Ardent Care

Allegation investigated: Unlawful eviction

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint received August 31, 2026. LPA Haley was greeted by staff and explained the reason for the visit upon entry. Regarding the allegation: Unlawful eviction During the investigation 3 of 3 individuals confirmed the complaint allegation. During interviews it was discovered, Resident 1 (R1) was sent to the hospital on August 27, 2026, because the resident would not allow staff to change the resident after a bowel movement. Upon arrival at the hospital, R1 was discharged the same day (8.27), and when the hospital staff called Ardent Care regarding R1’s discharge, the hospital Social Worker was told R1 can not come back to Ardent Care. During an interview with the facility Administrator Melinda Flores, it was confirmed hospital staff were told R1 can not come back to the facility. Continued on LIC9099C Substantiated Eventually Administrator Flores was told by the facility ombudsman that R1 needs to be accepted back to the facility and properly served an eviction notice and the Administrator agreed. However, R1 was discharged from the hospital to a Skilled Nursing Facility (SNF) and a placement agency has found new placement for the resident. Based on the evidence gathered during interviews and document review, the preponderance of evidence standard has been met, therefore, the allegation is found to be substantiated. A violation is being cited per California Code of Regulations Title 22. An exit interview was conducted, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 2, 2026 · control 22-AS-20260831081143

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87244(a) · Plan of correction due date: Sep 4, 2026

87224 (a)Eviction Procedures - The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty days written notice to the resident is required...This requirement was not met as evidenced by: Based on interview confirmation, Resident (1) was not allowed to come back to the facility after being sent to the hospital on August 27, 2026. R1 was discharged from the hospital the same day, August 27, 2026, and the facility refused to allow R1 to return to the facility.the state’s words, verbatim · CDSS document, Sep 2, 2026

Plan of correction: Administrator Flores will read and review the regulation section on Eviction Procedures and send a signed statement of acknowledgment and understanding to LPA Haley by 1:00pm on the POC due date (9.4).

Type of visit: Required - 1 Year

On today's date Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of completing an annual inspection. Upon arrival LPA was greeted and granted entry to the facility by facility staff. LPA explained the purpose of the visit, and Executive Director (ED) Melinda Olivarez-Flores was notified and was made available in order to assist LPA with the annual inspection. LPA began a tour of the facility and observed the following. The ED has a pending Administrator certificate. The facility is a one storied building equipped with 12 shared bedrooms and 3 private bedrooms, additionally the 12 shared bedrooms are equipped with there own restrooms, and the 3 private bedrooms are equipped with half bathrooms and have separate shared shower rooms. The facility is equipped with an outdoor shaded courtyard available for resident use. LPA observed the kitchen area to be clean and free of any mildew and debris, LPA observed all sharps and toxins to be locked away and inaccessible to residents in care. LPA observed the kitchen area to have a refrigerator and freezer that appeared to be in good repair and tested operational. LPA observed facility to have a two day supply of perishable food and a seven day supply of non-perishable food, and a sufficient amount of emergency water on hand. LPA observed all resident bedrooms to be large enough to walk about freely and accommodate all required furnishings including the following: A chest of drawers, a bed, clean linens in good repair; meaning no strains or tares, a reading lamp, and enough storage space to store personal belongings. LPA observed all resident restrooms to be clean and free of any mildew and debris. LPA observed restrooms to have required furnishings including the following: Grab bars, slip resistant floor matts, and a shower chair available if needed. Hot water temperature tested between 114.3 and 115.4 degrees Fahrenheit. CONTINUED ON LIC809-C LPA observed all smoke detectors and carbon monoxide detectors to be in good repair, and tested operational. LPA observed several fire extinguishers throughout the facility, and all fire extinguishers were fully charged and have an updated service tag attached to it. LPA observed first aid kit to have all required items including the following: Scissors, tweezers, adhesive tape, bandages, a thermometer, and a first aid manual. LPA conducted a tour of the exterior of the facility and observed the following: The exterior is equipped with a shaded quad area, and a side exit route that consists of unlocked doors and is free of any obstructions and hazards along the exit routes. LPA reviewed seven resident files and five staff files all files (staff and resident) had all required items. All staff annual training was complete and documented correctly. LPA reviewed medications. Per LPA review all medications are being administered per physicians orders. Based on observations and record review made during today's inspection no deficiencies will be issued per title 22 chapter 6 division 8 of the California code of regulations.the state’s words, verbatim · CDSS document, Jul 28, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct a Case Management visit. LPA was greeted and granted entry by staff. LPA met with Assistant Administrator (AA) Alex Blancarte and discussed the purpose of the visit. Administrator (AD) Melinda Flores was notified of LPAs presence at the facility and was available by phone to assist. LPA collected documents in congruent with complaint control # 22-AS-20210520100831.the state’s words, verbatim · CDSS document, May 6, 2026

Allegation investigated: Staff did not provide records to responsible party in a timely manner Lack of care and supervision for resident led to multiple falls

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct an investigation into the above mentioned complaint allegation. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Melinda Flores and discussed the purpose of the visit. The investigation into the allegation of staff did not provide records to responsible party in a timely manner revealed the following: It was alleged that documents were requested from Resident #1 (R1)s file and they were not received in a timely manner. LPA reviewed text messages and emails sent between Witness #1 (W1) and facility staff of W1 requesting R1s admission agreement on Tuesday February 3, 2026. LPA reviewed an email exchange between W1 and Witness #2 (W2) on February 14, 2026, where W2 provided the information to W1. W1 also requested fall/ incident reports from facility staff on February 16, 2026, and as of February 26, 2026, W1 still had not received the documents requested. LPA observed W1 as the responsible party/emergency contact for R1. Continue on LIC9099C Unsubstantiated LPA did not observe conservator papers or Power of Attorney(POA) paperwork in R1s file naming W1 as their authorized individual for the facility to share documentation with. Interviews with AD revealed that W1 requested documentation and the documents had to be sent by postal mail due to the facility scanner not working properly. AD requested a postal address from W1 and never received it. AD informed LPA that W2 came to the facility to pick up the documentation to send to W1 electronically on behalf of AD. AD informed LPA that R1 did not have a POA and was not conserved. The investigation into the allegation of lack of care and supervision for resident led to multiple falls revealed the following: It was alleged that R1 is lacking care and supervision by facility staff due to R1 having five or more falls while residing at the facility. LPA reviewed an Admission Agreement for R1 stating that they were admitted to the facility on February 26, 2024. LPA reviewed a physicians report for R1 dated August 20, 2025, stating that R1 has a diagnosis of Dementia, does not have motor impairment, is able to transfer to and from bed and is non ambulatory. This report was signed and dated by a medical professional. LPA reviewed incident reports regarding R1 from May 22, 2025, through January 19, 2026. LPA reviewed that R1 had three unwitnessed falls, four witnessed falls and one fall due to an aggressive act to another resident. LPA reviewed the incident reports to state that the witnessed falls were due to another resident moving R1s chair or R1 tripping. LPA reviewed a staff schedule for December 2025 through February 2026 that indicates four to five staff for the AM shift, three to four staff for the PM shift and two staff for the NOC shift. Interviews with staff revealed 3 of 3 staff informed LPA that R1 had witnessed falls due to R1 being aggressive and tripping. 3 of 3 staff informed LPA that R1 would trip due to attempting to get up and start walking even if something was in their way. 3 of 3 staff informed LPA that the falls are not due to a lack of care and supervision but due to the staff not being able to react fast enough when they see R1 moving and not observing what was in front of them. 2 of 3 staff informed LPA that R1s latest fall was due to R1 tripping over their wheel chair foot rests before attempting to ambulate. LPA interviewed 4 residents in care and 1 of 4 residents informed LPA that they feel safe at the facility, have never fallen and staff is always there to assist them. 3 of 4 residents did not confirm or deny the quality of care and supervision provided at the facility including R1. LPA observed R1 attempt to get up and ambulate without moving the objects in front of their feet. LPA observed staff assist R1 move the objects so that R1 would not trip and fall. Continue on 9099C LPA reviewed staff training conducted on February 5, 2026, on topics such as resident on resident bullying and recognizing a change in condition. Based on interviews conducted, observations and records reviewed the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 22-AS-20260206155019

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct a health and safety check in regards to the quality assurance noncompliance plan. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Melinda Flores and Assistant Administrator (AA) Alex Blancarte and discussed the purpose of the visit. LPA toured the facility and checked on residents in care. LPA observed the water to be between 113.9 and 116.6 degrees Fahrenheit in the resident restrooms. LPA observed the facility to have a two day perishable and seven day non perishable food supply on hand. LPA observed residents playing games in the activity room and watching tv in the living room. Residents appeared clean and well taken care of and expressed no concerns. LPA reviewed resident medications and no discrepancies were observed. LPA reviewed daily monitoring logs from December 1, 2025 through February 28, 2026 for all residents in care. Based on today's observations no deficiencies are being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 24, 2026

Allegation investigated: Narcotics are not properly destroyed. Staff are not properly trained. Facility did not have sufficient food. Facility staff are not following infection control practices. Facility staff did not meet the residents' needs.

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to investigate the above mentioned complaint allegations. LPA was greeted and granted entry by staff. LPA met with Assistant Administrator (AA) Alex Blancarte and discussed the purpose of the visit. The investigation into the allegations of Facility did not have sufficient food, Staff are not properly trained, Narcotics are not properly destroyed, Facility staff are not following infection control practices and Facility staff did not meet the residents' needs revealed the following: Regarding the allegation of narcotics are not properly destroyed, it was alleged that the facility Administrator was storing narcotics in their desk. LPA observed no medications found in the Administrators desk, credenza, shelf or closet. LPA observed no narcotics found in the Assistant Administrators desk or credenza. Continue on LIC9099C Unfounded Interviews with three of four staff revealed that narcotics are destroyed by two staff members and that they keep a destruction log at the facility. Two of four staff informed LPA that if the resident is on hospice, the LVN will destroy the medications before leaving the facility. One of four staff informed LPA that they have never destroyed medications at the facility due to their position. LPA observed a destruction of medication list for Resident#1 (R1) dated December 10, 2025 for two controlled substances that were destroyed by a hospice care nurse as well as a disposal lists for R1 and Resident #2 (R2) with two staff signatures on every entry during their stay at the facility until they left the facility. Therefore, the facility allegation of narcotics are not properly destroyed has been deemed UNFOUNDED. Regarding the allegation of Staff are not properly trained revealed the following: It was alleged that staff had not been trained on how to assist residents with transferring from a wheelchair. LPA observed an in service training dated July 2, 2025, covering topics of postural supports and caring for residents with dementia. LPA conducted interviews with residents and two of three residents were unable to confirm or deny if they have been injured due to staff assisting them in and out of their wheelchair. LPA observed faint bruising on two of three residents arms where the wheelchair lines up. LPA observed two of three residents fidgeting with their wheelchair and their arms hitting the wheelchair where the faint bruising was observed. Therefore, the facility allegation of Staff are not properly trained has been deemed UNFOUNDED. Regarding the allegation of Facility did not have sufficient food revealed the following: LPA observed the kitchen and pantry to have more than a two day perishable and seven day nonperishable food supply on hand. Interviews with four of four staff revealed that the facility has not had any issues with the food supply. One of three residents informed LPA that they get enough to eat and has not had a problem with getting food. Two of three residents were unable to confirm or deny the allegation. Therefore, the facility allegation of Facility did not have sufficient food has been deemed UNFOUNDED. Regarding the allegation of Facility staff are not following infection control practices revealed the following: It was alleged that staff are not disposing of their gloves before assisting in the dining room and kitchen. LPA observed the facility infection control plan that states facility staff are to perform hand hygiene before and after assisting residents with medications, food or assisting with bodily fluids. Four of four staff informed LPA that they are trained to take the gloves that are being used to assist residents off in the same room or bathroom that they are assisting the resident in. Continue on LIC9099C Four of four staff informed LPA that they are to dispose of the gloves, wash their hands and sanitize before moving on to prevent cross contamination in the facility. Three of four staff informed LPA that they are to not wear gloves in the facility hallways to ensure that they are following infection procedures. One of three residents informed LPA that staff are always sanitary. Two of three residents were unable to confirm or deny the allegation. LPA did not observe staff with gloves on outside of resident rooms or bathrooms. LPA observed an in service training dated February 6, 2025, and May 1, 2025, regarding facility protocols and infection control. Therefore, the allegation of Facility staff are not following infection control practices has been deemed UNFOUNDED. Regarding the allegation of Facility did not meet the residents’ needs revealed the following: It was alleged that staff are not hydrating residents as well as not providing a Hoyer lift for R2 causing them to be left soiled for an extended period of time. LPA observed an in service training dated August 27, 2025, covering topics of hydration and feeding. LPA observed a water dispenser for resident use in the facility lobby. LPA observed residents use the water dispenser for hydration needs. LPA observed staff filing cups and giving them to residents as needed. LPA observed a Patient Information Packet from Motion Complex Rehab rental agreement for a Hoyer lift and solid sling for R2. LPA observed a delivery ticket from Motion Complex Rehab dated December 2, 2025, stating that the lift had been delivered to the facility address. LPA interviewed residents and one of three residents informed LPA that all of their needs are taken care of. Two of three residents were unable to confirm or deny the allegation. Therefore, the allegation of Facility staff did not meet the resident’s needs has been deemed UNFOUNDED. The Department has investigated the above mentioned complaint allegations and based on observations, interviews and records reviewed, the above allegations have been deemed UNFOUNDED. This means that the allegations are false, could not have happened and/or is without a reasonable basis. The Department therefore has dismissed the complaint. An exit interview was conducted and a copy of this report was left at the facility. Upon interviews with staff it was revealed that one of four staff informed LPA that the staffing has improved but could be better. One of four staff informed LPA that the facility has been good with staffing and the residents needs are being met. One of four staff informed LPA that they are able to cover the shifts of the individuals that call out to ensure there is staff present to meet the residents needs. Upon interviews with one of three residents it was revealed that staff assist them and their needs are all met. Two of three residents could not confirm or deny the allegation. Although the above allegation may have happened there is not a preponderance of evidence to prove the alleged violation occurred; therefore the allegation facility did not ensure adequate staffing is deemed UNSUBSTANTIATED. Therefore, the Department dismisses the allegations. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 26, 2026 · control 22-AS-20251205141512

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct a health and safety check in regards to the quality assurance noncompliance plan. LPA was greeted and granted entry by staff. LPA met with Assistant Administrator (AA) Alex Blancarte and discussed the purpose of the visit. LPA toured the facility and checked on residents in care. LPA observed the water to be between 105.8 and 108.8 degrees Fahrenheit in the resident restrooms. LPA observed the facility to have a two day perishable and seven day non perishable food supply on hand. LPA observed residents playing games in the activity room and relaxing in the living room. Residents appeared clean and well taken care of. LPA reviewed daily monitoring logs and weekly medication audits for the weeks of September 9, 2025, through November 29, 2025 with notations of missing medtech signatures. LPA observed an in service conducted on November 25, 2025, regarding missing signatures on the medication administration record. LPA reviewed resident medications and observed signatures missing for two of five residents in the MAR. Based on today's observations a citation is being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AA Alex Blancarte and a copy of this report, LIC809D and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jan 6, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(3) · Plan of correction due date: Jan 20, 2026

87465(c)(3) Incidental Medical and Dental Care A record of each dose is maintained in the resident's record... This requirement was not met as evidence by: LPA observed 2 of 5 residents to not have the medication administration record signed off when medications have been given. This poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 6, 2026

Plan of correction: LPA observed an in service regarding medication signatures on November 25, 2025. Licensee stated they will write a medication policy regarding the MAR and do an in service on said policy and send proof to LPA by POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit for the purpose of conducting a health and safety check. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Melinda Flores and Assistant Administrator Alex Blancarte and discussed the purpose of the visit. LPA is following up on a death report that was submitted to the Regional Office on December 9, 2025, for Resident #1 (R1). LPA toured the facility and conducted a health and safety check on all residents in care. LPA obtained pertinent documentation from R1s facility file. No deficiencies were noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 11, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit for the purpose of conducting a Plan of Correction inspection for deficiencies issued on October 29, 2025 during complaint investigation 22-AS-20250930102714. LPA was greeted and granted entry by staff. LPA met with Administrator(AD) Melinda Flores and Assistant Administrator Alex Blancarte and discussed the purpose of the visit. LPA toured the facility and observed a two day perishable and seven day nonperishable food supply on hand. LPA observed a plan of action for future grocery trips so the facility is within regulations regarding the food supply on hand created by the AD of grocery deliveries being done twice a week with monitoring the food supply. Thus clearing the deficiency cited 87555(b)(26). LPA observed no cameras in resident rooms and observed a policy written by the AD regarding in-room cameras. LPA observed the policy to include consent, monitoring, access and no sound to be recorded. LPA observed the policy to adhere to residents personal rights and to stay in compliance with Title 22 Division 6 of the California Code of Regulations. Thus clearing the deficiency cited 87468.1(a)(2). Based on today’s observations the Plan of Corrections have been fulfilled by the assigned due date of October 31, 2025. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 12, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit for the purpose of conducting a case management to amend the LIC809D page from the complaint investigation 22-AS-20250930102714. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Melinda Flores and Assistant Administrator Alex Blancarte and discussed the purpose of the visit. LPA changed the section cited from 87469.1(a)(2) Personal Rights of Residents in all Facilities to the correct section of 87468.1(a)(2) Personal Rights of Residents in all Facilities. An exit interview was conducted with AD and a copy of this report along with amended LIC809D and Plan of Correction clearance letters were left at the facility.the state’s words, verbatim · CDSS document, Nov 12, 2025

Allegation investigated: Staff do not provide adequate food service Staff installed video camera with audio without resident's consent Staff did not ensure resident has hot water in the bathroom

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to investigate the above-mentioned complaint allegations. LPA was greeted and granted entry by staff. LPA met with AD Melinda Flores and Alex Blancarte and discussed the purpose of the visit. The investigation into the allegations of staff do not provide adequate food service, staff installed video camera with audio without resident's consent and staff did not ensure resident has hot water in the bathroom revealed the following: Regarding the allegation of staff do not provide adequate food service, LPA observed food menus for five cycles. The menus had a variety of fresh nutritious options for residents in care. LPA toured the facility kitchen and did not observe an adequate two-day perishable and seven day nonperishable food supply on hand. LPA observed staff walking into the facility with grocery bags. Continue on 9099C Substantiated Upon interviews with Staff 1(S1) it was revealed that they sent staff to the grocery store because they knew the food was going to be an issue. Therefore, the allegation has been deemed Substantiated. Regarding the allegation of staff installed video camera with audio without resident’s consent revealed the following: LPA toured the facility and observed a camera in room four. LPA observed text message screenshots with Resident 1s (R1) responsible party with S1 stating that on August 28, 2025, the camera was installed with a live feed picture of room four showing the two residents’ beds. LPA observed text messages from S1 saying that R1 had been informed of the camera and that they will be in R1s room indefinitely. At the time of the inspection S1 showed LPA that the feed is offline and no longer connected to the camera. S1 informed LPA that they left it there even though the feed is offline due to resident complaints going down since it has been installed. S1 informed LPA that they asked the responsible parties of the residents in room four to gain consent before installing the camera. S1 informed LPA that they are the only one that has access to the camera feed. Staff 2 (S2) informed LPA that it was suggested by S1 to put the camera in room 4 and that they asked the responsible parties of room 4 for consent. S2 informed LPA that the residents are not conserved and that S1 was the only one with access to the camera feed. Interviews with R1 revealed that they were not asked if they wanted the camera, but their responsible party gave consent. LPA did not observe conservatorship papers for R1 for this decision to be made on R1s behalf. LPA observed staff remove the camera from room four entirely at the time of the investigation. Therefore, the allegation has been deemed Substantiated. Regarding the allegation, staff did not ensure residents have hot water in the bathroom revealed the following: LPA toured the facility and went into R1s room and tested the water to be at 109.4 degrees Fahrenheit in room 3 at the time of the investigation. S1 informed LPA that a plumber came to the facility to fix R1s shower faucet due to it being stripped and unable to turn to the hot water side. R1 informed LPA that they had to go to another room multiple times to shower until their shower was eventually fixed. LPA observed a work order from a handyman stating that on October 3, 2025, they removed and installed a new faucet at the facility. Therefore, the allegation has been deemed Substantiated. Based on information gathered, interviews and records reviewed the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 are being cited on the attached LIC9099D. An exit interview was conducted with AD Melinda Flores and a copy of this report, LIC9099D and appeal rights were left at the facility. S1 informed LPA that most of the food offerings are on the diabetic diet already. S1 informed LPA that they only buy sugar free or Splenda alternative desserts and offer that to all residents in care. LPA observed a physician’s order dated June 16, 2025, stating that R1 cannot have barbecue flavored foods. During interviews it was revealed that four of four staff follow dietary restrictions and physician’s orders. Four of four staff informed LPA that they are aware of all residents who have dietary restrictions in the facility. LPA interviewed seven residents and two of seven have a special diet. One of seven residents informed LPA that staff follow their dietary restrictions. Two of seven residents informed LPA that they do not have dietary restrictions and four of seven residents could not tell LPA if they had any dietary restrictions. LPA observed 3 of 3 residents having their dietary restrictions being met during breakfast meal service. Therefore, the allegation has been deemed Unsubstantiated. Regarding the allegation staff interacts with resident in an inappropriate manner revealed the following: upon interviews with residents two of seven residents informed LPA that they have been embarrassed or insulted by staff at the facility. One of seven residents informed LPA that they have been yelled at by S1 and S1 denied the allegation. Four of four staff informed LPA that they have never observed staff yell, embarrass or insult residents in care. LPA observed that on June 11, 2025, S1 conducted an in-service training for staff regarding resident rights. Therefore, the allegation has been deemed Unsubstantiated. Regarding the allegation staff did not dispose of needle after use revealed the following: It is alleged that staff left R1s needle that goes into their glucose monitoring machine on their bed. Upon interviews it was revealed that four of four staff informed LPA that R1 uses a machine to test their glucose levels. Staff store it and put it together for R1 before R1 uses the machine themselves. One of four staff informed LPA that staff deposit the used needle in a bin on the medication cart for R1. Three of four staff are unaware of an incident that may have taken place and one of four staff was told about the incident and the care staff in question denied the allegation at the time of the incident. R1 informed LPA that they were sitting up in bed when they noticed something on their pillow and informed LPA that it was a needle that had been left by staff. Therefore, the allegation has been deemed Unsubstantiated. Although the above allegations may have happened there is not a preponderance of evidence to prove the alleged violations occurred; therefore, the allegations that staff do not ensure resident's dietary needs are met, staff interacts with resident in an inappropriate manner and staff did not dispose of needle after use are deemed UNSUBSTANTIATED. Therefore, the Department dismisses the allegations. An exit interview was conducted and a copy of this report was left at the facility. R1 informed LPA that they thought the signal system was not working due to not being able to hear the beeping anymore and had not pulled it for a few days. R1 informed LPA that the staff normally come when they use the pull chord. LPA observed R1 use the pull chord and receive assistance during the course of the interview. Three of seven residents informed LPA that they have never had to use the pull chord and three of seven residents informed LPA that they could not recall if they have had to use the signal system for help. LPA tested the signal system and observed it to be working and signaling staff with beeping. LPA observed the response time of care staff to be within a minute of pulling the chord. Therefore, the allegation is Unfounded. Regarding the allegation staff do not ensure a complete first aid kit is maintained at the facility revealed the following: It was alleged that the facility did not have a thermometer for resident use upon request. Upon interviews with Witness 1(W1) it was revealed that the facility did have a thermometer but the care staff they requested it from did not look in the proper spot. LPA observed a complete first aid kit at the facility which includes: sterile first aid dressings, bandages, scissors, tweezers and a thermometer. Therefore, the allegation is Unfounded. Based upon LPAs observations, interviews and information gathered during the investigation, the preponderance of evidence standard has not been met, therefore the above allegations are deemed UNFOUNDED. Meaning the allegations Staff do not respond to resident's calls for assistance and Staff do not ensure a complete first aid kit is maintained at the facility, could not have happened and/or is without a reasonable basis. The department therefore dismissed the complaint. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 29, 2025 · control 22-AS-20250930102714

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Oct 30, 2025

87468.1(a)(2) Personal Rights of Residents in all Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: LPA observed a camera in room 4 and a live feed picture was observed showing 2 resident beds. LPA did not observe conservatorship papers from R1 and R1 did not consent to the camera. This poses an immediate personal rigths risk to residents in care.the state’s words, verbatim · CDSS document, Oct 29, 2025

Plan of correction: LPA observed staff take the camera out of room 4 at the time of the inspection. Licensee stated they will write a policy on cameras in resident rooms, submit a statement of understanding and send to LPA by October 31, 2025. ***This is an amended report***

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(26) · Plan of correction due date: Oct 30, 2025

87555 (b)(26) General Food Service Requirements (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidence by: LPA did not observe a 2 day perishable and 7 day nonperishable food supply at the facility at the time of the investigation. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 29, 2025

Plan of correction: Licensee stated they will purchase groceries and send proof to LPA by POC due date. Licensee stated they submit a plan of action for future grocery trips so the facility is within regulations regarding food to LPA by 10/31/2025. ***This is an amended report***

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 19, 2025

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidence by: Based on interviews and record review LPA observed that room 3 had a broken faucet with no hot water causing R1 to go to a different room to shower. This poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 29, 2025

Plan of correction: LPA observed a work order to fix the faucet and was completed on October 3, 2025, where the faucet was replaced. LPA tested the water to be at 109.3 degrees Farenheit at the time of the investigation. CLEARED AT THE TIME OF THE INVESTIGATION.

Allegation investigated: Staff does not provide adequate supervision to resident in care.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to continue the investigation into the allegation listed above. LPA met with Administrator Melinda Flores and explained the reason for the visit. The investigation into the allegation revealed the following. It was alleged that, staff does not provide adequate supervision to resident in care, which led to Resident 1 (R1) falling on February 5, 2023 and February 6, 2023. Both incidents were reported to the Agency and R1's responsible party. After each incident staff assessed R1 and immediately called 911. After the fall on February 5, 2023 R1 had a bump on their forehead and after the fall on February 6, 2023 R1 had a bump on the back of their head. When R1 was admitted to the hospital after their fall on February 6, 2023 and discharged on February 9, 2023. R1 was admitted to the hospital because they suffered 2 falls, 2 days in a row, their loss of consciousness (on February 6), and history of hypertension. The Administrator reported that after the fall on February 5, 2023 R1 was placed on increased checks (hourly) and had a pressure pad but on their bed to notify staff when R1 got out of bed. R1 was encouraged to spend more time in the main activity room where most of the residents spend their day to minimize their risk of falls. Unsubstantiated The facility also put pads on the side of the bed in case R1 fell out of bed at night. According to R1's physician report dated August 18, 2022 R1 was diagnosed with Dementia and could ambulate. A review of hospital discharge paperwork shows R1's CT scans and X-rays were negative and showed no injuries. R1 was advised to drink more water to stay hydrated to help their Kidney function and advised to have a follow up appoint with their primary care physician (PCP) to check on their kidney function. 5 out of 5 staff interviewed reported that R1 is checked on hourly and always assisted. R1 did not respond to questions asked by LPA. The Administrator reported that they have scheduled a meeting with R1's responsible party to discuss their care plan. R1's responsible party could not be reached and was not interviewed. R1 moved out of the facility on December 18, 2023 and has since passed away. After R1 fell on February 5, 2023, the facility took action and since there have been no reports of any incidents involving R1. Based on the evidence gathered the allegation is unsubstantiated, meaning 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. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Oct 22, 2025 · control 22-AS-20230210111523

Allegation investigated: Resident engaged in inappropriate behavior with another resident while in care.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to deliver findings related to the investigation of the complaint allegation identified above. LPA arrived at facility and was greeted and granted entry by staff. LPA spoke with Melinda Flores, Administrator explained the purpose of the visit. Findings are based upon this investigation which included interviews conducted and resident file record review. It is alleged that a resident engaged in inappropriate behavior with another resident while in care. Record review revealed that CCLD received an LIC624 unusual incident report regarding residents (R1 & R2) for June 01, 2022, R1 was found in R2’s room on top of R2 over their face naked trying to force R2 to open Continued on LIC9099-C Substantiated their mouth. Staff intervened and attempted to get R1 removed from R2’s room, R1 became combative but staff was able to remove resident from R2’s bedroom. Staff checked R2 for any injuries, no injuries were noted. The interview with staff stated that they were not present at the time of incident, however per communication book incident was noted to have happened June 1, 2022, around 7:30pm. Copies of communication log reflects incident in question. During the course of the investigation, there was sufficient evidence to substantiate the allegation. The preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. See LIC9099-D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with the Administrator and a copy of this LIC9099 and LIC9099-D, along with a copy of the appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Sep 23, 2025 · control 22-AS-20220603100514

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Sep 23, 2025

(a) Residents in all residential care facilities for the elderly shall have all of the following rights: (3) to be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, ….This requirement was not met as evidenced by: based on interview and records review, the licensee did not provide a safe environment for resident R2 due to R1 entering bedroom naked and trying to force R2 to open their mouth to engage in inappropriate behavior at the facility, which poses an immediate safety and personal rights risk for persons in care.the state’s words, verbatim · CDSS document, Sep 23, 2025

Plan of correction: Administrator stated that R1 no longer reside at the facility due to the incident and was moved to an all-male board and care facility. The administrator corrected the incident in question within 30 days of it occurrence. POC cleared at time of visit due incident being corrected.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct a health and safety check in regards to the quality assurance noncompliance plan. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Melinda Flores and discussed the purpose of the visit. LPA toured the facility and checked on residents in care. LPA observed residents engaging in happy hour activity games in the activity room and napping in the communal living room. Residents appeared clean and well taken care of. LPA observed resident medications and MAR. LPA answer questions that the AD had and discussed trainings scheduled. LPA reviewed daily monitoring logs and weekly medication audits for the weeks of August 31, 2025, through September 9, 2025. Based on today's observations no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD Melinda Flores and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 19, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst’s (LPAs) Hanna Gough and Rose Ruppert arrived at the facility to conduct the required annual inspection. LPAs were greeted and granted entry by staff. LPAs met with Administrator (AD) Jenny Truong and explained the purpose of the visit. The facility currently has twenty two residents in care. The facility is a one story building with fourteen resident bedrooms, bathrooms, shower rooms, kitchen, living room, dining room, office, medication room, activity room, laundry room, and courtyard. Facility appears clean, safe, and sanitary. LPAs observed the required departmental postings in the lobby of the facility. LPAs observed all resident bedrooms had the required components and furnishings. LPAs observed R1 has bed rails with no orders on file. LPA observed room 11 to be a shared room with three residents. A civil penalty was assessed due to a violation to the fire clearance. LPAs observed the restrooms to have toilet paper, paper towels, and textured shower flooring. LPAs tested the water to be between 114.6-125.6 degrees Fahrenheit. LPAs observed the kitchen to be clean. LPAs observed a two day perishable and seven day nonperishable food supply on hand. LPAs observed the knives to be stored in the kitchen. LPAs observed a supply of toxins in the kitchen under the sink. The kitchen doors are locked making it inaccessible to residents in care. LPAs observed fire extinguishers throughout the facility charged and with a service date of November 4, 2024. LPAs observed the centrally stored medication to be in a locked closet located across from the caregiver counter. LPAs observed the laundry room to store a clean supply of fresh linens for resident use. LPAs observed the emergency food and water supply in the locked storage unit in the parking lot of the facility. LPAs observed the outdoor courtyard to be free of debris and cleared of obstructions with a shaded seating area for resident use. Continue on 809-C LPAs reviewed staff files and 1 of 3 staff does not have a health screening. LPAs reviewed files and 1 of 3 staff does not have initial training. LPAs observed resident files and 1 of 5 residents do not have a tb test on file. LPAs observed 3 of 5 residents do not have a needs and services plan. LPAs reviewed resident medication with staff and no discrepancies were observed. LPAs did a quarterly file review to check on the quality assurance noncompliance plan. Based on today’s inspection citations are being noted along with a technical violation per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD Jenny Truong and a copy of this report along with LIC809-D, 858, 859, technical violation, an immediate $500 civil penalty on LIC421IM, 811 and appeal rights were given at the time of inspection.the state’s words, verbatim · CDSS document, Aug 22, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analysts (LPAs) Hanna Gough and Rose Ruppert made an unannounced visit for the purpose of conducting a health and safety check. LPAs were greeted and granted entry by staff. LPAs met with Administrator (AD) Jenny Truong and discussed the purpose of the visit. During the annual visit LPAs followed up on a death report dated August 22, 2025 for R1. LPAs toured the facility and conducted a health and safety check on all residents in care. LPAs obtained pertinent documentation such as resident POLST, Physicians Report, Appraisal, Assisted Living Waiver (ALW), ALW assessments, Mortuary Information Facts with blank Death Report, and MAR. LPAs filled out the questionable death report and were present at the facility when the fire department arrived after a 911 call for R1 at 0800. An exit interview was conducted with AD Jenny Truong and a copy of this report along with LIC811 was left at the facility.the state’s words, verbatim · CDSS document, Aug 22, 2025

Allegation investigated: Staff fail to seek timely medical attention for resident Staff refuse resident to leave facility

On June 20, 2025, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver the findings of the investigation. LPA met with Administrator Melinda Flores and explained the purpose of the visit. The investigation included the following activities: On January 21, 2025, LPA Kim conducted the initial visit, during which relevant records were obtained. In addition, interviews were conducted with three staff members (S1–S3), five residents (R1–R5), and three witnesses (W1–W3). The investigation revealed the following: Continued on LIC 9099-C. Unsubstantiated Based on interviews conducted, five residents, one witness. and three staff denied staff refused to disclose information to responsible party. Two witnesses could not confirm or deny staff refused to disclose information to responsible party. W1 stated on January 12, 2025, the family member requested a copy of the medication list and medical records from the facility and the family received the list of medications and medical records on the day they requested it and S1 also confirmed during an interview. According to California Code of Regulations 87468.2 (a) (19), “[the resident or responsible party is] to have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and a cost that does not exceed the community standard for photocopies.” Based on Information gathered, the family has received the medical records within the two business day which does not corroborate the above allegation. This department has investigated the complaint and based on the observations, interviews, and the records that were reviewed, the above allegation is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Exit interview conducted and a copy of this report was provided to Administrator Melinda Flores. Allegation: Staff fail to seek timely medical attention for resident. It was alleged that on January 10, 2025, a resident began experiencing swelling in their eyes. Staff reportedly stated they would contact the doctor and obtain medication; however, the facility allegedly failed to follow through. The resident’s condition worsened, with continued eye swelling and the onset of coughing. During interviews, five out of five residents and three out of three staff members denied that staff failed to seek timely medical attention for the resident. One out of three witnesses claimed staff did fail to seek timely medical care, while the remaining two witnesses could neither confirm nor deny the allegation. One resident interview was conducted using a Spanish translator. On January 10, 2025, Staff 1 (S1) reported that Resident 1 (R1) had watery eyes and a runny nose, but staff were not concerned at the time. Staff 2 (S2) noted R1 was also coughing. By around January 12, 2025, both S1 and S2 observed that R1’s cough had worsened, prompting the facility to arrange an X-ray. On January 13, staff offered to take R1 to the hospital due to the worsening cough, but R1 declined. On the early morning of January 14, 2025, R1 requested to go to the hospital. Staff contacted R1’s Responsible Party (RP), who agreed to take R1 to the hospital. Based on the information gathered, there is insufficient evidence to support the allegation that the facility failed to seek timely medical attention for the resident. Allegation: Staff refuse resident to leave facility. It is alleged that facility staff did not allow family to take resident to the doctor. Based on interviews, five out of five residents and three out of three staff denied the allegation that staff refused resident to leave the facility. Based on interview with Witness 1 (W1), the staff refused resident to leave facility and two witnesses could not confirm or deny staff refused resident to leave facility. W1 stated the family requested to take R1 to the hospital but the facility prevented the family to take R1 to the hospital because R1 needed to take an X-ray at the facility. W1 stated family then asked if they can eat lunch at the outdoor area of the facility and the family ate lunch with the resident. Interview with S1 stated, on January 12, 2025 family mentioned taking R1 at the outdoor area within the facility premises, but it was misunderstood as leaving the facility. Continued on LIC 9099-C. S1 emphasized, the family never mentioned taking R1 to the doctor that day or go outside the facility for lunch. S2 stated the family never requested to leave the facility. The resident (R1) did not request to leave the facility and only the family member mentioned it to the R1 that the facility wouldn’t let them go out to lunch together. Based on Information gathered, there is no sufficient evidence to corroborate the above allegation. Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above 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 was conducted and a copy of the report was provided to Administrator Melinda Floresthe state’s words, verbatim · CDSS document, Jun 20, 2025 · control 22-AS-20250115141051

Allegation investigated: Staff restricted resident's visitation rights Staff engaged in a verbal altercation in front of resident in care

Licensing Program Analyst (LPA) Rose Ruppert made an announced visit to deliver findings after a complaint visit on April 3, 2025. LPA was greeted and granted entry and met with Alex Blancarte, Assistant Administrator (AA). LPA reviewed facility Visiting Policy, Visitor's Log for 2025, House Rules, Unusual Incident Reports and Staff Schedule. LPA also reviewed five of five resident records and four of four staff files. LPA interviewed residents, staff, family members and eyewitnesses regarding resident visitation rights. All residents denied allegation that visitation rights are restricted. LPA reviewed the visitor's log for 2025 and noted visitors were allowed to visit with the resident. The facility stated visiting hours in the House Rules from 8am to 8pm and the visitor had wanted to visit after 8:30pm. The visitor was advised by staff that the resident's roommate was already asleep and that visitors would not (Continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) be appropriate at this time. In all staff interviews it was noted that this resident's family member has had multiple incidents with staff members. The incident in this report occurred between the staff member and family member upon the resident's return to the community. An eyewitness to the incident stated the staff member was trying to de-escalate the situation and the resident asked the family member to stop. The resident walked away and went to their room. The staff member attempted to remain calm and resolve the situation. Upon resident interview, the resident denied the allegation. Although the above allegations may have happened there is not a preponderance of evidence to prove the alleged violatiosn occurred; therefore, the allegations that staff restricted resident's visitation rights and engaged in a verbal altercation in front of resident in care are unsubstantiated. An exit interview was conducted with Alex Biancarte, Assistant Administrator and a copy of the report was given at the time of the visit.the state’s words, verbatim · CDSS document, Apr 14, 2025 · control 22-AS-20250328143510

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted at the facility by Fabiola Fuentes, Medtech/Caregiver. LPA met with Melinda Flores, Administrator and explained the purpose of the inspection. The facility is one-story building with twelve shared resident bedrooms, two private resident bedrooms, each with their own bathroom. The facility also has two common bathrooms, kitchen, dining room, office, medication room, activity room, caregiver station, shower room, laundry room, living room, courtyard and outdoor storage. Facility appears clean, safe and sanitary. LPA observed the facility has the necessary postings posted on the walls. LPA noted residents were lounging in their rooms or the living room. All resident rooms had the required elements, including bed, chair, closet space and ample lighting. Facility has extra linens and hygiene supplies for residents in a storage room. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured between 105 and 120 degrees F. LPA observed facility has emergency food and water supply as well as additional emergency supplies. LPA observed the fire extinguisher was last serviced on October 2, 2023. Smoke/Carbon Monoxide detector/fire alarm were tested and noted as operational. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in the kitchen, storage or the laundry room. Knives are locked up separate from toxic chemicals. Medication for each resident is kept locked in the medication room. The courtyard has shaded sitting/lounging areas. Exit gates are unlocked. LPA observed exit gates to be unobstructed. Based on record review, LPA observed the medication administration record for four residents to be missing signatures. A deficiency is being issued. LPA reviewed four resident files and four staff files. LPA also reviewed medication for four residents. LPA interviewed one staff and two residents. Based on today's inspection, one deficiency is being issued. An exit interview was conducted and a copy of this report and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Aug 14, 2024

Allegation investigated: Facility did not ensure residents are not being overcharged

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Melinda Flores and explained the reason for today’s inspection. The investigation into the allegation that the facility did not ensure residents are not being overcharged revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, staff, and witnesses, and obtained and reviewed copies of the resident roster, staff roster, the facility’s brochure, Resident #1’s (R1) Appraisal dated July 1, 2020, R1’s Individual Service Plan dated May 11, 2020, R1’s Admission Agreement dated July 2, 2020, and the facility’s Plan of Operation. Regarding the allegation that the facility did not ensure residents are not being overcharged: it was alleged that residents whose incontinence supplies are covered by insurance are now being charged by the facility for incontinence supplies. LPA interviewed AD who reported that residents’ incontinence supplies are provided either by vendors who charge insurance or by the facility itself and if the facility provides the supplies there is an additional monthly charge in addition to the rate for basic services. Substantiated LPA reviewed the facility’s brochure which indicates the additional charge for incontinence supplies is currently $450 per month. Staff interviewed reported that there have been issues with incontinence supplies for R1. Per AD, R1 was getting incontinence supplies from a vendor, but there was an issue with R1’s insurance and between October 2023 and February 2024 the facility did not receive incontinence supplies for R1. Because R1 still needed incontinence care, facility staff began using the facility’s incontinence supplies, but AD was not made aware of this change by staff for about two months. R1’s family was charged the additional monthly charge for this five-month period and R1 is back to receiving incontinence supplies from a new vendor. LPA interviewed R1’s family who stated they had had not been made aware that the vendor had stopped delivering R1’s incontinence supplies and that the facility had begun using its own supplies until February 20, 2024 when the facility sent them the invoice for February 2024 via email. Information obtained was conflicting regarding whether the original vendor was coordinated by R1’s family or the facility, the number of months for which the additional charge for incontinence supplies was demanded, and whether the facility attempted to charge late fees for back-owed fees. AD and the licensee corroborated that the facility first notified R1’s family on February 20, 2024 that R1 had begun using the facility’s incontinence supplies and they would be charged an additional fee. LPA reviewed R1’s Appraisal dated July 1, 2020 and R1’s Individual Service Plan dated May 11, 2020 which indicate R1 needs assistance with toileting and incontinence care and interviews revealed that since entering the facility R1 received incontinence supplies from a vendor. However, in October 2023 the situation changed and R1 began needing to use the facility’s incontinence supplies. The facility did not properly notify R1’s family of this change in care and services provided by the facility or that R1’s family would have to pay an additional charge because no notice was provided until February 20, 2024. Regarding late fees, LPA reviewed R1’s Admission Agreement dated July 2, 2020 which states Invoices are … due by the 10th of each month” and “Late fees will occur after the 10th,” but does not specify how the late fee is calculated. However, LPA reviewed the facility’s Plan of Operation, which includes the facility’s approved admission agreement which does not include the language regarding late fees, meaning the facility cannot charge a late fee During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. Regarding the allegation that the administrator is not on the premises a sufficient number of hours to adequately manage the facility: it was alleged that AD is not at the facility and will not be at the facility until the third week of April 2024. LPA interviewed staff who corroborated that AD has been on leave from work due to medical issues since last week and the leave is expected to continue for a few more weeks, but stated that AD is reachable by phone. LPA interviewed AD via telephone who stated that they are currently on medical leave, but they still go to the facility twice a week, they manage the facility from home while recovering and are available by phone, the licensee is also available to be present at the facility, and the medication technicians are in charge while AD is not present at the facility. LPA confirmed during the inspection that, while AD was not physically present, AD is reachable by phone and knowledgeable about the situation at the facility. LPA observed the facility to be clean and organized and observed no health and safety issues, the residents were in good health and good spirits, the staff were responsive to the residents, and the medication technicians were knowledgeable and responsive to residents, pharmacies, and visiting medical professionals to coordinate resident care. Apart from the fact that AD is on medical leave, witness interviews did not reveal information that the facility is not being properly managed or that residents are not receiving proper care and supervision. While AD is temporarily unable to be present at the facility as often as usual, the facility is adequately managed by AD remotely and in-person and by the medication technicians while AD is not present. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, May 6, 2024 · control 22-AS-20240329153408

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(4)(B) · Plan of correction due date: Jun 3, 2024

87507 Admission Agreements … (g) … (4) … (B) The conditions under which a licensee may increase or change rates shall be specified in the admission agreement, pursuant to Health and Safety Code sections 1569.655 and 1569.657… This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not provide notice of a rate increase based on a change in the level of care of R1 within 2 business days after initially providing services at the new level of care, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 6, 2024

Plan of correction: Licensee stated they will refund or waive any charges for incontinence supplies for R1 incurred prior to February 16, 2024 as well as any late fees and will submit proof to LPA by POC due date.

Type of visit: POC

On this day Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced Plan of Correction (POC) visit in conjunction with complaint control #22-AS-20230630160447 and citation issued on 01/11/2024. LPA was greeted and granted entry into the facility by Medication Technician (MT) Fabiola Fuentes. LPA explained the reason for the visit. Administrator (AD) Melinda Flores arrived shortly after. On 02/01/2024, Licensee failed to correct the following: Deficiency cited under Title 22 Regulation 87412 (c)(1)(A)(B) pertaining to Personnel Records (Training and Orientation...in-service training). Deficiency cited under Title 22 Regulation 87412 (c)(1)(A)(B) pertaining to Personnel Records (Training and Orientation...in-service training) has NOT been cleared. Per California Code of Regulation under 87707 (a)(2) under Training Requirements If Advertising Dementia: Direct care staff shall complete at least eight hours of in-service training on the subject of serving residents with dementia within 12 months of working in the facility and in each succeeding 12-month period. Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with AD Flores and a copy of this report along with the LIC809D and Appeal Rights were provided at the time of this visit. Due to technical issues the visit shows 12:00PM-12:04PM; however the visit was from 12:00PM-12:54PM.the state’s words, verbatim · CDSS document, Mar 15, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c)(1)(A)(B) · Plan of correction due date: Mar 18, 2024

Personnel Records (1) training and orientation shall be documented: (A)...at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter...(B)For staff who provide direct care to residents with dementia...the licensee shall document ...orientation received as specified in Section 87707(a)(1)...in-service training received as specified in Section 87707(a)(2).This requirement is not met as evidence by: Based on LPA observations and file review S1 and S2 did not complete eight hours of dementia in-service training within their first 12 months of employment.the state’s words, verbatim · CDSS document, Mar 15, 2024

Plan of correction: Licensee to provide up to date training transcripts for S1 and S2 by POC due date.

Allegation investigated: Resident sustained a fall due to lack of supervision.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on 09/30/20. LPA was greeted and granted entry into the facility by Medication Technician (MT) Fabiola Fuentes. LPA explained the reason for the visit. Per Tittle 22, Section 87506 Resident Records under (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years. Due to the complaint being over three years LPA was unable to review Resident 1 (R1) records. This agency has investigated the complaint alleging that Resident sustained a fall due to lack of supervision. Regarding the allegation, the following was revealed: One of five individuals interviewed confirmed the allegation. During interviews conducted with residents, R1 reported that staff are helpful and stated that he has not had a fall due to lack of supervision. During the interviews Administrator (AD) stated that CONTINUED ON LIC9099-C... Unsubstantiated R1 had a change in condition and became wheelchair bounded. Per AD R1 did not have a fall due to lack of supervision. During the investigation LPA reviewed documents including the staff schedule dated January 2024. Per staff schedule on average there is one medication technician and two caregivers for the morning and evening shifts and one medication technician and one caregiver for the night shift for 21 residents in care. Based on the information gathered during the investigation, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Therefore, the allegation has been deemed to be UNSUBSTANTIATED, meaning although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred. LPA Ramirez conducted an exit interview with AD Flores, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 30, 2024 · control 22-AS-20200930151047

Allegation investigated: Staff hit the residents

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on 06/30/23. LPA was greeted and granted entry into the facility by Medication Technician (MT) Fabiola Fuentes. LPA explained the reason for the visit. Administrator (AD) Melinda Flores arrived shortly after. This agency has investigated the complaint alleging that staff hit the residents. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: One of eight individuals interviewed confirmed the allegation. During interviews conducted with residents, Resident 1 (R1) reported that no staff hits her or other residents and stated that staff are good to her. During interviews conducted with staff, Staff 1 (S1) reported that she has never witness staff hitting the residents and stated that if she sees staff hitting the residents that she would make a report since she is a mandated reporter. CONTINUED ON LIC9099-C... Unsubstantiated During the course of the interviews AD stated that she has not witness staff hitting the residents and reported that the caregivers and the residents are like family. Based on LPA's observation and information gathered during the investigation, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. LPA Ramirez conducted an exit interview with AD Flores, and a copy of this report was provided to the facility Records reviewed included the Staff In-Service trainings dated 10/2021-09/2022. Per Staff In-Service trainings S1 did not complete eight hours of dementia in-service training within their first 12 months of employment. S1 date of employment is listed as 09/20/21. Per Staff In-Service trainings S2 did not complete eight hours of dementia in-service training within their first 12 months of employment. S2 date of employment is listed as 02/16/21. Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: staff did not receive appropriate training is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. A deficiency is being cited under Personnel Records 87412(c)(1)(A)(B)(1)(2). An exit interview was conducted with AD Flores, and a copy of this report, 9099-D Page, and Appeal Rights was left at the facility.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 22-AS-20230630160447

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c)(1)(A)(B) · Plan of correction due date: Feb 1, 2024

Personnel Records (1) training and orientation shall be documented: (A)...at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter...(B)For staff who provide direct care to residents with dementia...the licensee shall document ...orientation received as specified in Section 87707(a)(1)...in-service training received as specified in Section 87707(a)(2).This requirement is not met as evidence by: Based on LPA observations and file review S1 and S2 did not complete eight hours of dementia in-service training within their first 12 months of employment.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: Facility to provide up to date training transcripts for S1 and S2 by POC due date.

Allegation investigated: Resident sustained an injury from lack of supervision.

LPA Haley made an unannounced visit to deliver the findings on the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit. Regarding the allegation: Resident sustained an injury from lack of supervision. During the investigation 7 interviews were conducted with facility staff, the resident involved, and a family member of the resident involved. None of the 7 individuals interviewed were able to support the complaint allegation as reported. During the investigation, it was discovered Resident 1 did have a fall in the middle of the night and was sent to the hospital for a head injury. All staff members interviewed, including the Administrator confirmed there were two employees working when R1 had an unwitnessed fall in her room around 3:00AM. During an interview with a family member of R1, it was discovered the family member was notified right away and went to the ER with R1. The family member had no problem with how the caregivers responded to the situation, “They (staff) responded correctly as far as I can tell.” Continued on LIC9099C Unsubstantiated During an interview with Resident 1 (R1) who suffered the unwitnessed fall, acknowledged falling down and sustaining an injury trying to walk, but did not know how the fall occurred. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, all allegation is deemed Unsubstantiated.the state’s words, verbatim · CDSS document, Dec 6, 2023 · control 22-AS-20231103104532

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jerome Haley conducted a case management visit regarding information discovered during the investigation into complaint control # 22-AS-20231103104532. During the complaint investigation mentioned above, it was discovered Staff 5 (S5) was working in the facility without being associated. It was discovered S5 was rehired in June of 2023 and is scheduled to work Tuesday – Saturday on the NOC (overnight) shift. S5’s employment and presence in the facility is confirmed by Administrator (AD) Melinda Olivarez, who provided dates of employment, and work schedule, and an LIC500 with S5’s name written on the document dated November 7, 2023. During the investigation into complaint control # 22-AS-20231103104532, Staff 4 (S4) confirmed working with S5, and wrote S5’s name on an incident report (LIC624) dated November 1, 2023 that was faxed and received at the Regional Office November 3, 2023. As of November 7, 2023, S5 was not associated with the facility, and S5’s name was not on the staff roster that was printed by the department. S5 was not listed and associated on the facility roster until December 2, 2023. As a result of today’s Case Management visit, deficiencies will be cited. An exit interview was conducted and a copy of this report, LIC809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 6, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87735(e)(1) · Plan of correction due date: Dec 13, 2023

87355 Criminal Record Clearance (e) "All individuals subject to a criminal record review...(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department..." This requirement is not met as evidenced by: Based on observations, interviews, and record review, S5 was working in the facility without being associated according to regulation guidelines. This poses a potential safety threat to residents in care.the state’s words, verbatim · CDSS document, Dec 6, 2023

Plan of correction: Licensee to review regulation section 87355 Criminal Record Clearance and submit a signed statement of understanding and acknowledgement of the regulation requirements. POC can be sent to LPA via email and is due by Tuesday, December 12, 2023 at 1:00PM

Allegation investigated: Lack of care and supervision from the facility's staff resulted in untimely medical attention for resident who sustained injuries.

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Melinda Flores, Administrator and explained the reason for the visit. The Department received a complaint on 02/08/2023 and LPA Mendivil conducted an initial visit on 02/09/2023. During the visit LPA Mendivil reviewed documents including physician’s reports, assessments, staff schedules and admission agreements. Regarding the allegation Lack of care and supervision from the facility's staff resulted in untimely medical attention for resident who sustained injuries., the investigation revealed the following: On 01/23/2023 Resident 1 (R1) was assessed by Administrator Melinda Flores at the facility. Based on interviews with Administrator Melinda it was reported that R1 had previous falls prior to moving into Ardent Care. Substantiated R1 was admitted into the facility on 2/1/23. Throughout R1’s stay at the facility multiple staff interviewed observed R1 wandering throughout the facility and had to be redirected, 5 out of 7 staff observed R1 dancing to music in her room. The remaining 2 staff members had no direct knowledge of R1’s initial demeanor. R1’s roommate indicated R1 was up all hours of the night. R1’s roommate stated that R1 would pace back and forth and would go through roommate’s dresser and remove roommates’ clothes. Based on R1’s physician’s report (LIC 602) dated 5/19/2022, R1’s primary diagnosis is dementia with behavioral disturbances and is noted to have aggressive behaviors with sundowning and was confused and disoriented. On 02/6/2023 R1s family visited R1 for the first time since moving in, and they found R1 in a wheelchair and was told by staff that R1 could not stand for long period of time. It was reported by staff that R1 was asked if they had fallen and R1 stated “no”. R1 began to complain of pain when assessed by staff and responsible party when left hip was touched. It was noted R1 was sent to UCI Hospital at 10:40am where they were diagnosed with a fractured pelvis. It was noted by staff in Services Notes on 02/05/2023 at 7am that R1 complained of pelvic, left leg and lower back pain. Based on Service Notes, staff noted R1 was placed in a wheelchair and 911 was not called. It was reported family was not notified until the incident on 02/06/2023. Per California Assisted Living Waiver Individual Service Plan (ALW ISP) dated 8/18/22 R1 requires reinforcement of safety precautions due to being a fall risk and requires assistance with mobility/ambulation. Based on ALW ISP R1 has a history of behaviors due to Alzheimer’s, R1 has a history of wandering behaviors. Based on hospital intake paperwork dated 02/06/2023 there was noted bruising on R1’s left hip and pelvis region. Per review of R1’s Admission Agreement dated 02/01/2023, it was noted that R1 would need assistance with dressing, reminders for eating, toileting, bathing, and grooming. Based on service notes R1 was noted to be placed in a wheelchair on 02/05/2023 at 7 am which would mean the resident was presenting with pain for at least 24 hours prior to be taken to the hospital. A civil penalty is pending determination, per H&S Code Section 1569.49(e). Based on the preponderance of evidence through record review and interviews the allegation Lack of care and supervision from the facility's staff resulted in untimely medical attention for resident who sustained injuries. is SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has occurred. The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8 and civil penalties assessed. An exit interview was conducted and a copy of this report and appeal rights was provided to the Administrator. It was reported by Administrator Melinda Flores that she suggests as a best practices to families to allow time for the resident to acclimate to the facility prior to visiting in person and not as instructions or rule. Based on interviews with R1’s family they followed the administrator’s advice. Based on R1’s physician’s report (LIC 602) dated 5/19/2022, R1’s primary diagnosis is dementia with behavioral disturbances. It was reported by facility that on 2/6/2023 R1s family visited R1 for the first time since moving in, and they found R1 in a wheelchair and was told by staff that R1 could not stand for long period of time. R1 was asked if they had fallen and R1 stated “no”. R1 began to complain of pain when assessed by staff and responsible party when left hip was touched. R1 was sent to UCI Hospital where they was diagnosed with a fractured pelvis. It was noted by staff in Services Notes on 02/05/2023 at 7am that R1 complained of pelvic, left leg and lower back pain. R1 was placed in a wheelchair and 911 was not called. It was reported family was notified on 02/06/2023, when the administrator was made aware of the issue. Based on the preponderance of evidence through interviews and records reviewed the allegations that Facility restricted a resident's ability to receive visitors and Facility failed to report a serious incident involving a resident to the Responsible Party are determined to be UNSUBSTANTIATED, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. This agency has investigated this complaint. No deficiencies cited. An exit interview was conducted and a copy of this report and confidential names list was provided.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 22-AS-20230208145448

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 1, 2023

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by resident was noted as a fall risk and resident was left in wheelchair due to pain for over 24 hours. This poses an immediate risk to health and safety to persons in care.the state’s words, verbatim · CDSS document, Nov 30, 2023

Plan of correction: Licensee to