated 07/05/2025), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (dated 06/18/2025) , LIC 603: Preplacement Appraisal Information (dated 07/04/2025), Medication Administration Record for R1 (December 2025), LIC 625 Appraisal/Needs & Service Plan (dated 09/23/1950), Shower Log (December 2025 -February 2026), Resident Tracking Log (February 2026). Substantiated The investigation revealed the following: Allegation: Staff do not ensure resident's personal hygiene needs are being met. It was alleged that facility staff do not ensure the resident's personal hygiene needs are being met. The resident stated the last time they received a bed bath from facility staff was around 2 or 3 months ago. The resident mentioned that it has been around 1 year since receiving an actual shower. It was also reported that facility staff do not assist with personal hygiene which the resident needs assistance with. On 02/19/2026 between the hours of 8:42am - 8:49am, LPA interviewed A1 regarding the allegation. A1 denied the allegation. A1 stated the resident is scheduled to receive showers at least twice per week per the Admission Agreement, but indicated the resident often receives bed baths instead, reportedly twice a week, and that hygiene care is provided daily by direct care staff. A1 stated she does not personally assist with hygiene care, but that staff assist the resident with changing clothes, incontinence care, and brushing teeth on a daily basis. A1 acknowledged that deviations from showering may occur due to resident refusal or health-related issues (e.g., pain preventing movement). A1 reported that the facility maintains records of bathing and hygiene care, and that staff are responsible for documenting care and reporting when hygiene supplies are low, at which point the family is notified or the facility provides items if needed. On 02/19/2026 between the hours of 9:21am -11:38am, LPA interviewed 5 staff in regards to the allegation. 2 of 5 staff confirmed the allegation and stated Resident 1 (R1) has been refusing showers since last year and cannot remember the last time R1 received a shower. Staff stated R1 gets bed baths usually twice a week but has been refusing. 1 of 5 staff did not confirm nor deny the allegation and stated the resident gets showers 3 days a week or upon request from the resident, and last month upon being assigned to the unit where R1 resides, personal hygiene assistance would be about 3 times a week. 2 of 5 staff were unaware of the allegation and stated they work in the memory care unit and do not assist R1 with showering or personal hygiene needs. Staff mentioned the facility keeps records using communication logs and shower sheets when residents are bathed or showered, and caregivers have to sign a shower sheet and document in the Activities of Daily Living (ADL) book. Investigation findings continue on LIC 9099-C On 02/19/2026 between the hours of 12:01pm - 2:11pm, LPA interviewed 10 residents in regards to the allegation. 2 of 10 residents confirmed the allegation. 1 of the 2 residents stated the last time they received assistance with a shower from staff is like months to a year. The resident stated it is not really often and once caregivers see the residents can independently take care of themselves, then no care is provided by staff even though the facility is supposed to provide care which is mentioned in their contract (Admission Agreement). Of the 2 resident who confirmed the the allegation mentioned staff are too slow with assisting and or never come, so they have to take their own shower because they cannot trust nor put their care in the hands of the caregivers. 1 of 10 residents did not confirm nor deny the allegation and stated staff help with changing and assist with their catheter, and about two weeks ago they had a bed bath. The resident stated they never refused bed baths/showers but would like a bed bath at least twice a week. 7 of 10 residents denied the allegation and stated they take their own showers independently, never ask for help since they do this themselves, take care of their own personal hygiene, and do not ask staff for help because they are independent. On 02/23/2026 between the hours of 8:30am - 11:00am, LPA conducted a records review and observed the following: According to the LIC 602A Physician's Report (dated 06/18/2024), page 5 of 9, Section 2 (Capacity for Self-Care), the resident is marked No for being able to bathe, dress, or groom self. Similarly, the LIC 603 Pre-Placement Appraisal Information (dated 07/04/2024) indicates Yes for needing help with bathing, hair care, and personal hygiene. Furthermore, the Admission Agreement under Section 3 (Basic Services), Item 8, specifies assistance with the following activities: a. dressing, c. toileting, d. bathing (twice weekly), and e. grooming. The shower logs for the month of February revealed R1's showers days are marked for Tuesdays and Thursday in the Spa Room. On the Resident Tracking Sheet (February 2026) for R1's during the AM, PM and NOC Shift it revealed: During the hours of 7am, 9am, 11am, 1pm, 3pm, 5pm, 7pm, 9pm, 10:30pm, 12am, 2am, 4am, 6am that S on the key which means for Supervised Safety was provided to the R1 on 02/01 - 02/05, 02/09 - 02/14, 02/17 - 02/18, 02/28 - 02/29. The following dates had no initials 02/06 - 02/08, 02/15 - 02/19 - 02/22. The facility did not provide written documentation of R1 refusing a shower and or bed bath. Investigation findings continue on LIC 9099-C The facility’s direct care staffing schedules from 02/08/2026 - 02/21/2026, stated the following: During the week of (02/08–02/14), the AM shift utilized 5 to 7 caregivers, the PM shift maintained 5 to 6 caregivers, and the NOC shift utilized 3 to 4 caregivers. Memory care coverage during this period consisted of 1 to 2 caregivers per shift. During the week of (02/15/2026 – 02/21/2026), staffing levels fluctuated, with the AM shift utilizing 4 to 7 caregivers and the PM shift utilizing 5 to 7 caregivers. The NOC shift had 2 caregivers on 02/16, 02/17, and 02/21. While memory care usually maintained 2 caregivers during the day, it dropped to 1 caregiver during the PM shift on 02/21 and remained at 1 caregiver for the majority of the NOC shifts throughout both weeks. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Catherine Dacara (Administrator) and a copy of this report was provided with appeal rightsthe state’s words, verbatim · CDSS document, Feb 23, 2026 · control 11-AS-20260217155337

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

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 by: Based on interviews & records review, the facility did not have any written refusals of showers for R1 on file nor could staff provide an exact date of the last time R1 received a shower and or bed bath.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: The Administrator will conduct training on personal rights and the necessary reporting requirements for CDSS CCL. Additionally, the Administrator will implement an internal data sheet to track resident refusals of ADLs. The administrator submit proof of training and internal data sheet for resident refusals of ADLs by the plan of correction due date and email proof to LPA Brown at Zina.Brown@dss.ca.gov

Allegation investigated: Staff does not prevent resident from smoking inside the facility.

*This report does not supersede the previous report dated 10/24/2025 but is used to clarify findings. * On 02/11/2026 at approximately 1:02 PM Licensing Program Analyst (LPA) Troy Watson made a subsequent unannounced visit to the facility listed above. LPA Watson was greeted by the Assistant Administrator Catherine Dacara and explained the purpose of the visit. LPA was granted entry into the facility. The investigation consisted of the following: On 10/24/2025 between 08:01 AM – 04:56 PM the department requested, obtained, and reviewed the following documents: Resident Roster (10/08/25), Staff Roster (10/01/25), Smoking Policy (01/18/23), Staff Schedule (10/19/25 – 10/25/25), Unusual Incident Report (10/09/25 – 10/10/25), Psychiatric Emergency Team Assessment (10/10/25), and Placement for Evaluation and Treatment documentation (10/10/25). CONTINUED ON LIC9099-C Unsubstantiated On 10/24/2025 between 08:01 AM – 04:56 PM the department conducted interviews with Staff #1 – #5 (S1–S5) and Resident #2 – #11 (R2–R11). An attempt to interview Resident #1 (R1) was made, but the resident was no longer at the facility and could not be contacted. LPA Watson toured the facility with the Assistant Administrator, Catherine Dacara, and found the facility clean and in good repair. The investigation revealed the following: Allegation: Staff do not prevent residents from smoking inside the facility It was alleged that staff failed to prevent residents from smoking inside the facility, resulting in R1 reportedly igniting their shirt while smoking in their bedroom, creating a fire hazard and risk of injury. On 10/24/2025 between 08:01 AM – 04:56 PM LPA Watson interviewed Staff #1 – #5 (S1–S5). Of those interviewed, 5 out of 5 staff denied the above allegation. On 10/24/2025 LPA Watson interviewed Residents #2– #11 (R2– R11). Of those interviewed, 10 out of 10 denied the above allegation. On 10/24/2025 between 08:01 AM – 04:56 PM the department conducted an interview with the Assistant Administrator, Catherine Dacara (S1) and they were asked the question, does staff prevent residents from smoking inside the facility? S1 answered that residents and staff are not permitted to smoke inside the facility, and that a designated smoking patio outside the facility is provided for this purpose. The facility enforces its posted house rules prohibiting smoking on the premises, and staff assist residents by holding their cigarettes to ensure compliance and safety. LPA Watson reviewed the Smoking Policy records, and it showed on pg.1, section 8, under Procedures that “There will be designated times for supervised smoking set by the administration.” A review of the Unusual Incident Report dated 10/09/25 – 10/10/25 revealed that R1 was witnessed on 10/09/25 at approximately 7:00 AM trying to set his shirt on fire using a lighter and attempted to put it out with a broom, causing heavy smoke inside his room.Further review of the Unusual Incident Report also showed that R1 told staff fireworks shot into his room and caused the smoke, but there was no evidence or proof of fireworks being recovered from that incident. Based on record reviews, staff and client interviews, and observations, there is insufficient evidence to support the allegation: “Staff do not prevent residents from smoking inside the facility.” 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 the Assistant Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 11-AS-20251017130143

Allegation investigated: Licensee did not follow proper eviction procedures for resident.

*On 02/05/2026, Licensing Program Analyst (LPA), Socorro Leandro conducted a subsequent visit to deliver an amended complaint investigation report and re-issue an updated Title 22 Regulation being cited. This report supersedes the report dated 10/08/2025. The purpose of this report is to update the citation provided on 10/08/2025 but the finding remains substantiated.* Investigation consisted of the following: On 09/22/2025, Resident 1 (R1's) records were gathered. On 10/06/2025, R1 and Staff 1 (S1) were interviewed and R1’s records were gathered. On 10/07/2025, R1’s records were reviewed which consisted of New Resident Alert; Admission Agreement dated 04/04/2025; Identification and Emergency Information; Thirty Day Notice to Quit dated 05/07/2025; L.A. Superior Court, Long Beach, Eviction Restoration Notice dated 10/06/2025; and emails between the Department and the Facility were reviewed. On 10/08/2025, LPA Leandro conducted an unannounced subsequent complaint investigation visit. On 02/05/2026, LPA Leandro conducted an unannounced subsequent complaint investigation visit and met with the Interim Executive Director, Catherine Dacara, and explained tthe purpose of the visit. Substantiated Investigation revealed the following: Allegation: “Licensee did not follow proper eviction procedures for resident”, it is being alleged that the facility did not follow proper eviction procedures for R1. Interviews conducted revealed the following: According to S1 the facility did follow proper eviction procedures. According to R1 the facility did not follow proper eviction procedures, furthermore, R1 indicated that they do not read or understand the English language, additionally, R1 indicated that they received their Eviction Notice in English and not in their native language. R1’s records reviewed revealed the following: the New Resident Alert states R1 “only speaks Spanish.” The Thirty Day Notice to Quit dated 05/07/2025 indicates that R1 did not follow general policies of the facility [referring to CCR87224(a)(3)] but did not describe how R1 did not follow said general policies of the facility, furthermore, the document indicates that R1 is not an appropriate fit for the facility [referring to CCR87224(a)(4)] but did not conduct/provide a reappraisal of R1 as stated in regulation CCR87224(a)(4) and explain how R1 is not an appropriate fit for the facility. Substantiated: Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, plans of corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Interim Executive Director, Catherine Dacara .the state’s words, verbatim · CDSS document, Feb 5, 2026 · control 11-AS-20250919141527

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

87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement is not met as evidenced by: Based on interviews and records review the licensee did not comply with the section cited above in the 30-day notice issued by the licensee on 05/07/2025 did not state specific facts on why R1 was not an appropriate fit for the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: The Interim Executive Director, Catherine Dacara has agreed to re-read CCR 87224 Eviction Procedures (d), create a plan to stay in compliance with CCR’s Eviction Procedures, and to retrain staff on eviction procedures and email proof of corrections. Email to: Socorro.Leandro@dss.ca.gov Zina.Brown@dss.ca.gov Janae.Hammond@dss.ca.gov

Allegation investigated: Staff members worked while under the influence of alcohol.

On 1/29/2026, LPA Alfonso Iniguez conducted an unannounced initial complaint visit. LPA Iniguez met Catherine Dacara/Assistant Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Assistant Administrator Interview (A#1), Staff Interviews (S#1-S#6) and Residents Interviews (R#1-R#7) .LPA gathered the following documents: copy of facility resident roster dated : 1/29/26, copy of facility staff roster or LIC 500 dated: 1/9/2026, copy of facility employee conduct dated:1/29/26, copy of facility meeting sign-in sheet dated: 1/20/26. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Allegation: Staff members worked while under the influence of alcohol. The details of the complaint alleged that (S#1) and (S#2) are drinking alcohol while working at the facility. On January 29, 2026, at approximately 1:00 PM during the records review, LPA Iniguez examined the facility’s employee conduct policy dated January 29, 2026. The policy lists, as grounds for discipline or termination, reporting to work intoxicated or under the influence of alcohol or non-prescribed drugs, and bringing or using alcoholic beverages on facility property or while conducting company business offsite, unless authorized. LPA Iniguez also reviewed the facility meeting sign-in sheet from January 20, 2026, which confirms that all staff attended a mandatory in-service meeting where the code of conduct was discussed. On January 29, 2026, at approximately 10:00 AM during an interview with the assistant administrator (A#1), she stated that (S#1) and (S#2) were not observed consuming alcohol during work hours. In addition, (A#1) explained that the facility has policies and procedures regarding staff consuming alcohol or being under the influence while on duty, which are clearly outlined in the employee code of conduct and reinforced through regular in-service training. Additionally, (A#1) confirmed that there have been no prior concerns, complaints, or disciplinary actions involving (S#1) or (S#2) related to alcohol use or inappropriate workplace conduct. On January 29, 2026, at approximately 10:30 AM, during an interview with staff members (S#1) and (S#2), they stated that they had not consumed any alcohol during work hours. In addition, both staff confirmed they are aware of the facility’s policy regarding alcohol use while on duty and explained that they understand drinking while at work is strictly prohibited. Additionally, (S#1 and S#2) stated that they have never consumed alcohol during work hours in the past and have never been involved in any similar incidents at the facility. Evaluation Report continues LIC 9099-C On January 29, 2026, at approximately 11:00 AM, during an interview with facility staff members (S#3 through S#6), (4) out of (4) staff members stated that they had never observed S#1 or S#2 consuming alcohol or appearing under the influence during work hours. They further indicated that they are not aware of any incidents or conversations among staff regarding alcohol use while on duty. Additionally, (4) out of (4) staff confirmed that they have no concerns about staff conduct or behavior that could affect the safety and well-being of clients. On January 29, 2026, at approximately 12:00 PM, during interviews with residents (R#1 through R#7), (7) out of (7) residents stated that they have never noticed any staff members drinking alcohol or appearing to be under the influence while working. They further indicated that they have not observed any unusual behavior from staff that made them feel uncomfortable or concerned. Additionally, (7) out of (7) residents expressed that they feel staff are attentive and able to provide care and supervision at all times, and they feel safe in the facility. 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 Catherine Dacara/Assistant Administrator.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 11-AS-20260122094156

Allegation investigated: Staff sexually abused resident in care

On 1/22/2026, at 1:35pm, Licensing Program Analyst (LPA) Zina Brown conducted an subsequent unannounced complaint investigation in order to deliver investigation findings for the allegation listed above.During today’s visit, LPA met with Catherine Dacara (Assistant Administrator), and explained the purpose of the visit. The investigation consisted of the following: LPA requested copies of the staff roster (dated 10/01/2025), resident roster (dated 10/08/2025), Resident #1 (R1's) documents such as LIC 601: Identification and Emergency Form (dated 02/26/2025), LIC 602: Physician Report (dated 02/07/2025), LIC 603: Preplacement Appraisal Information, Functional Capability Assessment, Medication Administration Record (August 2025 - October 2025), Staff #1 (S1) documents such as LIC 501: Personnel Record/Job Application, Job Description (for Direct Care Staff), Interview Statement (dated 08/14/2025), ID/Driver License (Employment Authorization valid 08/02/2024 - 08/01/2028), Training Complete, Suspension Notification (dated 08/14/2025), Termination Statement (dated 08/25/2025), Report Receipt/Application for Release of Report from Long Beach Police Department. The complaint was referred to the department Investigation Bureau for further investigation. The department obtained the Long Beach Police Department Report, Interviewed the Administrator (A1), Staff #1- Staff #3 (S1-S3), Interviewed Resident #1 (R1) and Witness #1 (W1). Substantiated The investigation revealed the following: Allegation: Facility staff sexual abused resident in care. The department interviewed A1 regarding the allegation. A1 stated S1 was terminated from the facility for job performance issues, inappropriate interactions with residents, and inappropriate communications with fellow staff members. A1 stated R1 reported to staff members that S1 kissed R1 on the neck and chest and touched himself through his pants while in front of R1. The department interviewed S1–S3 regarding the allegation. One out of three staff interviewed denied the allegation, stating he was always professional and never displayed any inappropriate behaviors, such as kissing residents or touching himself while employed at the facility. Two out of the three staff interviewed confirmed being aware of S1’s inappropriate interactions with residents, which consisted of kissing residents on the cheek or chest and touching himself in front of residents. The department interviewed Witness #1, and W1 stated S1 was employed by the facility but was quickly terminated for inappropriate interactions with a resident, as well as job performance issues. W1 stated the inappropriate interaction with a resident occurred when S1 was found lying in a resident’s bed next to the resident while on his phone. The department interviewed R1 regarding the allegation, and R1 confirmed the allegation and disclosed S1 kissed R1 on the cheek and chest and touched himself through his pants. R1 further stated S1 hugged R1 every time S1 saw R1, and all of S1’s inappropriate behaviors made the resident uncomfortable. The department obtained a copy of the Long Beach Police Department report, which contains statements from facility staff regarding S1’s inappropriate behaviors. The department reviewed S1’s termination documents from Glen Park at Long Beach and another facility, both of which list similar reasons for S1’s termination, including inappropriate interactions with residents. Based on interviews conducted and records reviewed the department finds enough evidence to support that S1 sexually abused R1. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Catherine Dacara (Assistant Administrator) and copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 11-AS-20251007143756

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jan 23, 2026

Personal Rights of Residents: (3) To be free from punishment, humiliation, intimidation, abuse, or actions of a punitive nature, such as withholding money or interfering with daily living functions. This requirement was not met as evidenced by: Based on interview & records review, facility Staff 1 (S1) sexually abused Resident 1 (R1) by kissing R1 on the neck & touching their own groin area in front of R1. This violation poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 22, 2026

Plan of correction: Licensee/Administrator shall ensure a training for all staff on Title 22, Section 87468.1 “Personal Rights” is conducted & send the sign in sheets and training materials to the CCLD by the Plan of Correction (POC) due to the attention of: Zina.Brown@dss.ca.gov

Type of visit: Case Management - Other

On 01/22/2026, Licensing Program Analysts (LPA) Zina Brown conducted an unannounced Case Management visit to Glen Park at Long Beach. The purpose of today’s visit is to serve an ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY for staff #1. LPA met with Catherine Dacara (Assistant Administrator) and explained the purpose of today’s visit. An investigation conducted by the California Department of Social Services determined that staff #1 violated California Code of Regulations Title 22 for the resident's personal rights. Government Code 11522 was also issued, informing the licensee that an excluded person may petition for reinstatement to the Department one year after the effective date of the exclusion order. LPA delivered copies of the immediate exclusion letters for the following facility to Catherine Dacara (Assistant Administrator). Staff #1 (S1) was not present at the facility at the time of the visit. Staff #1 was mailed the Immediate Exclusion Order letter and Government Code 11522. The Assistant Administrator was read the Immediate Exclusion from Facility Order and acknowledged understanding the immediate exclusion order and that the mentioned staff is not allowed to be physically present in the facility. An exit interview was conducted with Catherine Dacara (Assistant Administrator) and copies of Order to Licensee/Facility of Immediate Exclusion from Facility and Government Code 11522 were provided. The report was signed by Catherine Dacara (Assistant Administrator) and copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 22, 2026

Allegation investigated: Staff are mishandling the residents medications

On 01/15/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent complaint visit to the facility listed above. LPA met with Assistant Administrator, Catherine Dacara, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA interviewed a Resident and delivered findings for the complaint. During a subsequent visit conducted on 12/04/2025, LPA conducted a medication review for eight (8) residents, observed lunch service, and received and reviewed the following documents Medication Administration Records (MAR) for December 2025, Weekly Menus for four (4) weeks, Sanitation and Food Safety Checklist for Assisted Living by RDs for Healthcare INC (dated 11/072025, 10/03/2025, and 09/05/2025), and invoices from Sysco for November and December 2025. During the initial visit on 10/21/2025, LPA inspected the facility, interviewed Staff S1-S8, interviewed Residents R1-R10, conducted a narcotic medication count, and received and reviewed the Staff Roster, Resident Roster, Resident Diabetic List, Physician’s Report for R1-R10, In-Service Training Log, Substantiated Medication Management Program verification, med tech Certification of Completion in Basic Medication Training, and med tech Basic Medication Shadow Training Logs. The following additional documents were requested and are to be emailed to LPA Unusual Incident Reports (URI), Physician’s Orders, Needs and Service Plan, and Medication Administration Records (MAR). The investigation revealed the following: Allegation: Staff are not following resident’s diabetic needs The allegation alleges that med techs are giving residents their insulin. During the facility visit, LPA observed residents going to the Medication Room to see the trained LVN, to have their blood sugar level checked, and to receive their insulin injections. During the visit, LPA observed insulin secured in a locked refrigerator, in the medication room. During record review, LPA reviewed the training and in-service logs for the LVN and medication technicians and observed they have received training regarding medication administration. LPA reviewed the Plan of Operation that indicates a licensed skilled professional can assist with self-administration of injections. LPA received and reviewed Resident R2-R 11’s Medication Administration Record (MAR) and observed glucose testing and insulin injections signed off by the LVN. During interviews with Staff S1-S8, were asked who checks residents’ sugar and provides insulin injections, eight (8) out of eight (8) stated the LVN is who tests residents’ sugar and gives insulin injections. During interviews with Residents R1-R11, were asked who provides them with their insulin shots and tests their sugar, eight (8) out of eleven (11) stated the nurse gives them their shots and tests their sugar. One resident stated they do their own sugar testing, and the nurse is there to document the numbers, and they do their own injections with the nurse watching. Two residents stated they do not require glucose testing or insulin injections. 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: Staff are not providing adequate food service The allegation alleges that residents are unable to get a second serving of food during mealtimes due to the kitchen running out of food. During the facility inspection, LPA observed lunch being prepared and served. LPA observed staff preparing residents plates using scoopers measuring half (1/2) a cup for mixed vegetables, fruit, and stuffing. Soup was measured using an 8 fluid ounce ladle. Residents were provided with one to two pieces of chicken with gravy. LPA observed a resident who wanted an alternative meal, and they were provided with either a turkey or ham sandwich, fruit, vegetables, soup, and stuffing. LPA observed multiple residents served a second serving of lunch. After all residents were provided with their meals, LPA observed an ample supply of prepared food still in the kitchen. Additionally, LPA inspected the food supply in the kitchen and observed a two (2) day supply of perishable foods and a seven (7) day supply of nonperishable foods. During record review, LPA received and reviewed invoices from Sysco listing food deliveries on the following dates 12/03/2025, 11/28/2025, 11/25/2025, 11/21/2025, 11/18/2025, 11/14/2025, 11/11/2025, 11/07/2025, 11/05/2025, and 11/04/2025. The food delivered consisted of dairy, meats, poultry, canned goods, frozen goods, dry goods, and condiments. Additionally, LPA received and reviewed the Sanitation and Food Safety Checklist for Assisted Living dated 09/25/2025 and 11/07/2025. On both forms, indicates the facility has a “one week of nonperishable food and 2 days perishable are available.” During interviews with Staff S1-S8, were asked if residents are able to have a second serving during mealtimes, eight (8) out of eight (8) stated residents are able to have a second serving of food during mealtimes. During interviews with Residents R1-R11, were asked if they are provided with enough food throughout the day, eleven (11) out of eleven (11) stated yes, they are provided with enough food throughout the day. 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: Staff are eating the food for the residents The allegation alleges that staff are eating all the food resulting in there not being enough food for residents. During the facility inspection, LPA observed lunch being prepared and served. LPA observed staff preparing residents plates using scoopers measuring half (1/2) a cup for mixed vegetables, fruit, and stuffing. Soup was measured using an 8 fluid ounce ladle. Residents were provided with one to two pieces of chicken with gravy. LPA observed a resident who wanted an alternative meal, and they were provided with either a turkey or ham sandwich, fruit, vegetables, soup, and stuffing. LPA observed multiple residents served a second serving of lunch. After all residents were provided with their meals, LPA observed an ample supply of food prepared in the kitchen. LPA did not observe any staff eating the food that was served from the kitchen. During review of an Admission Agreement, LPA observed a resident’s guest may purchase a meal and eat with the resident they are visiting. During interviews with Staff S1-S8, were asked if staff eat the food served to the residents, six (6) out of eight (8) stated they have eaten or seen staff eating the food served to the residents. Additionally, four (4) out of eight (8) stated meals are available for purchase and some staff eat the food for quality testing. During interviews with Residents R1-R11, were asked if there has been a time they wanted a second serving and it was not available due to the kitchen running out of food, eleven (11) out of eleven (11) stated no, the kitchen has not run out of food. 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. An exit interview was conducted with Catherine Dacara, and a copy of this report was provided. Medication Management Program verification, med tech Certification of Completion in Basic Medication Training, and med tech Basic Medication Shadow Training Logs. The following additional documents were requested and are to be emailed to LPA Unusual Incident Reports (URI), Physician’s Orders, Needs and Service Plan, and Medication Administration Records (MAR). The investigation revealed the following: Staff are mishandling the residents medications The allegation alleges residents are not getting their medication because the medication is missing. During the facility inspection, LPA conducted a medication review for eight (8) residents. LPA observed three (3) out of eight (8) residents had medications that were unable to be located in the medication cart and medication room. Additionally, LPA observed two (2) out of eight (8) resident’s medications were not consistent with documented records. During interviews with Staff S1-S8, were asked if there have been any medication errors or missing medications in the past, five (5) out of eight (8) staff stated yes, there was recently a medication error that was documented and reported. During interviews with Residents R1-R11, were asked if there have been any medication errors or missing medications in the past, four (4) out of eleven (11) stated yes, they have had missing medications that the staff did not know what happened to them. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Assistant Administrator, Catherine Dacara, and a copy of this report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 11-AS-20251013125552

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jan 25, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of centrally stored medications. This requirement was not met as evidence during record review, observation, and interviews, during medication audit staff were unable to locate 3 of R4’s PRN medications, 4 of R6’s medications, and 1 of R9’s medications.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: The Licensee agrees to retrain staff on properly storing centrally stored medications and ensuring they are secured and will work with TSP to implement new procedures they feel is needed. Training Logs will be emailed to LPA by POC.

Allegation investigated: Staff do not assist resident with ambulating. Staff handled resident in a rough manner. Staff do not assist resident with arranging transportation.

On 01/07/2026 at 8:23am, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit at this facility to deliver the complaint investigation findings for the allegations above. During today’s visit, LPA met with Catherine Dacara (Assistant Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 12/29/2025 at 8:50am, Licensing Program Analysts (LPA) Zina Brown, requested documentation & conducted interviews with, Staff (S1-S10) & Residents (R1-R10), between the hours of 9:41am - 4:00 pm. At 12:45pm, LPA obtained the following documentation: Resident Roster (dated 12/19/2025), Employee Schedule Week of 12/21/2025 - 12/27/2025, LIC 601: Identification & Emergency Information, LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (dated 06/18/2025), LIC 625 Appraisal/Needs & Service Plan (dated 09/23/2025) & list of non-ambulatory residents (received on 12/29/2025). On 01/07/2026, LPA conducted an interview with Administrator (A1) between the hours of 9:38am - 10:01am. Investigation findings continues on LIC 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not assist resident with ambulating It was alleged that facility staff failed to assist a resident for days at a time and that prior to 12/21/2025 the resident had not been out of bed since 12/16/2025. It was also alleged that staff told resident they cannot get the resident out of bed. On 01/07/2026 between the hours of 9:38am -10:01am, LPA interviewed the Administrator in regard to the allegation. A1 denied the allegation and stated caregivers routinely check on residents in the morning and offer assistance getting out of bed. A1 stated that residents are assisted based on their willingness and ability to transfer safely. Additional caregivers assist when a two- or three-person transfer is required, and the nurse is contacted if a resident is in pain. A1 acknowledged awareness of a R10 remaining in bed prior to 12/21/2025 but denied that any caregiver refused to assist a resident without reason. On 12/29/2025 between the hours of 9:43am - 4:00pm, the LPA interviewed 10 staff regarding the allegation. 9 of 10 staff denied the allegation and stated resident who need assistance with ambulation will help upon request and or following the directives of the residents care plan. 1 of 10 staff did not confirm nor deny the allegation and stated due to R10 have a neck injury it was advised resident be on bed rest for 3-4 days. On 12/29/2025, between the hours of 11:24am - 2:26pm, the LPA interviewed 10 residents regarding the allegation. 1 of 10 residents confirmed the allegation and stated they are suppose to get help from staff when they want to get out of bed but that doesn't happen ; staff would take too long to assist them so they would get themselves out of bed. 9 of 10 residents denied the allegation. 3 of 9 residents stated staff will come by in the morning to assist with transferring, while 6 of 9 residents independently get themselves out of bed. On 01/07/2026 between the hours of 8:40am - 8:45am, LPA conducted a records review and observed the following: the LIC 625 Appraisal/Needs & Service Plan (dated 09/23/2025) stated for R10 one caregiver reported that two of caregivers are not able to transfer R10 due to an unintentional fall as a result of the resident's weight. Caregivers noted R10 needs at least 3 caregivers to assist him with his ADLs and transfer. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Investigation findings continues on LIC 9099-C Allegation; Staff handled resident in a rough manner It was alleged that staff attempted to transfer a resident from their bed to their wheelchair by pulling their arms to raise themselves from the bed which the resident reported that a male caregiver pulled the resident up too quickly by their arms and hurt the residents neck. On 01/07/2026 between the hours of 9:38am -10:01am, LPA interviewed the Administrator in regard to the allegation. A1 denied the allegation and stated that staff are trained to use appropriate transfer techniques based on resident ability. A1 stated that staff are instructed to contact the nurse if a resident appears uncomfortable or in pain and to complete a report if a resident reports injury. A1 stated they were not aware of any caregiver handling a resident roughly during a transfer. On 12/29/2025 between the hours of 9:43am - 4:00pm, the LPA interviewed 10 staff regarding the allegation. 10 of 10 staff denied the allegation and expressed not handling the resident in a rough manner. On 12/29/2025, between the hours of 11:24am - 2:26pm, the LPA interviewed 10 residents regarding the allegation. 10 of 10 residents denied the allegation and stated never experiencing being handle in a rough manner by staff. On 01/07/2026 , between the hours of 9:20am - 9:25am, LPA conducted a records review and observed the following: LPA did not observe any incidents reports nor resident notes in regards to this allegation. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Investigation findings continues on LIC 9099-C Allegation : Staff do not assist resident with arranging transportation It was alleged that staff do not assist a resident with scheduling their ACCESS transportation services, resulting in the resident being unable to attend church services. On 01/07/2026 between the hours of 9:38am -10:01am, LPA interviewed the Administrator in regard to the allegation. A1 denied the allegation and stated that the facility assists residents with scheduling ACCESS transportation upon request. A1 stated that some residents schedule their own transportation. A1 reported that transportation issues involving R10 occurred due to scheduling errors and missed phone calls, not staff inaction. A1 stated that if ACCESS cancels transportation, staff notify the resident and offer to reschedule. On 12/29/2025 between the hours of 9:43am -4:00pm, the LPA interviewed 10 staff regarding the allegation. 8 of 10 staff denied the allegation and stated resident or the resident's family will arrange their own transportation but the front desk will assist with arranging transportation for the residents upon request. 2 of 10 staff were unaware of the allegation. 2 of the 2 staff stated not having any knowledge of residents transportation being delayed and or canceled. On 12/29/2025, between the hours of 11:24am - 2:26pm, the LPA interviewed 10 residents regarding the allegation. 8 of 10 residents denied the allegation and states making arrangements for transportation themselves. 2 of 10 residents did not confirm nor deny the allegation. 1 of 2 residents stated not knowing how to setting up rides or transportation but would like to someone who would help them get more information on how to do so in regards to this matter. While the other 1 of 2 resident stated this allegation does not apply at all due to them never trying to go somewhere. On 01/07/2026 , between the hours of 9:20am - 9:25am, LPA conducted a records review and observed the following: LPA did not observe any reports and or notes in regards to this allegation. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies were cited for the allegations above. An exit interview was conducted with Catherine Dacara (Assistant Administrator) & a copy of this report is provided.the state’s words, verbatim · CDSS document, Jan 7, 2026 · control 11-AS-20251223093452

Type of visit: Case Management - Deficiencies

On 01/07/2025, The Department conducted an unannounced visit to deliver findings for the alleged allegations for complaint Control Number 11-AS-20251223093452. LPA met with Catherine Dacara (Assistant Administrator) as the purpose of the visit was explained. On 01/07/2025 between the hours of 8:30am - 8:45am, LPA conducted a records review and observed the following: the department did not receive a LIC 625: Serious/Unusual Incident Report in regard to Resident 10 (R10) having an unwitnessed fall and being sent out to the hospital on 12/09/2025. The facility failed to report the incident as required to the department. Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. Exit interview conducted with Catherine Dacara (Assistant Administrator), appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 7, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jan 21, 2026

Reporting Requirements(a)(1)Each licensee shall submit serious incident reports to. . . the Department may require, including the following: (1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence of any of the events This requirement was not met as evidenced by: based observation, LPA observed that the facility did submit a LIC 624 to the department within 7 day of incident occurring.the state’s words, verbatim · CDSS document, Jan 7, 2026

Plan of correction: The facility shall will submit a serious incident reports (by 01/08/2026) for the incident that occur on 12/09/2025 with the resident (R10) who had an unwitnessed fall & went to the hospital. Also the facility will conduct an in-service training on reporting requirement for all staff. The completion of training must be fax to 424-544-1016 or zina.brown@dss.ca.gov to department by POC due date.

Allegation investigated: Staff do not insure an appropriate skilled professional is administering insulin to residents.

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Type of visit: Case Management - Deficiencies

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Allegation investigated: Staff are not adequately trained.

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Allegation investigated: Staff do not insure an appropriate skilled professional is administering insulin to residents.

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Allegation investigated: Staff do not ensure residents are cleaned properly.

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Allegation investigated: Staff mismanaged resident medication

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Allegation investigated: Staff refused to change resident's soiled diaper

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Allegation investigated: Staff does not prevent resident from smoking inside the facility.

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Allegation investigated: Licensee did not follow proper eviction procedures for resident.

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Type of visit: Case Management - Deficiencies

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Type of visit: Case Management - Health Checks

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Allegation investigated: Staff did not safeguard resident’s personal belongings. Staff did not protect resident from financial abuse.

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Allegation investigated: Staff are mismanaging residents medication.

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Type of visit: Office

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Allegation investigated: Facility staff failed to prevent resident from getting an infection.

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Allegation investigated: Facility staff not providing adequate food service

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Type of visit: Case Management - Other

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Type of visit: Case Management - Deficiencies

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Type of visit: Required - 1 Year

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Allegation investigated: Staff are not providing resident with daily meals. Staff are not addressing resident bathing needs. Staff are restricting resident from participation in activities. Staff are financially abusing resident. Staff do not respond to residents call button in a timely manner.

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Allegation investigated: Facility staff not providing adequate food service.

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Allegation investigated: Staff is stealing residents personal property.

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Allegation investigated: Staff do not ensure that resident has transportation to receive substance abuse and mental health treatment.

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Allegation investigated: Staff illegally evicted resident in care.

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Type of visit: Case Management - Other

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Allegation investigated: Staff is stealing residents personal property.

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Allegation investigated: Staff do not properly maintain the residents report. Staff mishandled the residents personal funds. Staff do not have proper documentation regarding the residents. Staff did not properly report incidents involving residents. Staff did not prevent the residents from engaging in an altercation. Staff allow a resident to be soiled for extended period of time. Staff did not address the residents change in medical condition. Staff did not seek timely medical attention for a resident.

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Allegation investigated: Staff did not provide clients medical records in a timely manner.

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Allegation investigated: Resident did not receive medication as prescribed.

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Allegation investigated: Licensee does not ensure facility is adequately staffed to meet resident's needs. Staff are not properly trained. Staff did not properly assess residents prior to admission.

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Allegation investigated: Staff did not meet resident's showering needs. Staff did not seek resident timely medical attention. Staff did not ensure security of resident's personal belongings. Staff gave an explanation of circumstances at the time of resident's death, different from what a doctor reported.

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Type of visit: Case Management - Other

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Allegation investigated: Staff are not ensuring resident's medication is being administered as prescribed. Facility staff mismanaged residents’ medication. Facility staff are financially abusing residents.

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Type of visit: Case Management - Deficiencies

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Allegation investigated: Staff unable to meet residents care needs.

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Allegation investigated: Staff are not ensuring residents have clean linens Staff are not assisting residents with changing clothes Staff are not assisting residents with showers Staff are not assisting residents with medications timely Staff do not assist resident with follow-up medical appointments

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Allegation investigated: Staff is not allowing resident to return to facility for re-entry.

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Type of visit: Case Management - Deficiencies

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Allegation investigated: Facility staff did not dispense medications to resident as prescribed

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Allegation investigated: Staff physically abused resident. Staff was under the influence while caring and supervising resident.

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Allegation investigated: Staff are not properly following general food service requirements

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Allegation investigated: Facility staff are not providing resident with appropriate supervision, resulting in falls. Staff are mismanaging resident's medication Staff do not ensure that resident's toileting needs are being met Staff do not ensure that resident's showering needs are being met. Staff do not ensure that facility has sufficient clean linen Facility is serving expired beverages Staff do not ensure that resident receives a sufficient quantity of food. Staff do not ensure that facility is kept clean and sanitary

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Type of visit: Case Management - Deficiencies

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Type of visit: Case Management - Other

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Type of visit: Case Management - Other

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Allegation investigated: Facility staff speak inappropriately to residents in care. Facility staff handle residents in a rough manner.

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Allegation investigated: Staff do not ensure a comfortable living environment for residents Staff do not prevent residents from entering other resident's rooms Staff do not meet resident’s modified dietary needs

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Allegation investigated: Staff engaged in an intimate relationship with a resident.

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Allegation investigated: Staff are not meeting resident's dietary needs

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Type of visit: Case Management - Deficiencies

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Allegation investigated: Resident sustained fractures due to staff dropping resident while transferring.

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Allegation investigated: Staff do not treat resident with dignity or respect Staff are not following resident's Admission Agreement Staff does not provide adequate food service

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Allegation investigated: Licensee did not ensure the facility has a qualified Administrator on site.

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Type of visit: Case Management - Other

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Type of visit: Required - 1 Year

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Allegation investigated: Staff did not safeguard resident's funds. Staff is acting as the payee for several independent residents. Staff do not treat residents with dignity or respect.

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Allegation investigated: Staff yelled at resident in care. Staff does not ensure resident is administered medications. Staff does not follow resident's dietary orders. Staff does not ensure resident's room is clean.

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Allegation investigated: Staff do not ensure that a resident's toileting needs are met. Staff are not addressing pests at the facility. Staff do not answer a resident's call button in a timely manner. Staff do not monitor a resident for change in condition.

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Allegation investigated: Resident's dietary needs are not being met

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Allegation investigated: Staff did not safeguard a resident's personal belongings. Staff do not ensure that a resident's medical condition is properly managed. Staff do not assist resident with showering.

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Allegation investigated: Staff mismanaged resident's medications. Staff did not administer medication as prescribed.

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Allegation investigated: Resident abuse. Altering/falsifying records. Resident’s personal supplies being distributed to other residents. Uncleared staff working at facility.

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Allegation investigated: Staff did not prevent a resident from physically assaulting another resident in care. Staff did not administer medication as prescribed.

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Allegation investigated: Staff did not prevent a resident from physically assaulting another resident in care. Staff did not administer medication as prescribed.

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Allegation investigated: Facility staff did not safeguard resident's personal belongings.

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Allegation investigated: Staff did not meet resident's showering needs. Staff did not seek resident timely medical attention. Staff did not ensure security of resident's personal belongings. Staff gave an explanation of circumstances at the time of resident's death, different from what a doctor reported.

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Allegation investigated: Staff did not assist resident withing obtaining care. Staff do not answer resident's call button in a timely manner Staff speaks to resident in an inappropriate manner Staff did not allow resident to possess personal belonging Staff do not assist resident with showering

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Allegation investigated: Staff did not meet resident's dietary needs. Staff did not clean resident's room. staff yelled at resident. Staff made inappropriate comment toward resident.

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Allegation investigated: Staff handled resident in a rough manner. Staff does not respond to resident’s call for assistance. Staff does not serve nutritious meals. Staff served resident expired milk

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