Regency Grand at West Covina

Allegation investigated: Staff interacted with a resident in an inappropriate manner. Staff are not following residents dietary plan. Staff do not ensure that facility is kept clean and sanitary. Staff are neglecting residents in care. Staff are generating inaccurate incident reports. Staff do not respond to residents call for assistance in a timely manner.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit regarding the above-mentioned allegations. LPA met with Mary Mims-Burris, Executive Director and explained the purpose of the visit. The investigation consisted of the following: On 06/30/2026, LPA toured the facility's common areas, assisted living/memory care units, kitchen and dining room. LPA obtained a copy of the staff & resident rosters, Weekly meal menu/schedule, West Covina Police Report (06/22/2026), Staff #1 (S1) - Staff #2 (S2) files such as clearances & training logs, Resident #1 (R1) - Resident #3 (R3) files indicating dietary requirements and physician's report, Unusual incident/injury reports/SIRs (May-June 2026) and Ombudsman/LTCO contact information. LPA interviewed (6) Staff and (12) Residents. During today's visit, LPA obtained a copy of the staff & resident rosters, toured the common areas, and simulated a call for assistance in a resident's room (Rm. #254) to measure staff response time. LPA also contacted the LTCO/Ombudsman 3x, but no response received. *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: Allegation: "Staff interacted with a resident in an inappropriate manner." It is alleged that a staff was sexually harassing staff, drugging staff, and grooming and flirting with residents. No additional information provided. All (6) staff interviewed including the alleged perpetrator denied the allegation, stating that they are trained in abuse/neglect. Staff stated this is the first time they’ve heard about this and have not witnessed anyone making unwanted sexual advances or intimidating other staff or residents. S1 stated that police was called due to domestic issue between (2) residents, but no arrests made. All (12) residents interviewed denied the allegation, stating that none of the staff have engaged in any behavior that could be interpreted as flirting or grooming. Residents also stated that they have not observed any staff behaving unprofessionally around them. Documents reviewed revealed that the staff accused of this behavior had no history of sexual misconduct nor prior disciplinary actions. During the visits on 06/30/2026 and 07/24/2026, LPA did not observe inappropriate behavior from any staff. Therefore, there was insufficient evidence to corroborate with this allegation. Allegation: "Staff are not following residents dietary plan." It is alleged that staff are unaware of residents' dietary plans and restrictions, leading to cross-contamination of food allergens. It is also alleged that a resident was served cross contaminated food, and there was a choking incident two to three months ago due to staff not chopping food. (6) of (6) staff interviewed denied the allegation, stating that a process is in place anytime a resident's diet is changed. S1 stated that a dietitian is involved in meal planning to meet the residents' dietary needs. Some staff explained that whenever there is a new resident with a special diet or dietary changes, a diet order is generated and sent to the food services director, who then notifies the kitchen staff. S5 stated that the kitchen has a dietary board list of allergies and restricted diets along with pictures of the residents. Residents interviewed denied the allegation, stating that staff are aware of their dietary plans and restrictions. Some residents indicated that they have seen a resident coughing while eating but not choking. LPA reviewed incident reports (January-June 2026) submitted to CCLD and found no incidents of food allergen cross-contamination or choking. Records reviewed indicated that the kitchen staff have the proper food handling and safety training. During the visits on 06/30/2026 and 07/24/2026, LPA observed the board in the kitchen that staff could see and there was no inappropriate food served during lunch. Therefore, there was insufficient evidence to corroborate with this allegation. Allegation: "Staff do not ensure that facility is kept clean and sanitary." It is alleged that a resident had to go outside and urinate in the bushes and shards of shattered glass were left on the kitchen's juice counter and carpet for approximately eight minutes. All (6) staff interviewed denied the allegation, stating that they completed training on neglect/abuse. Staff stated they have not seen any residents urinate in the bushes and no one has reported doing so. S5 had seen the broken glass on the juice counter due to a server breaking the glass by accident. S5 stated that they cleaned it immediately and that residents do not have access to that area. All (12) residents interviewed denied the allegation, stating that they have not seen anyone urinate in the bushes. Additionally, residents stated that they do not have access to the juice counter section. During the visits on 06/30/2026 and 07/24/2026, LPA did not observe any hazards or health threats from poor sanitation. Therefore, there was insufficient evidence to corroborate with this allegation. Allegation: "Staff are neglecting residents in care." It is alleged residents were abandoned in the dining room and residents with dementia are left outside for four hours causing the residents to get sunburned without staff checks. All (6) staff interviewed denied the allegation, stating that they completed training on neglect/abuse and would never leave residents outside for so long. Staff stated that although they have meal schedules, residents may stay in the dining room after mealtimes. Staff also stated they are always on the move, and they would have seen if resident(s) remained there for a long time, and if so, they would have paid attention to them. If the residents want, staff in memory care unit can take them to the courtyard next to the dining room, where staff are around to watch out for them. All (12) residents interviewed denied the allegation, stating that they were welcome to spend time in the dining room or anywhere in the common areas and were never left alone. Some residents stated they enjoyed sitting outside but did not get sunburn because they stayed in the shade and staff regularly checked on them. During the visits on 06/30/2026 and 07/24/2026, LPA observed positive interactions between staff-residents. Therefore, there was insufficient evidence to corroborate with this allegation. Allegation: "Staff are generating inaccurate incident reports." It is alleged that the facility incident reports may be inaccurate as the executive director interviews residents with cognitive impairments or residents that did not witness the incident. Staff interviewed denied the allegation. S1-S2 stated that they are responsible in reporting incidents and they report them as accurate as possible, including serious injuries. Staff stated that they ensure that law enforcement and other agencies are notified. Staff also stated that they prioritize residents' safety and follow reporting processes for corrective actions. Residents interviewed could not comment on this as they are not familiar with the process of generating incident reports. LPA reviewed incident reports submitted to CCLD between January-May 2026, and it revealed that incidents were properly observed and documented. Furthermore, there were no reports of residents with cognitive impairments being interviewed or of witness limitations. Therefore, there was insufficient evidence to corroborate with this allegation. Allegation: "Staff do not respond to residents call for assistance in a timely manner." It is alleged that residents are left waiting for 30-40 minutes when they are using their pagers. All (6) staff interviewed denied the allegation of slow response times, stating that caregivers attend to residents' calls as quickly as possible and have received training. Staff confirmed that they have adequate staffing who provide care and supervision, including night and on-call staff, and they also follow residents’ care plans. Staff explained that calls are prioritized based on urgency, such as life-safety emergencies or falls, and caregivers use walkie talkies to communicate about calls for assistance. S2 stated that they monitor response times to ensure calls are attended promptly, otherwise, the call will repeat itself, until the resident has been assisted. Other staff interviewed stated that residents do not use pagers, but they have call lights in their rooms (by the bed and bathroom) or wear pendants (optional with fee). All (12) residents interviewed denied the allegation and (5) of (12) residents who have pendants stated that staff respond to their calls immediately. Some residents stated they can manage their daily chores with minimal assistance. In order to measure call response times, at 11:05 am, LPA pushed the call light in Room #254 during the visit on 07/24/2026, and it took staff 02:55 minutes to respond. During both visits, LPA observed the residents to be clean and interact well with staff and other residents. Therefore, there is insufficient evidence to corroborate the allegation. Based on statements and interviews conducted with staff, residents, review of resident/staff files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided to the Executive Director, Mary Mims-Burris.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 28-AS-20260622123136

Allegation investigated: Facility is in disrepair.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to deliver findings on the above allegation. LPA met with Tabatha Lenoue and explained the purpose of today's visit. The investigation consisted of the following: On 3/6/26 LPA conducted initial visit obtained copies of Staff and Resident Rosters, copy of invoice for plumbing and dry wall repairs, toured facility, interviewed 6 Staff (S1-S6) and 10 Residents (R1-R10). LPA requested for copies of roof inspection and bids to be forwarded to LPA via email. On 3/10/26 LPA received and reviewed copies of the requested documents (plumbing invoice, invoice for drywall repairs, and Proposal/Bid for Roof repairs) and interviewed 1 Resident (R11) via phone call. (Continued on LIC9099-C) Substantiated Allegation: Facility is in disrepair. It is alleged that there are ongoing leaks throughout the facility that begin on the third floor and extend down to the first floor, several ceiling tiles throughout the facility show water damage, and multiple AC vents are rusted. LPA toured facility and observed multiple areas that indicated previous leaks, observations were made in 2 resident bedrooms, throughout the ceiling panels on the 3rd floor, in the exercise room and dining room ceilings, and on the 1st floor hallway ceiling. LPA interviewed 11 residents and 6 out of 11 residents denied the allegation; 5 of the 11 residents stated they have had leaks in their rooms during the last storm or due to piping issues, but the leaks have since been replaced, all 11 residents stated that they have observed watermarks throughout the facility that suggest there was a leak or water damage. LPA interviewed 6 staff and 5 out of the 6 staff stated they have witnessed leaks in the facility. Interview with S5 and S6 revealed that the facility has had ongoing issues with leaks and plumbing and that they have had repairs done to fix these issues, the facility has had half of the roof repairs and is in process of getting the other half repairs, there has been quotes provided and the licensee is waiting on the owner of the property to agree and make the needed repairs. LPA was provided with the invoice to the most recent pipe repairs in that were completed in the 3rd floor laundry room, during tour LPA observed that the repairs to the laundry room were complete. LPA was also provided with the quote for roof repairs that was dated 2/19/26. Based on LPAs observations, interviews which were conducted and facility record review, the preponderance of evidence standard has been met, therefore the above allegations 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 held, and a copy of this report and appeal rights were provided. Allegation: Facility staff are not responding to call pendants in a timely manner. It is alleged that R1 had experienced a fall in May 2025 and there was no response from the staff, R1 ultimately had to lift themselves back up without assistance. LPA interviewed 11 residents and 10 out of 11 residents denied the allegation; 6 of the 11 residents stated they have used their pendant for assistance and staff responded right away. LPA interviewed 6 staff and each denied the allegation, S1-S3 stated that when a resident pulls their call string or press their call pendant the call goes directly to the them, and if the assigned caregiver is busy assisting another resident they communicate with other caregivers via walkie talkies to ensure the residents are being attended to in a timely manner. Allegation: Facility staff are not meeting residents’ needs. It is alleged that residents are frequently not receiving required assistance, including help returning to their rooms after dinner, toileting assistance, and other routine care needs. LPA interviewed 11 residents and 10 out of 11 residents denied the allegation and stated they feel that staff are meeting their needs, 3 of the 11 residents stated they do see some residents waiting to be assisted at times but this is usually because staff are busy assisting other residents. LPA interviewed 6 staff and each denied the allegation; S3 explained that residents may wait a little longer to be assisted back to their rooms after meals as there are many residents that require assistance that finish their meals at the same time, therefore, there may be a bit of a wait at times. During tour LPA observed residents in the dining, and 3 residents in wheelchairs were observed being assisted by staff to another area. Allegation: Facility staff does not ensure facility is free of mold. It is alleged that there is mold within resident rooms. LPA toured facility and a total of 10 resident rooms were entered and inspected for mold, there was no present mold observed in any of the rooms, LPA did not observe any odors of mold in the rooms. During tour LPA observed ceiling panels missing on the 3rd floor hallway, where the missing panels were LPA observed dark spots and areas that appeared to be mold, S5 stated that there was previously a concerns of mold in the area, however, the area was treated with a mold treatment that kills mold at the root and prevents mold from returning. LPA interviewed 11 residents and 10 out of 11 residents denied the allegation and stated they have not seen any mold in their rooms or in the facility. LPA interviewed 6 staff and 5 out of 6 staff denied the allegation and stated that they have not seen or heard of there being mold in the facility. Based on statements, interviews conducted with staff/residents and review of facility records, there was not enough supportive evidence to concur with the reported allegations. 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, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 12, 2026 · control 28-AS-20260303153553

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 27, 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 as evidence by: During facility tour LPA observed multiple ceiling panels missing, it was confirmed through interviews that there are leaks from the roof when it rains (LPA also observed water marks on the ceiling throughout the facility that also confirms a leak had been present) , and that there have been multiple plumbing leaks and repairs.the state’s words, verbatim · CDSS document, Apr 12, 2026

Plan of correction: Administrator/Licensee provided LPA with Invoices to the repairs for the plumbing repairs and copy of proposal for roof repair. Administrator/Licensee to provide LPA with the scheduled date for the roof repair, provide details on how long repairs will take and if residents will be affected during the repairs. Photos of the ceiling panels being replaced on third floor are to be submitted to LPA via email (tena.herrera@dss.ca.gov). Additionally Administrator/Licensee is to provide LPA with a plan on how they will ensure that facility pluming and roof is in good repair and free from leaks at all times.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA met with Mary Mims-Burris, Executive Director and explained the purpose of the visit. The facility is licensed to serve age range 60 and over, approved for (49) ambulatory and (111) non ambulatory including those in memory care unit with delayed egress. Hospice waiver approved for 15 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. Staff are trained in the proper use of required PPEs. The emergency infection control plan has been reviewed/updated as recommended. The plan was last reviewed on 02/11/2026. Operational Requirement: The plan of operation included the Infection Control Plan. The facility has a Dementia Waiver in place. A hospice waiver for (15) residents is approved. A fire clearance is in place, approved for 49 ambulatory and 111 non-ambulatory with no bedridden residents. Liability Insurance in the amount of ($1,000,000) per occurrence and total amount of general aggregate ($3,000,000) is valid, expires on 09/01/2026. Physical Plant/Environment Safety: The facility is a three story building. The grounds in the facility are well landscaped and have a leveled walkway to the entrance of the building. The facility consists of: First floor: Main lobby, Administrative offices including Executive Director's office, Wellness director office, Resident coordinator office, Assistant director office, Memory care unit, Assisted living resident's rooms, Multi purpose room, Residents' mailboxes, Bistro, Lounge, Library, Dining room, Community laundry room, Unisex bathrooms, (2) Elevators, Kitchen, Pantry and Main patio by the main entrance. Second floor: Assisted living residents' bedrooms, Activity room/lounge, Community laundry room and Unisex bathroom. Third floor: Assisted living residents' bedrooms, Community laundry room, Billiard/Activity room, Gym and Unisex bathroom. 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 is equipped with cameras installed in the hallways near the elevators. Each residents' room has their own bathroom, mini kitchen and balcony. The bathrooms were observed to be clean and operational with grab bars and non skid mats. Cleaning supplies and toxic substances are inaccessible to residents. LPA toured and tested hot water temperature in eight (8) random resident rooms in different floors (Rooms #134, #135, #238, #252, #317, #325) and (Rooms #118, #122) in Memory Care unit. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The kitchen was observed and there was a sufficient amount of perishable and non-perishable food supplies, however, food supplies were not stored in an organized manner. Fire extinguishers were observed throughout the facility and were fully charged, last serviced on 01/09/2026. The carbon monoxide detectors are operable and in compliance. Facility has fire sprinklers. LPA reviewed the annual fire inspection and testing report. Pull Fire alarm system observed and connected to the City of West Covina Fire Department. Delayed egress devices in place. *****REPORT CONTINUED ON LIC809-C**** Staffing: There are adequate staff members to provide care and supervision to the residents, including the Administrator. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Administrator's certificate is valid, expires on 10/02/2027. Personnel Records-Training: LPA reviewed (6) staff files. Proof of staff training, health clearance, vaccinations, food handling certificate, and 1st Aid/CPR training are current. Resident Rights-Information: Resident personal rights and complaint hot line information posters are posted. The facility provides internet services to all residents and have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted outside the main dining room and displayed on a television in the common area. Some special activities were also posted inside the elevators. The facility has a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry area consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. LPA observed that the food supplies are not organized, the refrigerator included left over that were not properly covered and unlabeled food items. LPA also observed personal items such as sweater and a small bag inside the food pantry. Incident Medical and Dental: Residents medications were reviewed containing 30-day supply of medications to confirm medication is given as prescribed and is documented properly. The facility uses the Electronic Medication Administration Record (EMAR) log to document medications given. Medications are centrally stored and locked in the medication room. Facility uses medical carts. Medical and dental transportation is provided. First aid is available in the assisted living and memory care units medication rooms. Resident Records/Incident Reports: A total of ten (10) resident files in both assisted living and memory care units were reviewed. They contained Admission Agreements, ID and Emergency information, Physician's Reports, Pre Placement Appraisal, Functional Capability Assessment, Medical Consent and Personal Rights. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Residents with Special Health Needs: Nine (9) residents are under hospice care and a complete hospice care plan is maintained in the facility. Thirteen (13) residents are using oxygen and "No smoking In Use" signs are posted on the residents doors. Appraisals were observed in resident files. No deficiencies cited. Technical advisories issued. Exit interview conducted and a copy of the report was provided to Mary Mims-Burris, Executive Director.the state’s words, verbatim · CDSS document, Mar 9, 2026

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff are not providing nutritious meals to residents in care.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with Mary Mims-Burris, Executive Director and explained the purpose of the visit. The investigation consisted of the following: LPA conducted a tour of the facility including the kitchen, dining room during lunch time, and observed facility food supply. LPA obtained copies of the staff & resident rosters, dining hours schedule, weekly meal menus for 11/09/2025 - 12/13/202, today's menu and always available menu, Food council minutes (11/28/2025), Residency/Admission Agreement and Resident handbook indicating supplemental charges for additional dining services provided. LPA also reviewed pertinent files for cook staff. Between 11:45am-1:00pm, LPA interviewed Staff #1 (S1) - Staff #4 (S4) and Resident #1 (R1) - Resident #13 (R13). *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: "Staff are not providing nutritious meals to residents in care." It is alleged that residents have not been served nutritious meals, and facility has not provided healthier options like fruits and vegetables. During interviews with the residents, thirteen (13) out of (13) interviewed did not corroborate the allegation. Interviewed residents stated that they like the food served to them and the facility provide them fruits and vegetables all the time. In addition, residents stated that they are satisfied with the quality of the food provided and they also get to choose from the alternate menu if they request for it. During interviews with four (4) staff, all denied the allegation that residents are not provided nutritious meals. S1-S2 stated that they use a meal planning service company to customize and approve menus for the facility. They use (5) weekly menus that they rotate on a quarterly basis and the meal plan/menus are approved by a registered dietitian. Furthermore, S1-S2 indicated that they have not heard any complaints from the residents regarding the nutritious meals they are served. LPA's review of the staff files revealed that the cooks have the proper training and culinary experience. During the tour of the kitchen and dining area, LPA observed that residents were served a balanced plate with lean protein, whole grains, vegetables and a bowl of assorted fruits. LPA also observed sufficient food supply for 7 days non perishables and 2 day perishables including fresh fruits and vegetables. Based LPA's observations and on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate 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 and a copy of this report was provided to Mary Mims-Burris, Executive Director.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 28-AS-20251203083729

Allegation investigated: Facility staff are not preventing resident from bullying other residents in care.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with Mary Mims-Burris, Executive Director and explained the purpose of the visit. The investigation consisted of the following: LPA obtained copies of the staff & resident rosters, Staff in service training (Residents' Rights), House Rules, Resident #1 (R1) and Resident #2 (R2) pertinent files and Incident report. LPA interviewed Staff #1 (S1) - Staff #4 (S4), (S2 was telephonically interviewed at 12:57pm) and Resident #1 (R1) - Resident #12 (R12). In regards to the allegation: “Facility staff are not preventing resident from bullying other residents in care.” It is alleged that on 06/12/2025, R1 was bullied by R2 who has been bullying residents and staff for months without consequence. (4) out of (4) staff interviewed denied the allegation. Staff interviewed stated that the facility conducts internal investigation and do corrective actions on problems immediately. Interview with Staff #1 (S1) revealed that they investigated the incident and spoke with Resident #1 (R1) and Resident #2 (R2) in order to discuss the matter. S1 believed the issue was resolved. ***CONTINUED ON LIC9099-C*** Unsubstantiated Furthermore, S1 checked on R1 the next day, who stated she was doing well. S1 indicated that R2 has been repeatedly reminded of the residents’ rights and the house rules. S1 met with R2 on 06/13/2025 at 2pm to address the issue and R2 was verbally warned that if the behavior continues in the future, R2 must move elsewhere. Today, both R1 and R2 were interviewed, and they believed the issue was resolved. (12) out of (12) residents interviewed feel safe and comfortable in the community. (11) of (12) residents interviewed denied being bullied by other residents. Additionally, residents stated that if they have issues, the staff are always available to talk to and act on resolving the issue right away. Documentation reviewed and interviews conducted do not corroborate this 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 held and a copy of the report was provided to Mary Mims-Burris, Executive Directorthe state’s words, verbatim · CDSS document, Jun 23, 2025 · control 28-AS-20250617164800

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Daniel Konishi conducted the Unannounced required annual inspection. LPA arrived unannounced and met with the Executive Director, Mary Mims-Burris and assisted with the visit. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. The fire clearance is approved for 49 ambulatory and 111 non-ambulatory. Currently, the facility has 11 hospice waiver residents and 6 home health residents. The initial annual visit was conducted on 04/24/2025. During the initial visit the following eight (8) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Infection Control, Operational Requirement, Physical Plant Environmental Safety, Resident Right-Information, Planned Activities, Food Services, Incidental Medical and Dental, Disaster Preparedness. During today’s annual visit, the following four (4) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Staffing, Personnel Records-Training, Resident Records-Personnel Reports, Resident with Special Health Needs. Staffing: Facility has sufficient staffing for care and supervision to the residents. Personnel Records-Training: All the staff in the facility are over 18 years old and fingerprint cleared with the facility. The administrator is Mary Mims-Burris and her administrator certificate expires on 10/02/2025. LPA reviewed all nine (9) staff files and they all have the required documents in file which included: health screening, TB test result, employee rights, required training hours and updated first aid certificate. Resident Records-Incident Reports: LPA inspected eleven (11) residents files which include eight (8) residents files from Assisted Living and three (3) residents files from Memory Care and they all have the required documents in file which included: admission agreements, Physician's Reports, Updated Needs and Service Plan, Pre-appraisal, TB clearance, Physician’s Orders, Personal Rights, and medication records. Resident with Special Health Needs: No residents in the facility with prohibited health conditions. No residents in the facility with postural supports. Currently there are eleven (11) residents on hospices and six (6) residents on home health. Individual Service Plan and appraisals are on resident's files for home health and hospice. There are interior and exterior space available on the facility premises to permit residents with dementia to wander freely and safely. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit Interview conducted and a copy of the report were provided to the Executive Director, Mary Mims-Burris.the state’s words, verbatim · CDSS document, Apr 29, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Daniel Konishi conducted the Unannounced required annual inspection. LPA arrived unannounced and met with the Executive Director, Mary Mims-Burris and assisted with the visit. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. The fire clearance is approved for 49 ambulatory and 111 non-ambulatory. Currently, the facility has 11 hospice waiver residents and 3 home health residents. On today's date, LPA inspected the eight (8) domains include: Infection Control, Operational Requirement, Physical Plant Environmental Safety, Resident Right-Information, Planned Activities, Food Services, Incidental Medical and Dental, Disaster Preparedness. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Operational Requirement: The current plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 15 residents is approved. A fire clearance approved for 49 ambulatory and 111 non-ambulatory with no bedridden residents. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($2,000,000) is in place. Physical Plant and Environmental Safety: The facility is a three-story building. The first floor includes memory care unit and assisted living resident's rooms, main lobby, administrative office, Bristol, wellness director office, two activity rooms, resident coordinator office, assistant director office, Chart room, Library, Multi-purpose room, resident mailbox, community laundry room, dining room and facility kitchen. The 2nd floor includes laundry room, activity room, unisex bathroom and assisted living residents' rooms. Physical Plant and Environmental Safety [Cont.]: The 3rd floor include laundry room, activity room, exercise room and unisex bathroom and assisted living residents' rooms. During the facility tour, LPA inspected Room #106, #108. #122, #123, #218, #220, #221, #320 and #321, #335, #351 and they all have sufficient lighting and required furniture in the residents’ rooms. For the resident bathrooms, they are clean, sanitary and in a good working condition. All the residents’ bathrooms have the required Nonskid mat and grab bar in the bathtub and toilet. LPA tested the hot water temperature and they are between 116.8-degrees F and 123.4-degrees F (Rm#106 was 122.1 degrees F, Rm#108 was 123.2 degrees F, Rm#218 was 123.4 degrees F, Rm#220 was 121.8 degrees F, Rm#335 was 122.8 degrees F, and Rm#351 was 121.4 degrees F) which are not within the Tittle 22 regulation. The carbon monoxide detector is located in the laundry room and it's working properly. LPA reviewed the annual fire inspection and testing report via the state fire marshal and everything is working well. All the cleaning solutions and chemicals are locked in the janitor room and inaccessible to the residents. Facility has a telephone service on the premises. The backyard / rear grounds of the facility is well landscaped and the passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris and the trash can or containers have the covered lids. Resident's Right Information: LPA observed the required posters posted nearby the residents' mailbox which include Long Term Care Ombudsman, Community Care Licensing Complaint and Personal Right Poster. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted and LPA reviewed the calendar for both Assisted Living and Memory Care Unit. The facility does have an active Resident Council. Food Services: Currently the facility has about 3 residents in the Assisted Living and 2 residents in the Memory Care Unit are required to have modified diet. The facility has ample supply for two days perishable and seven days non-perishable food supply. The facility kitchen is clean and kept free of litter, rodents and insects. All food in the facility are stored properly. [Continue in LIC809-C] Incidental Medical and Dental: LPA inspected twelve (12) residents' medication which include nine (9) from Assisted Living and three (3) from Memory Care Unit and they are centrally stored and locked in the medication room and they seemed accurate and updated and also contained 30 days’ supply of medication. The facility would also provide medical and dental transportation if needed Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610E) and it’s updated on 01/08/2025. The last fire drill was conducted on 03/11/2025. The facility has two temporary alternative shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training. Due to time restraint and LPA was not able to complete the full inspection tool and interview residents and staff and LPA will come back at another time to complete. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809-D. Exit Interview conducted and a copy of the report with appeal rights were provided to the Executive Director, Mary Mims-Burris.the state’s words, verbatim · CDSS document, Apr 24, 2025

Allegation investigated: Staff speaks inappropriately to resident in care Facility is in disrepair

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent compliant investigation visit regarding the above allegations. LPA met with Mary Mims Burris Executive Director and explained the reason for the visit. The investigation consisted of the following: On 3/6/25 LPA Deleon and LPM Fierros conducted an unannounced complaint investigation visit and toured the facility, obtained a copy of the staff and resident roster, resident #1's face sheet, admission agreement, and medical assessment, repair invoices from February to March 2025. LPA conducted interviews with administrator and staff 1 (S1) and resident #1(R1) . On 3/25/25 LPA Flores conduced interviews with 9 residents and 7 staff, requested work orders, LPA toured room #354 and #206 and delivered findings. The investigation revealed the following: Regarding allegation: Staff speak inappropriately to resident in care. It is alleged staff is harassing resident for disrepairs in the room. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with residents revealed 9 out of 9 residents interview stated staff are respectful, calm when addressing residents, and helpful around the facility. One resident stated to have felt blamed over an incident with the physical plant of the facility. Interviews with staff revealed 7 out of 7 staff stated staff are respectful when speaking to the residents, communication with residents is professional, and they always maintain a calm manner. Administrator stated that upon an incident with that resulted in a lot of damage from a resident’s shower, administrator questioned the resident how the handle broke. However, Administrator did not blame the resident of using tools to break the shower handle. Therefore, although the resident felt administrator was blaming the resident for breaking the shower handle there is not sufficient evidence or witnesses to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility is in disrepair. It is alleged bathroom handle broke on 2/14/25 and resident reported it many times prior to that, which has resulted in resident not being able to shower in own bathroom. Interviews with residents revealed 8 out of 9 residents have either not experience anything in their rooms to be in disrepair or facility’s staff have successfully repair reported items in a timely manner. 1 out of 9 residents stated to have had difficulties with shower handle and on one occasion the shower handles broke, with water gashing out. Per R1 since the shower in their room was out of order, facility staff provided assistance in a vacant room to use the shower while the shower was repaired. Interviews with staff revealed when an item is reported to be repaired in the residents’ room, maintenance is quick to respond and finish repairs. Interview with maintenance assistant revealed, staff responded three times prior the incident in which the water gashed and replace parts inside the shower handle or shower handle. Per maintenance staff the shower handles are all uniform in each room and replacement supplies are the same as well. They also stated that the mechanism of the shower handle must be treated in a gentle manner without excessive turns or turning all the way as the screw inside can break off. Which is what happened in room #354’s shower handles each time it was replaced. Per maintenance assistance, the three times the shower handle was repaired, staff explained to the resident how to use the shower handles to prevent them from breaking again. Administrator explained that the last time the shower handles broke, the shower was out of order for a couple of weeks as they had to replace the dry wall and provided a similar mechanism to the shower handle which has been better for the resident. During facility's tour conducted on 3/6/25 and 3/25/25 facility was observed in good repair. (CONTINUED ON LIC 9099C) Documents reviewed revealed maintenance staff responded to the following work order dates in room #354; On 12/30/24 staff greased the area of shower handle. On 1/15/25 staff removed and replaced the shower handles. On 1/19/25 shower cartridge was replaced. On 2/1/25 shower cartridge was replaced. Incident report dated 3/7/25 notes incident occurred on 2/14/25 in which “shower stem broke into the wall.” Although the shower handles broke more than once, facility staff replaced it each time and assisted R1 with guidance to use the handles properly. Therefore, this allegation is unsubstantiated. 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 was conducted with Mary Mims Burris and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 25, 2025 · control 28-AS-20250225160630

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Christine Wong conducted an Annual/Required visit by using the Compliance And Regulatory Enforcement (CARE) Tools on 03/12/24 but due to time restrains and LPAs Christine Wong and Daniel Konishi has returned on today's date 03/14/24 to finish the remaining Ten ( 10) domains. LPA met with Receptionist Debbie Golden who allowed entry into the facility and Shortly after, the Administrator Mary Mims-Burris arrived and assisted with the visit On today's date, LPA inspected the Nine (9) domains include: Infection Control, Operational Requirement, Staffing, Personnel Records-Training, Resident Right-Information, Planned Activities, Incidental Medical and Dental, Resident Records and Incident reports, Disaster Preparedness and Residents with Special Health Needs. 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirement: The current plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 15 residents is approved. A fire clearance approved for 49 ambulatory and 111 non-ambulatory with no bed ridden residents. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($2,000,000) is in place. 3. Staffing- Facility has sufficient staffing for care and supervision to the residents. 4. Personnel Records-Training: All the staff in the facility are over 18 years old and fingerprint cleared with the facility. The administrator is Mary Mims-Burris and her administrator certificate expired on 10/2/23 and currently is pending application in our internal CCL system since 10/3/23. LPA reviewed all 10 staff files and they all have the required documents in file which included: health screening, TB test result, required training hours and updated first aid certificate. 5. Resident's Right Information: LPA observed the required posters posted nearby the residents' mailbox which include Long Term Care Ombudsman, Community Care Licensing Complaint and Personal Right Poster. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician. 6. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted and LPA reviewed the calendar for both Assisted Living and Memory Care Unit. The facility does have an active Resident Council. 7. Incidental Medical and Dental: LPA inspected eight (8) residents' medication which include (3) from Assisted Living and (5) from Memory Care Unit and they are centrally stored and locked in the medication room and they are seemed accurate and updated and also contained 30 days supply of medication. The facility would also provide medical and dental transportation if needed. 8. Resident Records-Incident Reports: LPA inspected 10 residents files and they all have the required documents in file which included : admission agreements, Physician's Reports, Updated Needs and Service Plan, Pre-appraisal, TB clearance, Physician's Orders, medical consent, and medication records. 9. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610E) and its updated on 03/2024. The last fire drill was conducted on 01/18/24 The facility has two temporary alternative shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training. 10. Resident with Special Health Needs. No residents in the facility with prohibited health condition. Currently there are 11 resident on hospices and two residents on home health. Individual Service Plan and appraisals are on resident's files for home health and hospice. Exit Interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 14, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Wong conducted the Unannounced required annual inspection. LPA arrived unannounced and met with Administrator Mary Mims-Burris and assisted with the visit. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. The fire clearance is approved for 49 ambulatory and 111 non-ambulatory. Currently, the facility has 11 hospice waiver residents and 3 home health residents. On the above date, LPA completed the domain of Physical plant and environmental safety and food service today. Physical Plant and Environmental Safety: The facility is a three story building. The first floor includes memory care unit and assisted living resident's rooms, main lobby, administrative office, Bristol, wellness director office, two activity rooms, resident coordinator office, assistant director office, Chart room, Library, Multi-purpose room, resident mail box, community laundry room, dining room and facility kitchen. The 2nd floor includes laundry room, activity room, unisex bathroom and assisted living residents' rooms. The 3rd floor include laundry room, activity room, exercise room and unisex bathroom and assisted living residents' rooms. During the facility tour, LPA inspected Room #135, #106. #123, #117, #221, #216, #250, #353, #320 and #321 and they all have sufficient lighting and required furniture in the residents rooms. For the resident bathrooms, they are clean, sanitary and in a good working condition. All the residents bathrooms have the required Non skid mat and grab bar in the bath tub and toilet. LPA tested the hot water temperature and they are between 112.4 and 116.6 degrees F which are within the Tittle 22 regulation. The carbon monoxide detector is located in the laundry room and it's working properly. LPA reviewed the annual fire inspection and testing report via the state fire marshal and everything is working well. All the cleaning solutions and chemicals are locked in the janitor room and inaccessible to the residents. Facility has a telephone service on the premises. The backyard / rear grounds of the facility is well landscaped and the passageways are free of obstruction. The outdoor activity area is free of visible hazards and debris and the trash can or containers have the covered lids. Food service: Currently the facility has about 12 residents in the Assisted Living and 2 residents in the Memory Care Unit are required to have modified diet and LPA reviewed and observed the doctor's order. The facility has ample supply for two days perishable and seven days non-perishable food supply. The facility kitchen is clean and kept free of litter, rodents and insects. All food in the facility are stored properly. Due to time restraint and LPA was not able to complete the full inspection tool and interview residents and staff and LPA will come back at another time to complete. On today's date, there's no deficiencies were observed. Exit Interview and copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 12, 2024