Jasmines Residential Care for Elderly

Allegation investigated: Staff did not report incident to appropriate parties.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 06/26/2026 regarding the above allegation. On 06/04/2026, LPA Ramirez conducted an initial complaint investigation visit and a need for further investigation was documented. During today’s visit LPA Ramirez was greeted by Levita Maghirang and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez conducted Staff interviews#1- 3 (S1-S3), Witness#1-2 (W1-W2), attempted resident interview# 1, 3,5 (R1, R3, R5), resident interview#2, 4 (R2, R4) and physical plant tour. See 9099-C Substantiated The investigation revealed the following: regarding the allegation “Staff did not report incident to appropriate parties.” It is alleged that facility staff did not report an incident regarding R1 to R1’s responsible party. Record review of R1’s resident file revealed that R1 was admitted into the facility on 05/21/2026 and was receiving hospice care. Review of R1’s admission agreement revealed that R1’s family is the responsible party on record. Interview of S1 revealed that on 05/23/2026, around 7:40 am, R1’s vitals were dropping and S1 called S3 to inform them about R1’s vitals. Interview of S3 revealed that they called R1’s hospice team on 05/23/2026 at 7:45 am to advise them that R1’s vital were dropping and they needed to come see R1. S1, S2 and S3 revealed that they did not contact R1’responsible party to advise them that R1 had a change in condition. Interview of S3 revealed that they did not contact R1’s responsible party to advise them of R1’s change of condition around 7:40 am. Interview of W1 revealed that they contacted R1’s responsible party around 11am to update them on R1’s condition. Interview with W2 revealed that they treated R1 on 05/22/2026 at around 11pm and were allowed entry into the facility without issues. Three (3) out of the three (3) staff interviewed corroborated this allegation. Interview with witness#1 (W1) corroborated this allegation. Based on LPAs record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 9099D. Exit interview was conducted and a copy of this report, 9099-D and appeals rights were provided.the state’s words, verbatim · CDSS document, Jun 26, 2026 · control 28-AS-20260601091210

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Jun 27, 2026

Personal Rights 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 ervices, including ongoing evaluations, as appropriate to their needs. This requirement was not: Licensee did not call R1's responsible party to inform them of R1's change of condition on 05/23/2026 at 7:40am. This poses an immediate risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Jun 26, 2026

Plan of correction: The licensee will draft a plan that will discuss how residents representatives will be regularly informed by the licensee regarding activities related to a resident’s care services, including ongoing evaluations, as appropriate to their needs. Plan must be received via email.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit-Deficiencies on 06/04/2026. LPA was greeted by Administrator Levita Maghirang and Alternate Administrator Lesile Lantano and explained the purpose of the visit. Case Management findings: On 06/04/2026, LPA Ramirez conducted interviews and resident record reviews. Resident interviews revealed that R1 has their medication crushed and put in their juice. Record review of R1’s file revealed that R1 does not have a physician’s order for crushed medications. Staff interviews corroborated that R1 has their medication crushed and placed in their juice. LPA Ramirez issued one (1) type B deficiency based on interviews and record review. During record review of R2’s resident record, LPA observed R2’s Death Report dated 05/23/2026. LPA Ramirez requested proof that the licensee notified this department in writing within seven (7) days of R2’s death. The licensee could not provide proof when requested. LPA Ramirez issued one (1) type B deficiency based on this record review. Based on LPA’s review and interviews, two (2) deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8, are cited on the attached LIC 809-D. Exit interview conducted. A copy of this report, 809-D and appeals rights.the state’s words, verbatim · CDSS document, Jun 4, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Jun 11, 2026

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require: (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. (A) Death of any resident from any cause regardless of where the death occurred. This requirement was not met as evidenced by: Licensee could not provide proof R2's death report was submitted to this department within 7 days of 05/23/2026.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: Licensee will draft a plan and explain how the facility will comply with this regulation in the future. Plan must be received by 6/11/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(a)(5)(D) · Plan of correction due date: Jun 11, 2026

(a) A plan for incidental medical shall be developed.The plan shall encourage medical care,provide for assistance in obtaining such care, compliance with the following: (5) staff may assist persons with self-administration. Assistance with self administered medications shall be limited to the following: (D) Assistance with self administration does not hiding,camouflaging medications in other substances without the resident's knowledge and consent, or infringing upon a resident's right to refuse to take a medication. This requirement was not met: Staff crushed R1's meds and put in R1's juice w/o a Dr order.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: Licensee will obtain physician's order to specify the name of the medication to be crushed and specific dosage by 06/11/26

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Rui Jen Huang, caregiver for the facility, and explained the purpose of the visit. Administrator Levita Maghirang arrived shortly thereafter. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a single-story home located in a residential neighborhood. The facility consists of four (4) resident bedrooms,a living room, a kitchen, a dining room which contains the washer and dryer for the facility, a detached garage which contains extra food supplies, a backyard with a shaded area, two (2) resident restrooms which measured 105.1 and 105.5 degrees Fahrenheit respectively. The facility was observed to be in good repair. Two (2) fully charged fire extinguishers are kept on the premises. Operational Requirements: · Fire clearance was approved by LA County Fire Department for a capacity of six (6) non-ambulatory residents, one (1) bedridden resident, and a hospice waiver approved for four (4) residents. · Care and supervision to meet the clients’ needs was observed. Staffing: · Four (4) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Four (4) staff files were reviewed for criminal background clearance and training. · All Four (4) staff records have a health screening with a Tuberculosis clearance, First Aid/CPR trainings that are active, and required annual trainings. Resident Rights/Information: · Physician orders were reviewed for three (3) resident files. · Medications were also reviewed for three (3) residents. Resident Records/Incident Reports: · Three (3) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. · During visit it was discovered that Resident #1 had passed away two (2) weeks ago, and Resident #2 was hospitalized for pneumonia on 5/5/2026, however incident reports were not received by the licensing agency for these incidents. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have are assisted with medication management by staff. Disaster Preparedness: · Emergency and Disaster Plan (LIC610E) was posted in the facility and LPA obtained a copy. · The last emergency and disaster drill was conducted on 4/3/2026. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. · LPA observed that there all three (3) residents have half-bed rails on their beds, however there is no physician’s order in their files for the half-rails. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit is documented on the LIC809D page. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, May 18, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Ruijen Huang, caregiver for the facility, and explained the purpose of the visit. Administrator/Licensee Levita Maghirang arrived shortly thereafter. There are two (2) non-ambulatory, one (1) ambulatory, and one (1) bedridden residents residing within the home. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents, six (6) of which may be non-ambulatory, one (1) of which may be bedridden, and a hospice waiver approved for four (4) residents. The facility consists of a kitchen, a dining room, a living room, five (5) resident bedrooms, two bathrooms of which Restroom #1 had a hot water temperature reading of 116.7 Degrees Fahrenheit, and Restroom #2 which had a hot water temperature reading of 115.4 Degrees Fahrenheit. The facility was observed to be in good repair. Exit doors are free of any obstruction. The facility has a fully charged fire extinguisher kept in the facility. Operational Requirements: · The Program Design was reviewed. · Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, six (6) of which may be non-ambulatory, one (1) of which may be bedridden, and a hospice waiver approved for four (4) residents. · Care and supervision to meet the clients’ needs was observed. Staffing: · Five (5) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Five (5) staff files were reviewed for criminal background clearance and training. · All Five (5) staff records reviewed have a health screening with a Tuberculosis clearance, and five (5) staff have First Aid/CPR trainings that are active. · The administrator’s certificate expires on 10/16/2025. · Staff did not have the required twenty (20) hours of retraining on file including dementia care, hospice care, postural supports, and restricted health conditions. Resident Rights/Information: · Physician orders were reviewed for four (4) resident files. · Medications were also reviewed for four (4) residents. Resident Records/Incident Reports: · Four (4) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. · One (1) resident with dementia did not have a physician’s report that has been completed within the past year. · Two (2) residents did not have a reappraisal conducted within the past year. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. Disaster Preparedness: · Emergency and Disaster Plan (LIC610E) was found in the facility. · There was no documented disaster drill kept at the facility. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs: · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. · The sole side exit of the facility was kept locked with a padlock without approval from the fire department or in their fire clearance. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit is documented on the LIC809D pages. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, May 15, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Erik Zaragoza and Daniel Konishi conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Moris Shockley, President and CEO of Hollenbeck Palms, and was granted entrance. Administrator Diana Medina arrived shortly thereafter. There are one-hundred and sixty-two (162) residents currently living in the facility. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control practices and Personal Protective Equipment (PPEs) were observed. Infection Control Plan will be submitted to LPA within seven (7) days. Physical Plant/Environment Safety: · The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents, all of which may be non-ambulatory, four (4) may be receiving hospice, and one (1) of which may be bedridden. It has four (4) resident rooms, a dining room which also contains the facility’s washing and drying machines, a kitchen, two (2) residents bathrooms of which Restroom #1 had a hot water temperature reading at 109.8 Degrees F and Restroom #2 had a hot water temperature reading of 107.1 Degrees F, a backyard patio which contained a shaded area for residents, and also a detached garage that functions as the facility’s storage and holds additional food and incontinence supplies. Cleaning supplies and chemicals are kept locked in a cabinet in the kitchen. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility has two (2) fully charged fire extinguisher located on both floors of the facility, including the basement. There were no sharp objects that were left accessible to residents. · Water temperature readings measured between the required 105 - 120 degrees Fahrenheit. Operational Requirements: · The facility did not have a Plan of Operation on record, administrator was asked to provide this to LPA at a later date. · Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, all of which may be non-ambulatory, four (4) may be receiving hospice, and one (1) of which may be bedridden. · Care and supervision to meet the clients’ needs was observed. Staffing: · A total of seventeen (17) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Five (5) staff files were reviewed for criminal background clearance and training. · Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training. Resident Rights/Information: · Physician orders were reviewed for four (4) resident files. · Medications were also reviewed for four (4) residents. Resident Records/Incident Reports: · Four (4) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. · Staff training was on file. Disaster Preparedness: · Emergency and Disaster Plan was publicly posted and found within the facility. · An emergency and disaster drill was last documented in 2020. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 5, 2024