Activcare at Yorba Linda

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

Allegation investigated: Illegal eviction

An unannounced complaint investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above. LPA met with Executive Director (ED) Rick Ledesama. Complaint alleges Resident 1 (R1) was issued an illegal eviction. During the course of the investigation, LPA obtained a copy of 30-day eviction notice issued to R1 on August 26, 2026 and observed eviction notice did not meet regulation requirements. Based on record review, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of regulations (see LIC9099-D). An exit interview was conducted and a copy of this report and appeal rights were left at the facility. Substantiatedthe state’s words, verbatim · CDSS document, Sep 8, 2026 · control 22-AS-20260831092137

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d)(1)(D) · Plan of correction due date: Sep 22, 2026

(d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction... (1) The notice to quit shall include the following information: (D) The following exact statement as specified in Health and Safety Code Section 1569.683(a)(4)... This requirement is not met as evidenced by: Based on record review, Licensee did not comply with section cited above as 30-day eviction notice issued to R1 did not include statement as specified in Health and Safety Code Section 1569.683(a)(4), which poses a potential person rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 8, 2026

Plan of correction: AD stated they will revise 30-day eviction notice to include required statement and new date of issuance, and a copy will be provided to LPA via email by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Executive Director (ED) Enrique Ledesma and the purpose of the inspection was discussed. During the inspection, LPA and ED conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and observed the following: The facility is a single-story building, which consists of 54 resident bedrooms, 38 bathrooms, and an outdoor courtyard. Select resident bedrooms were inspected and observed to have the required furnishings. LPA observed residents’ beds had linens and blankets. LPA observed residents socializing in common areas and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew and faucets and toilets were operational. Water temperature tested between 109.4 – 117.5 degrees Fahrenheit. LPA observed the courtyard had multiple shaded sitting areas. The facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Commercial smoke detectors and carbon monoxide detectors are inspected by Orange County Fire Authority on an annual basis with last inspection date of September 8, 2025. Fire extinguishers, which are located in facility common areas, were observed to be fully charged with service tags dated September 4, 2025. Facility appliances were observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication was observed to be centrally stored and locked in medication carts. LPA reviewed eight resident files and four staff files. LPA interviewed select residents and staff. Based on the observations made during today’s inspection, no deficiencies are being cited 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, Jul 29, 2026

Allegation investigated: Resident sustained injury due to lack of care from staff

On June 17, 2026, 1:00 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced subsequent complaint visit to deliver findings at the above facility for the above allegation. LPA Kim met with Marketing Director Shannon Buckholz and explained the purpose of the visit. Administrator Enrique Ledesma was out of the office for the week, and the Facility Designee of Responsibility is Marketing Director Buckholz. The investigation consisted of the following: LPA Kim conducted a physical tour of the facility. LPA Kim reviewed and obtained copies of staff roster, resident roster, staff schedule, and one resident’s record, which include: Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans/Appraisal, Progress notes, Incident reports, and other pertinent records. The investigation revealed the following: Continued on LIC9099C Unsubstantiated Allegation: Resident sustained injury due to lack of care from staff It is alleged that the resident had noticeable multiple bruises on their face, purple and green color, bilateral cheeks, right jaw, and noticeable swelling on right forehead from a lack of care from staff. Based on record review, Resident #1's (R1) Physician Report dated January 24, 2025, diagnoses R1 with major depressive disorder and dementia. It is noted on Facility charting notes, many incidents with R1 having behavioral issues such as impulse behavioral issues and not following staff direction, which led to the incident where R1 had multiple bruises due to an unwitnessed fall. Facility Incident Report dated on July 30, 2025, R1 was sent to the hospital due to an unwitnessed fall, falling face first to the ground. R1 was found to have full range of motion and hematoma to the right side of their face and a scratch on the bridge of their nose. Facility charting notes dated July 30, 2025, also confirmed the Incident Report, which stated R1 was sent to the hospital due to an unwitnessed fall where R1 fell to the ground face first with injury to their face. Hospital record dated on July 30, 2025, confirmed the fall and hematoma right forehead. Facility Charting Notes dated on August 3, 2025, due to the fall from July 30, 2025, R1 was noted with skin discoloration to right eye, left eye, and cheek. It was noted R1 did not complain of pain or discomfort. Facility Charting Notes dated August 5, 2025, due to the fall from July 30, 2025, it is noted there is a continuation of facial discoloration and swelling from R1’s forehead. It is also noted a yellowish and greenish discoloration to the right side of face/cheek. Purplish and greenish discoloration to bilateral eye area. After Visit Summary hospital record dated on August 17, 2025, stated R1 was sent to the hospital on August 17, 2025 due to agitation, and was discharged from the facility on August 22, 2025. Facility Charting notes dated August 22, 2025, at 6:00PM, that R1 returned to the facility from the hospital. Prior to the hospitalization on August 17, 2025, Resident still had some bruises remaining prior to being admitted to the hospital. Based on interviews, five staff denied the allegation. One resident could not confirm or deny the allegation. Five staff stated the resident did not sustain an injury due to lack of care from staff. Five staff stated the resident had behavioral issues due to impulse and agitation. Staff #1 (S1) stated that the R1 had a fall on July 30, 2025, and staff responded in a timely manner. R1 was sent to the hospital for the unwitnessed fall Continued on LIC9099-C due to hematoma on their right forehead and scratch on the bridge of their nose. S2 stated the resident returned to the facility on the same day based on reviewing the charting notes. S2 recalls the bruising getting worse on the right side of their eye and also bruising to the left side. S2 stated it is common for a fall of that nature where discoloration and bruising to show up progressively after the initial fall. S2 stated the bruising would take some time before it healed and was very likely it didn’t heal completely prior to R1’s hospitalization on August 17, 2025. Based on information gathered, there is not sufficient evidence to corroborate the above allegation. Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above allegation Resident sustained injury due to lack of care from staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted a copy of the report was provided to Marketing Director Shannen Buckholz.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 22-AS-20250820085829

Allegation investigated: Staff are not using a proper place to wash residents clothing Staff are not meeting residents diapering needs Staff are contaminating surfaces in residents rooms Staff did not ensure the facility was not malodorous Staff are not showering residents when needed Staff are not ensuring the facility floors are clean

On June 17, 2026, 8:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced subsequent complaint visit to deliver findings at the above facility for the above allegations. LPA Kim met with Marketing Director Shannon Buckholz and explained the purpose of the visit. Administrator Enrique Ledesma was out of the office for the week, and the Facility Designee of Responsibility is Marketing Director Buckholz. The investigation consisted of the following: LPA Kim conducted a physical tour of the facility. LPA Kim reviewed and obtained copies of staff roster, resident roster, staff schedule, staff information, facility cleaning schedule, and seven resident’s record, which include: Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans/Reappraisal, Progress notes, and other pertinent records. LPA Kim reviewed and obtained copies of two staff files, which include: contact information, employee application, and LIC 503. The investigation revealed the following: Continued on LIC9099C Unsubstantiated Allegation: Staff are not using a proper place to wash residents clothing It is alleged that In the dining area, soiled garments and briefs were washed together in a container and left to air dry on counters. Based on interviews conducted, five residents and five staff denied the allegation. Five residents and four staff stated that they have not witnessed any clothes, soiled or unsoiled, left to air dry on counters. The residents and staff stated there was not an instance where they watched anyone wash soiled garments and briefs in any container or in the sink at the common areas. S3 and S4 stated there are facility barrels in each hallway for residents and staff to drop off soiled clothes and garments. The Janitor picks it up twice a day. Laundry aids are the only people to wash and clean clothes and garments. They only place to clean in the facility is the designated laundry area. They do not wash or dry clothes outside the designated laundry room and drying areas. Based on observation, on April 22, 2026, and June 17, 2026, LPA observed there was no clothes being washed in a container in common areas. LPA did not observe any clothes that were left to air dry on counters, tables, and chairs in the common area. LPA went to the designated laundry room and drying areas to observe and confirm S3 statement that laundry aids only washed and dried clothes in these designated areas. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Staff are not meeting residents diapering needs It is alleged that in a resident’s room, a caregiver did not wash resident completely and there was some fecal matter left on the resident’s hip, despite being told there was a dirty spot. Based on record review, LPA reviewed the Bowel Movement record for April 2026 and June 2026. The facility keeps track of bowel movement and when they provide diapering changes for the residents. There is no record for if showers were provided when a bowel movement occurred. Based on interviews, five residents and five staff denied the allegation. All staff and residents stated the staff thoroughly clean the residents. S1 and S3 stated that if the resident requested a shower after changing their diapers, then they would provide a shower if requested Based on observation, on April 22, 2026, and June 17, 2026, LPA did not observe any caregivers not properly providing residents for their diapering needs. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Continued on LIC9099C Allegation: Staff are contaminating surfaces in residents rooms It is alleged caregivers are placing soiled briefs containing feces on bedside surfaces, including near pillows and bed areas. Based on interviews, five residents and fivestaff denied the allegation. All staff and residents stated that there have been no instances where soiled clothes or briefs were placed on a resident’s bed, pillows, or other surface areas in a resident’s room. S1 and S2 stated whenever a resident gets their briefs changed, they place the soiled briefs in a trash bin, and place the soiled clothes in another bag. The soiled clothes will go to facility barrels to be picked up to be washed in the laundry, and the soiled briefs will be taken out of the room and disposed properly. Based on observation, on April 22, 2026, and June 17, 2026, LPA did not observe any soiled clothes or soiled briefs with feces placed on any resident’s bed, pillows, or any surfaces in the resident’s room Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Staff did not ensure the facility was not malodorous It is alleged that throughout the facility, including hallways, there is a strong persistent odor of urine. Based on record review, Housekeeping Assignment indicates the following common areas must be cleaned everyday: offices, bathrooms, copy room, conference room, medication room, shower rooms, all hallways, 300 Hall public restroom, beauty room, and they need to dust the kitchenettes. The following rooms need to be cleaned everyday: 105, 107, 204, 206, 209, 301, 304, 305, 307, 405, 408, and 409. Based on observations, on April 22, 2026, and June 17, 2026, LPA did not smell a strong persistent odor of urine or any other malodorous odor anywhere in the facility. Based on interviews, five residents and five staff denied the allegation. Residents and staff stated they have not had smelled a strong persistent odor of urine or any other malodorous odor. S5 stated they regularly clean the facility to make sure the hallways and public areas are clean and sanitary. S5 stated they will follow all steps to make sure there is no odor of urine or any malodorous odor in the facility. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Continued on LIC9099C Allegation: Staff are not showering residents when needed It is alleged that a resident had significant diarrhea and was not properly cleaned or showered. The caregiver stated that residents are typically wiped and not immediately showered. It was alleged the resident was only cleaned partially. Based on record review, a shower schedule for 100 Hall, 200 Hall, 300 Hall, and 400 hall list all the residents who need assistance for showers during the week. Facility do not keep a record when a resident requests additional showers outside of their shower schedule. Based on interviews, five residents and five staff denied the allegation. S3 stated the facility follows the shower schedule. S4 confirmed that the facility does not keep a record of when residents request additional showers after a bowel movement or diapering change. All staff stated if a resident requested a shower after bowel movement, or if the staff believed it was necessary, a shower would be provided. Five residents stated the facility maintains and cleans them regularly thoroughly. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Staff are not ensuring the facility floors are clean It is alleged that urine was left on the floor in a hallway area and not cleaned up. Based on interviews, five staff and five residents denied the allegation. S2 stated they do not keep a log when they clean up urine or other substances in the hallway. All staff and all residents stated the facility maintains a clean facility where it is rare to see urine and other substances in the facility. S4 and S5 stated that it is common to see spills and substances in the dining areas. All staff stated that if there were spills or urine left, they would contact housekeeping and maintenance. S5 stated they would make sure everything is cleaned up properly and is sanitary. Based on observations, on April 22, 2026, and June 17, 2026, LPA did not observe any urine or any spills on the floor in any hallways. LPA observed spills from the dining areas, but the facility promptly cleaned up all the messes in a timely manner and kept the area sanitary. Based on information gathered, there is not 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 Staff are not using a proper place to wash residents clothing, Staff are not meeting Continued on LIC9099C residents diapering needs, Staff are contaminating surfaces in residents rooms, Staff did not ensure the facility was not malodorous, Staff are not showering residents when needed, and Staff are not ensuring the facility floors are clean. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted a copy of the report was provided to Marketing Director Shannen Buckholz.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 22-AS-20260414132445

Allegation investigated: Resident suffered multiple falls while in care. Facility forcing resident to take medications. Facility not allowing resident access to their bedroom. Facility administrator medication without obtaining consent from resident's responsible party.

On January 21, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to continue the investigation into the allegations listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director (ED) Enrique Ledesma was present and assisted on today's visit. During the course of the investigation, the Department interviewed residents, interviewed staff, reviewed and obtained pertinent documents to the complaint. Regarding the allegation, resident suffered multiple falls while in the care, the following has been concluded: It was alleged that Resident #1 (R1) sustained multiple falls while in care. The Department was unable to review any records for R1 due to R1 moving out of the facility on September 19, 2022. Additionally, the facility no longer has any records for R1 on the premises. The Department conducted an interview with R1. However, R1 was unable to provide a statement regarding any falls she might have sustained while at the facility. The Department conducted four staff interviews. Four out of the four staff interviewed confirmed that R1 sustained falls while at the facility. CONTINUED ON LIC9099-C Unsubstantiated Staff interviewed stated that R1 sustained some falls due to R1 attempting to transfer herself, even though she required assistance with transferring. Staff interviewed also stated that the facility put fall prevention methods in place for R1. The fall prevention methods put in place for R1 included a lowered bell, a fall mat, a tab alarm, and additional routine checks. Additionally, staff interviewed stated that R1 did not sustain any injuries from her falls at the facility. Although R1 sustained falls while at the facility, staff interviewed confirmed that fall prevention techniques were put in place to deter future falls, and prevent any serious injuries. Regarding the allegation, facility forcing resident to take medications, the following has been concluded: It was alleged that R1 was forced to take medications. The Department conducted an interview with R1. However, R1 was unable to provide a statement regarding this allegation. The Department conducted seven resident interviews. One resident was unable to be qualified for an interview and another resident declined to be interview. However, five out of the seven residents interviewed denied the allegation and stated that they have never been forced to take any medications. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and stated that R1 was never forced to take any medications. Regarding the allegation, facility not allowing resident access to their bedroom, the following has been concluded: It was alleged that the facility did not allow R1 access to her bedroom. The Department conducted an interview with R1. However, R1 was unable to provide a statement regarding this allegation. The Department conducted four staff interviews. One out of the four staff interviewed was unable to recall any information about this allegation. However, three out of the four staff interviewed denied the allegation. Staff interviewed stated that R1 was encouraged to be in the main activity room so that she could be observed by more staff since she had a history of falls at the facility. Staff interviewed also stated that they would assist R1 to her bedroom if she requested to go there. The Department conducted seven resident interviews. One resident was unable to be qualified for an interview and another resident declined to be interview. However, five out of the seven residents interviewed denied the allegation and stated that they are allowed to go to their bedrooms whenever they want to. Regarding the allegation, facility administering medication without obtaining consent from resident's responsible party, the following has been concluded: It was alleged that the facility administered R1's PRN Ativan medication without obtaining consent from R1's responsible party. CONTINUED ON LIC9099-C Regarding the allegation, facility not providing a variety of meals to resident, the following has been concluded: The Department conducted seven resident interviews. One resident was unable to be qualified for an interview and another resident declined to be interview. However, five out of the seven residents interviewed denied the allegation. Residents interviewed stated that they are satisfied with the food provided by the facility. Residents interviewed also confirmed the facility provides alternative food options if they do not like the meals that are served on that day. The Department conducted four staff interviews. Four out of the four staff interviewed denied the allegation and confirmed the facility provides alternative food options if residents are not satisfied with the meals that are served on that day. The Department inspected the food menu provided to residents and observed the facility provides a variety of food options to residents. The Department also observed that residents are able to order off of the alternative menu if they are not satisfied with the food options served on that day. Based on the evidence gathered during this investigation, the complaint is UNFOUNDED, meaning that the two allegations are false, could not have happened and/or is without reasonable basis. An exit interview was conducted with Executive Director Enrique Ledesma and a copy of the report was provided. The Department conducted an interview with R1. However, R1 was unable to provide a statement regarding this allegation. The Department conducted four staff interviews. One out of the four staff interviewed was recall any information about this allegation. However, three out of the four staff interviewed denied the allegation. Staff interviewed stated that consent was received from R1's responsible party regarding R1's PRN Ativan medication. The Department was unable to review any medication administration records for R1 due to R1 moving out of the facility on September 19, 2022. Additionally, the facility no longer has any records for R1 on the premises. Due to the conflicting information received during the investigation, 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 violation occurred; therefore, the four allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Enrique Ledesma and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 22-AS-20220830093135

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Edward Kim conducted a case management visit to document a deficiency observed during the investigation of complaint 22-AS-20250820085829 but unrelated to the allegation investigated. During the visit at the facility, LPA reviewed R1’s Facility’s Progress Notes and observed the following falls were listed in the Progress Notes, but no incident reports were received by the department: February 12, 2025, February 26, 2025, February 28, 2025, June 8, 2025, June 10, 2025, July 2, 2025, around 1:30 AM, July 2, 2025, around 8:20 AM, July 4, 2025, July 6, 2025, July 11, 2025, July 14, 2025, July 19, 2025, July 25, 2025, July 30, 2025, and August 3, 2025. A deficiency was cited during the visit according to Title 22 Division 6 Chapter 8. The facility did not send incident reports of when R1 had falls on February 12, 2025, February 26, 2025, February 28, 2025, June 8, 2025, June 10, 2025, July 2, 2025, around 1:30 AM, July 2, 2025, around 8:20 AM, July 4, 2025, July 6, 2025, July 11, 2025, July 14, 2025, July 19, 2025, July 25, 2025, July 30, 2025, and August 3, 2025. An exit interview was conducted, and a copy of this report, LIC811, and appeal rights were provided to Executive Director Enrique Ledesma.the state’s words, verbatim · CDSS document, Aug 26, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 9, 2025

87211(a)Each licensee shall furnish to the licensing agency ...(1)A written report shall be submitted to the licensing agency... within seven days... (D)Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. LPA observed Licensee did not send incident reports for falls on R1, which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 26, 2025

Plan of correction: Licensee states they will read and sign a statement of understanding for California Code of Regulations 87211(a)(1)(D). Licensee will send proof of this to CCLD via email to edward.kim@dss.ca.gov by POC due date on September 9, 2025.

Type of visit: Required - 1 Year

On July 25, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Executive Director (ED) Enrique Ledesma and explained the purpose of the visit. The facility is licensed to operate for eighty (80) non-ambulatory, of which seventeen (17) may be bedridden, and have a hospice waiver for fifteen (15) residents. Facility is approved for delayed egress and secure perimeter, and a waiver for locked perimeter gates. The facility is a single-story structure, which consists of the following: fifty-four (54) resident bedrooms, six (6) office rooms, thirty-eight (38) bathrooms, waiting area, activity area, dining room, kitchen, and two (2) outdoor covered patio areas. LPA Kim toured indoor and outdoor of the physical plant with ED Ledesma. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The following bedrooms were inspected: Resident Room 102, Resident Room 203, Resident Room 206, Resident Room 207, Resident Room 208, Resident Room 302, Resident Room 305, Resident Room 402 and Resident Room 406. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 110.4 degrees F and 117.5 degrees F. A comfortable temperature of 75 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food is stored in the kitchen. Emergency water and emergency supplies were stored in a storage closet. A working telephone (714-577-8005) remains available and is dedicated to the residents. LPA Kim reviewed the facility’s plan of operation, emergency and disaster plan, and fire/safety drill log. The facility conducted a Fire/Safety Drill on June 15, 2025. The facility has eleven (11) fire extinguishers that were charged and they were all serviced on September 5, 2024. All smoke detectors and carbon monoxide detectors were operable and last checked on October 29, 2024, by Orange County Fire Authority. First Aid was maintained and contained all the necessary elements. Certificate of Liability insurance is effective October 10, 2024, and expires on October 10, 2025. LPA Kim conducted an audit of eight (8) resident files (R1-R8), eight (8) staff files (S1-S8), and medication and medication administration record. LPA observed R1’s medical assessment dated June 25, 2024, and was diagnosed with dementia. LPA also observed S1, S2, and S3 did not complete twenty hours of training for 2024. LPA conducted six (6) resident interviews and four (4) staff interviews. A deficiency was cited during the visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8). The annual twenty hours of staff training for three out of eight staff (S1, S2, and S3), were not completed. A technical violation was assessed during the visit. LPA observed R1, diagnosed with dementia, did not have a current medical assessment for 2025. The last medical assessment was dated June 25, 2024. An exit interview was conducted, and a copy of this report, LIC811, LIC809D, and appeal rights were provided to Executive Director Enrique Ledesma.the state’s words, verbatim · CDSS document, Jul 25, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On November 21, 2024, at 9:15am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced Case Management Visit to follow-up on an incident report that was self reported from the facility. LPA Kim was greeted and granted entry by staff. LPA explained the purpose of the visit to Marketing Director Shannen Buckholz. During today’s visit, LPA conducted a health and safety check, and there were no imminent health/safety concerns observed. Facility maintained at a comfortable temperature for the residents in care. LPA obtained Staff Roster, Resident Roster, and R1’s records which includes the Physician’s Report, Admission’s Agreement, Emergency Information, Consent Forms, Incident Reports, and Appraisal and Needs/Service Plan. LPA conducted three staff interviews and attempted two staff phone interviews. No deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report was provided to the Marketing Director Shannen Buckholz.the state’s words, verbatim · CDSS document, Nov 21, 2024

Type of visit: Required - 1 Year

On July 18, 2024 around 8:25AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Executive Director (ED) Enrique Ledesma and explained the purpose of the visit. The facility is licensed to operate for sixty (60) non-ambulatory, of which 15 may be bedridden, and have a hospice waiver for fifteen (15) residents. Facility is approved for delayed egress and secure perimeter, and a waiver for locked perimeter gates. The facility is a single-story structure, which consists of the following: fifty-three (53) resident bedrooms, six (6) office rooms, thirty-eight (38) bathrooms, waiting area, activity area, dining room, kitchen, and two (2) outdoor covered patio areas. LPA Kim toured indoor and outdoor of the physical plant with ED Ledesma. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The following bedrooms were inspected: Resident Room 101, Resident Room 106, Resident Room 206, Resident Room 209, Resident Room 306, Resident Room 307, Resident Room 310, Resident Room 401 and Resident Room 409. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 107.2 degrees F and 114.9 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Emergency food is stored in the kitchen. Emergency water and emergency supplies were stored in a storage closet. A working telephone (714-577-8005) remains available. LPA Kim reviewed the facility’s plan of operation, emergency and disaster plan, and fire/safety drill log. The facility conducted a Fire/Safety Drill on April 22, 2024. The facility has eleven (11) fire extinguishers that are charged and they were all serviced on September 22, 2023, smoke detectors, and carbon monoxide detectors were operable and last checked on November 7, 2023. First Aid was maintained and contained all the necessary elements. LPA Kim conducted an audit of ten (10) resident files (R1-R10), eight (8) staff files (S1-S8), and medication and medication administration record were all in order and complete. LPA conducted three (3) resident interviews and seven (7) staff interviews. A Technical violation was assessed during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted, and a copy of this report was provided to Executive Director Enrique Ledesma.the state’s words, verbatim · CDSS document, Jul 18, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.