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Allegation investigated: Due to staff neglect, resident sustained severe injuries. Staff retained a resident with a prohibited health condition.

On 05/28/2026, at approximately 10:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint investigation findings regarding LIC802 - Complaint Report #21-AS-20251212082305, which was received by Community Care Licensing (CCL) on 12/12/2025. Reporting Party alleges due to staff neglect, resident sustained severe injuries and staff retained a resident with a prohibited health condition. LPA met with Manuel Baldeo, Designated Responsible Party (DRP). On 12/8/2025, Resident 1 (R1) presented to the hospital with an unstageable pressure wound to their coccyx area, stage II pressure wound to their left hip, and fluid-filled blisters on both heels. R1’s recurrent coccyx injury was present but almost fully healed upon their admission to the facility (9/24/2025). No other wounds were present at the time. Continued on LIC9099C... Substantiatedthe state’s words, verbatim · CDSS document, May 28, 2026 · control 21-AS-20251212082305

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff neglect resulted in resident sustaining a fracture

On 12/09/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint #21-AS-20250701084339 investigation findings and met with Lia Miller, Director of Operations. Reporting Party (RP) alleges that staff neglect resulted in resident sustaining a fracture. LPA Florio conducted 10-day complaint investigation visit on 07/01/2025 and obtained documents, made observations, and conducted interviews. On 6/25/2025, at about 1927 hours, Resident 1 (R1) was admitted to a local emergency department (ED) with complaints of a swollen leg and was diagnosed with a right femur fracture and a hip fracture. On 6/26/2025, R1 had surgery for a hip fracture where a cephalomedullary nail was inserted. R1 was diagnosed with a comminuted proximal femur fracture with a non displaced neck component. Several staff interviews revealed consistent statements of not knowing how R1 had sustained an injury given that R1 was bed bound and unable to get out of bed on their own. Continued othe state’s words, verbatim · CDSS document, Dec 9, 2025 · control 21-AS-20250701084339

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff handled residents in a rough manner Staff left residents in wet briefs for extended periods of time Staff bathed resident with cold water Staff overmedicated residents

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation Staff, residents and persons responsible for the residents were interviewed. Four unannounced site visits were conducted and pertinent documents obtained and reviewed. The following determinations are made: No evidence of medication errors or abuse of residents was found; The "Incontinent Care & Toileting Residential Documentation logs for a 60 day period before and after receipt of the complaint indicate residents were checked and changed appropriately; Three of the four showers on site are functioning properly with hot water; All family members with residents in care that were interviewed have indicated satisfaction with the care provided; The Hospice nurses notes for the two Hospice patients interviewed indicate no abuse and good care being provided by staff. Although the allegations may be true, based on statements and documents, ththe state’s words, verbatim · CDSS document, Aug 20, 2024 · control 21-AS-20240419124724

Allegation investigated: Staff did not treat resident with dignity and respect. Staff interfered with resident’s visits.

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:30AM to deliver findings regarding the above allegations. LPA was greeted by staff, and Administrator, Babita Dhawan arrived shortly after. LPA and Administrator discussed the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews, made observations, and reviewed documents. Complaint alleges that staff did not treat resident with dignity and respect. Residents interviewed indicated that they are treated well at the facility. Staff interviewed indicated that they have not witnessed other staff treating residents poorly. Continued on LIC9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 26, 2024 · control 21-AS-20240125155602

Allegation investigated: Insufficient staffing Food is not being served at appropriate temperature

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:30AM to deliver findings regarding the above allegations. LPA was greeted by staff, and Administrator, Babita Dhawan arrived shortly after. LPA and Administrator discussed the purpose of the visit. Complaint alleges there is insufficient staffing. Throughout the course of the investigation, LPA conducted interviews, made observations, and reviewed documents. Administrator and staff confirmed that there are multiple residents who require a two person assist. Based on document review, there is one staff on during night shift. Facility has a memory care unit as well as an assisted living unit. In order for staff to assist residents in one department, it requires them to leave residents in another department unattended. Based on document review and interview, facility does not have sufficient staffing to meet resident needs. Continued on LIC9099-C Substantiatedthe state’s words, verbatim · CDSS document, Apr 26, 2024 · control 21-AS-20240216103748

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff left the medication room door open making medications accessible to residents in care

At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Administrator Babita Dhawan, toured the building, reviewed records and interviewed staff. On a previous visit, 07/18/2023, LPA toured the building and observed the door to the medication room did not close securely. The door swung closed, but did not latch, causing the door to be left unsecured. LPA observed the door was left unsecured when staff left the area. LPA advised the facility to address the issue immediately. LPA observed during this visit the door has been repaired and it closes securely. LPA observed the medication technician ensure the door is secured before they leave the area. Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations (CCRs),the state’s words, verbatim · CDSS document, Oct 2, 2023 · control 21-AS-20230711112325