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Type of visit: Case Management - Deficiencies

On today's date Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of conducting a case management visit in order to observe if corrections have been made to the deficiency that was issued. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Administrator (AD) Ngoc "Nick" Mai. LPA explained the purposes of the visit and began a tour of the facility. LPA observed residents lounging in their respective bedrooms and in common areas of the facility. LPA observed hallway area, living room area, kitchen area, and bathroom areas to be clean and sanitary. LPA conducted a tour of the exterior of the facility and observed the exterior to have large obstructions along the backyard. The outdoor shaded sitting area is not accessible or suitable for residents in care. Based upon observations the plan of correction has not been met, and a penalty has been assessed for a failure to correct. AD was notified that the penalty will continue to accrue until the correction is made. An exit interview was conducted and a copy of this report, the deficiency, and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Jul 7, 2026

Type of visit: Case Management - Other

On today's date Licensing Program Analyst (LPA) William Vanegas conducted an unannounced case management visit for the purposes of ensuring the facility has corrected a repeat violation. Upon arrival LPA was greeted and granted entry to the facility by Administrator (AD) Ngoc "Nick" Mai. LPA explained the purpose of the visit, and began a tour of the facility. Accompanied by AD. LPA observed the following: The facility continues to have a large amount of miscellaneous items through out the exterior and interior of the facility. AD has failed to correct the deficiency and a new deficiency will be reissued on today's date. An exit interview was conducted with AD and a copy of this report, a copy of the deficiency, and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Jun 18, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87308(C) · Plan of correction due date: Jul 3, 2026

87308: Resident and Support Services (c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage. Based on observations made by LPA the Administrator failed to ensure that sufficient storage space was made available to store items, and allow for a clean and sanitary environment for residents in care which poses an immediate personal rights violation for residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2026

Plan of correction: Administrator agrees to clear out all debris and obsturctions that were observed to be on the premices durring LPA's inspection. LPA will conduct a plan of correction visit to confirm that correction has been made by P.O.C due date.

Type of visit: POC

On today's date Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of conducting a plan of correction visit. In regard to deficiencies that were issued on April 23, 2026. Upon arrival LPA was greeted and granted entry to the facility by Administrator (AD) Ngoc "Nick" Mai. LPA explained the purpose of the visit, and began a tour of the facility. LPA observed the following. LPA observed residents to be lounging in the common areas of the facility, and eating breakfast. LPA began a tour of the outside of the facility and observed the following. LPA observed outdoor shaded sitting area to still be inaccessible to residents in care. LPA also observed many miscellaneous items and debris to be around the facilities backyard. LPA observed at least one side exit to be clear of debris and was accessible for residents in care to exit the facility through the side gate in the case of an emergency. Based on observations made during today's inspection a failure to correct penalty will be issued to the facility. An exit interview was conducted with AD and a copy of this report and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, May 11, 2026

Allegation investigated: -Staff do not ensure that facility is clean and sanitary

On this day Licensing Program Analyst (LPA) William Vanegas made an unannounced visit to the facility for the purpose of delivering the findings of the above-mentioned allegation. LPA was greeted and granted entry into the facility by caregiving staff after introducing himself and stating the purpose for the visit. LPA began to explain the detailed information of the findings. LPA Vanegas explained the following. LPA conducted the initial 10-day visit on March 30, 2026. LPA conducted a tour of the interior and exterior of the facility and gathered photo evidence in relation to the above-mentioned allegation. Additionally, LPA interviewed two of two staff and interviewed the complainant in regard to the above-mentioned allegation. In regard to the allegation stating Staff do not ensure that the facility is clean and sanitary the following has been concluded: LPA conducted two staff interviews. No resident interviews were conducted due to all residents being asleep at the time of unannounced inspection date and time. Two out of two staff confirmed the allegation being investigated. Staff 1 (S1) states that they have encouraged Administrator to organize items in the facility, and that some of the items laying around the facility belong to a resident who does not have a storage unit where they can store them. CONTINUED ON LIC 9099-C Substantiated Continuation from LIC9099 S2 admitted to having these items around the facility due to wanting to repair them and have them be used for the benefit of the residents in care. Per LPA’s observations many miscellaneous items were observed scattered throughout the exterior of the facility, Additionally LPA observed side exit routes to have items along the walls of the exit routes which partially obstructs the side exit routes. LPA observed that although the side exit is partially obstructed residents are still capable of exiting through the side exit. Based on the observations made by LPA, photographic evidence, and interviews conducted with staff, the preponderance of evidence standard has been met therefore the allegation is substantiated. A deficiency will be cited per Title 22 division 6 chapter 8 of the California Code of Regulations. An exit interview was conducted, and a copy of the report and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 22-AS-20260320114355

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87308(C) · Plan of correction due date: May 11, 2026

87308: Resident and Support Services (c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage. Based on observations made by LPA the Administrator failed to ensure that sufficient storage space was made available to store items, and allow for a clean and sanitary environment for residents in care which poses an immediate personal rights violation for residents in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Administrator agrees to clear out all debris and obsturctions that were observed to be on the premices durring LPA's inspection. LPA will conduct a plan of correction visit to confirm that correction has been made by P.O.C due date.

Allegation investigated: -Staff financially abused resident

On this day Licensing Program Analyst (LPA) William Vanegas made an unannounced visit to the facility for the purpose of delivering the findings of the above-mentioned allegation. LPA was greeted and granted entry into the facility by caregiving staff after introducing himself and stating the purpose for the visit. LPA began to explain the detailed information of the findings. LPA Vanegas explained the following. Regarding the allegation that Staff Financially Abused Resident The following has been concluded: Based on the evidence gathered and interviews conducted R1 invested a total of $72,500 at their own discretion. Based on Interview with R1 they stated that they invested money at their own discretion however they feel that they were talked into investing. Based on interview with Potential Witness 1 (PW1) They advised R1 not to invest their money as this was the only type of income they have at the moment. PW1 states that they were not the designated P.O.A at the time of the investment and could not detour R1 from investing their money. CONTINUED ON LIC9099-C Unsubstantiated Continuation from LIC9099 Interview with S2 revealed that they never witnessed any offer to R1 to invest in a company, and they have never witnessed any exchange of funds from any residents to S1. S1 states that R1 learned about the company on their own and they never offered an opportunity to invest in the company. S1 provided a receipt of where the invested money went directly to the stem cell company. As a result of the documents collected and interviews conducted the allegation is found to be unsubstantiated, meaning that based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported. 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.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 22-AS-20260210150244

Type of visit: Case Management - Deficiencies

On today's date Licensing Program Analyst (LPA) William Vanegas conducted an unannounced inspection for the purposes of conducting a visit to deliver findings for a complaint received by our department. Upon arrival LPA was greeted and granted entry into the facility by care giving staff. LPA explained the purpose of the inspection and explained the findings to the staff on duty. LPA conducted a tour of the facility and observed additional violations per title 22 chapter 8 division 6 of the California Code of Regulations. LPA observed the outdoor shaded sitting area to be inaccessible to residents in care due to having large objects underneath it. A deficiency was issued on today's date. Additionally LPA observed the side gates to be obstructed causing a potential safety risk to residents in care. A deficiency was issued on today's date. Based on the observations made during today's visit deficiencies will be issued per title 22 chapter 8 division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: May 11, 2026

87307 Personal Accommodations and Services(d) The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. Based on observations made by LPA the Administrator failed to meet this requirement by containing large objects along the passage ways of the side exits making the exits inaccessable which poses a potenial saftey risk to residents in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Administrator agrees to store away or dispose of the objects observed to be obstructing the side exit routes by P.O.C due date. LPA will conduct a P.O.C visit to ensure the correction has been made.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87219(h)(2)(h) · Plan of correction due date: May 11, 2026

87219 Planned Activities (h) The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas that are easily accessible to residents, protected from traffic, and have adequate shady areas. Based on observations the Administrator failed to meet this requirement by storing large ammounts of objects unerneath the shaded sitting area.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Administrator agrees to find adequate storage for the objects located underneath the shaded sitting area by P.O.C due date. LPA will conduct a P.O.C visit to ensure the correction has been made.

Allegation investigated: Staff did not follow a resident's dietary needs

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to deliver findings on the complaint allegation listed above. LPA was greeted and granted entry by staff after introducing himself and stating the purpose of the visit. The complaint investigation consisted of interviews with facility staff, a witnesses, a resident family member, and document review. During interviews, 5 of 5 individuals were not able to provide any corroborating evidence or information to support the complaint allegation. According to Staff 1 (S1), Resident 1 (R1) passed away at UCI Medical Center. S1 explained, R1 was sent to the hospital due to a cough and after consulting with the residents family. R1 passed away at the hospital about a week later. S1 talked a little about R1’s diagnoses and explained that everyone including the nurses at CalOptima knew R1 was in poor health. Continued on LIC9099C Unsubstantiated According to W1, there were no concerns about the care of R1 at the facility. W1 stated, the facility did a great job. W1 explained, R1’s spouse was present and would go to the facility to assist with R1’s feeding. W1 denied R1 was on a special diet that was related to the residents health condition. W1 says R1 was on a special diet due to the residents age and for no other reason. W1 denied R1 was on any dietary restrictions and was told to avoid foods that are spicy or salty only. W1 says R1 was not restricted to only eating certain foods. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the 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, the allegation is deemed Unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 22-AS-20211129125638

Type of visit: Case Management - Deficiencies

On December 22, 2025, Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit to conduct a case management visit to follow up on deficiencies cited. LPA was greeted and granted entry by staff on duty. LPA stated the purpose of the visit. Staff on duty notified Administrator Ngoc Mai. The purpose of the case management visit was to revisit the deficiencies noted on November 24, 2025. Administrator called the social worker to follow up on the TB test for Resident #2. The social worker confirmed the TB test is negative and reported they would bring the results to the facility today. The request was sent to the PCP on December 10, 2025. Administrator reported he will fax the emergency disaster drill today. LPA reminded administrator that he should send it no later than December 24, 2025. Admission agreement for Resident #3, CPR certification for Staff #2, and 20 hours of training for Staff #2 have been received via email. An exit interview was conducted with the administrator and a copy of this report was reviewed and provided at the end of the visit.the state’s words, verbatim · CDSS document, Dec 22, 2025

Type of visit: Required - 1 Year

On November 24, 2025, Licensing Program Analyst (LPA) Garlli Tat conducted an unannounced visit to the facility for the purpose of a required annual inspection. LPA explained the purpose for the visit and was greeted and granted entry by Administrator (AD), Ngoc Mai. For this visit, there are two staff members on duty, including the AD, both of which are background cleared and associated. The PUB475 ‘See Something, Say Something’ poster was observed to be located in the hallway. LPA observed the Administrator's Certificate for Ngoc Mai, which expires on July 11, 2027. The facility is a Residential Care facility for the Elderly (RCFE) licensed for six residents, six of which may be non-ambulatory, two of which may be bedridden, and a hospice waiver for six. LPA toured the interior and exterior portions of the facility with the AD. For this visit, there are a total of two non-ambulatory and three ambulatory residents in care, one is on hospice, and none are bedridden. The facility is a single story home. There are a total of six bedrooms, five of which are resident bedrooms, and one bedroom is for staff. LPA toured each bedroom with the AD and observed that bedrooms were provided with furniture in good repair, clean linens, and adequate storage space. LPA observed the staff room is kept locked and inaccessible to residents in care. Smoke and carbon monoxide detectors as well as auditory exit alarms were tested and operational. There are a total of two bathrooms for both staff and residents. Continued on LIC 809-C. Bathrooms were observed to be in good repair, toilets and faucets were operational and showers were equipped with grab bars and non-skid floor mats. Water temperature in the bathrooms were measured to be 112.6 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked in the kitchen cabinet and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen. Fire extinguisher had a purchase date of June 1, 2025. LPA observed the emergency disaster and evacuation plan, which is in a binder in the office. Facility had back-up emergency food and water supply, located in the garage. LPA observed that the First Aid kit had all the required components. Medications were observed to be locked in a cabinet in the kitchen, inaccessible to residents in care. Chemicals were observed to be locked underneath the kitchen sink and in the garage. LPA observed the door leading to the attached two car garage is kept locked and inaccessible to residents in care. The garage is used for storage and laundry. For the exterior portion, LPA observed patio furniture under shading and there are two exit gate in the backyard that can be opened in case of an emergency. There is a shed in the backyard which is locked and used for storage. No bodies of water were observed. During this visit, five resident files and two staff files were reviewed. All staff are background cleared and associated with the facility. LPA reviewed residents’ medication and medication records. Based on today's observations, there are deficiencies being cited per Title 22 of the California Code of Regulations. There is also a Technical Violation being issued during this visit. An exit interview was conducted with Ngoc Mai. This report was reviewed with the administrator and a copy was provided at the end of the visit. Appeal Rights were reviewed.the state’s words, verbatim · CDSS document, Nov 24, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff do not ensure resident's special diet is followed

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced visit to the facility to continue the investigation and to deliver the findings. LPA Rodriguez explained the purpose of today's visit, was greeted, and granted entry by facility administrator (AD) Ngoc "Nick" Mai. It was alleged that staff do not ensure resident's special diet is followed. 2 out of 2 resident interviews and 1 out of 1 staff interview did not corroborate with the allegation. Per resident 1 's (R1) physician report, R1 is to be on a puree diet. R1 is the only resident at the facility who has a special diet, while the remaining 4 residents do not require special dietary orders. Upon entrance of the facility, LPA observed staff preparing R1's breakfast by pureéing it with a blender. During the tour of the facility, LPA observed that the facility is equipped with multiple blenders and supplies to ensure that R1's special dietary needs are followed. Continued on LIC9099-C... Unsubstantiated Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the 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 with AD Mai. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Sep 24, 2025 · control 22-AS-20220620170336

Allegation investigated: Staff are not addressing a resident's hygiene needs while in care

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced visit to the facility to continue the investigation and to deliver the findings. LPA Rodriguez explained the purpose of today's visit, was greeted, and granted entry by facility administrator (AD) Ngoc "Nick" Mai. It was alleged that staff are not addressing a resident's hygiene needs while in care. 2 out of 2 resident interviews and 1 out of 1 staff interview did not corroborate with the allegation by verifying that staff assist with tolieting and showering needs. Per resident 1 's (R1) physician report, R1 requires assistance with showering. Per interviews, showering schedule for each resident ranges between 2 to 4 times a week. During the tour of the facility, LPA observed that all residents are clean, and that the facility is equipped with multiple supplies to ensure resident hygiene needs are met (such as pads, diapers, tolieting supples, shampoo and soap). Continued on LIC9099-C... Unsubstantiated Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the 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 with AD Mai. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Sep 24, 2025 · control 22-AS-20220831160613

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Samer Haddadin made an unannounced visit to conduct a case management. LPA met with Administrator Mai Ngoc and stated the purpose of this visit. . The purpose of this case management visit was to amend the annual visit report dated back on November 25th, 2024 and re-print deficiencies and the original 809 annual inspection report and the 809-D pages. An exit interview was conducted and a copy of this report was provided to AD at the facility,the state’s words, verbatim · CDSS document, Dec 4, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Samer Haddadin made an unannounced required annual inspection at this facility. LPA met with Administrator Mai Ngoc and stated the purpose of this visit. The facility is a single level home and licensed for six non-ambulatory of which two may be bedridden with a hospice waiver for six. This facility is a Residential Care Facility for the Elderly/Dementia. The facility had 6 bedrooms in which 4 are used for resident and 2 for staff members. LPA toured the interior and exterior portions of the facility. Resident rooms were provided with furniture, chair, clean linen, adequate storage space, and kept free of tripping hazards. Hard wired smoke detectors, carbon monoxide and audible exit alarms were tested to be operational. LPA did not observe the required PUB 475 to be in the right size. Also, LPA asked AD for liability insurance, AD stated he does not have one currently on his person will provide it. LPA did not observe any emergency drill documentation. All files of staff and clients contained all required documentation. Bathrooms were observed to be in good repair and provided with grab bars and hot water was measured at 126.6 degrees Fahrenheit. Facility did not met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. For the exterior portion, facility did not have a shaded area and nor chairs; grounds were unclear of tripping hazards and no space for activities. Facility has a 2-car garage and is kept locked and used for storage; the garage also had an operational washer and dryer. Based on this inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. . ***THIS IS AN AMENDED REPORT***the state’s words, verbatim · CDSS document, Nov 25, 2024

Allegation investigated: Facility staff did not adequately supervise resident in care.

Licensing Program Analyst (LPA) Michael Tea made an unannounced complaint visit on this day to deliver findings for the allegations mentioned above. LPA met with Caregiver (CG) staff Quy "Anna" Mai while administrator was not present. It was alleged that facility staff did not adequately supervise resident while in care. During the investigation LPA interviewed staff and attempted to interview resident; obtained staff and resident roster, checked resident file, admission agreement, level of care assessment, discharge paperwork. The investigation determined the following: During investigation, LPA obtain and reviewed Resident 1’s (R1) physician’s report dated 02/17/2023 showing that R1’s primary diagnosis is dementia. In section 14, “Mental Condition,” sub-section k “able to leave facility unassisted” the doctor marked “NO.” R1 is unable to leave the facility without a staff assisting them. On the evening of 2/01/23, R1 left the facility unassisted and was missing until the following morning. (Continued on LIC9099C) Substantiated Per interview with AD Mai allows R1 to sit outside on the facility front porch unsupervised. AD stated he leaves the front door unlock for R1. AD explained that R1 usually comes back from outside and goes in their room and closes their door. The night of the incident, AD Mai check and saw a blanket covering R1’s pillow and thought R1 was in bed. AD stated he didn’t hear R1 leave. AD reported the door alarm was turned off because it irritates R1. AD Mai was not aware that R1 was missing until in the morning where he usually wakes up R1 for breakfast. Upon realizing R1 was missing, AD checked the facility and surrounding neighborhood and notified police & R1’s responsible party. AD does not recall notifying CCLD about R1's elopement. LPA did not find any SIRs from the facility around that time period of the incident. R1 was brought to UCI Medical Center via paramedics after a syncope and collapse. After a series of tests, R1 was diagnosed with facial trauma to their forehead and nose. Per hospital discharge paperwork dated 2/2/23, R1’s head CT scan did not show any signs of acute intercranial hemorrhage, herniation or hydrocephalus. AD Mai was not aware that R1 was brought to the hospital upon admission. AD Mai was contacted by hospital staff upon finding his business card in R1’s pocket. Hospital records note R1 did not recall the event and was unclear how they came to be in Orange County. LPA attempted to interview R1 who refused to speak with LPA. Therefore, based on the preponderance of evidence through records reviewed and interviews the allegation facility staff did not adequately supervise resident while in care is determined to be 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. An exit interview was conducted with Caregiver Quy "Anna" Mai and Ngoc “Nick” Mai over the phone and a copy of this report and appeal rights was provided.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 22-AS-20230203140953

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 27, 2024

Basic Services ... 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 is not being met as evidenced Based on interview and review of documents licensee failed to supervise R1 in which they left the facility unassisted and ended up at emergency at hospital.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Licensee to provide a written statement of understanding of the regulation and forward to LPA by POC due date.

Type of visit: Case Management - Deficiencies

On today's date, Licensing Program Analyst (LPA) Michael Tea conducted this case management in conjunction with the continued Complaint visit Control #:22-AS-20230203140953. LPA Tea met with Caregiver (CG) Quy "Anna" Mai and discussed purpose of today's case management visit - Deficiencies visit. Administrator Ngoc "Nick" Mai was not present but LPA spoke to AD Mai over the phone. During the visit LPA Tea was greeted and granted entry by a new staff, Sau Nguyen. LPA observed that AD was not present and just the staff was alone with the residents at the facility. LPA was able to talk to AD Mai over the phone and asked where he was. AD Mai said he is far away from the facility in San Bernardino obtaining cooking utensils for the facility and that the residents are being supervised by the present staff who is AD Mai's cousin, who he plans to hire as a caregiver for the facility. AD Mai said that he was testing him out with the residents. LPA Tea asked AD Mai if he had the staff fingerprinted and passed background clearance. AD Mai said he just started the paperwork. LPA explained that all staff whether test trial or not is required to have full background clearance to be at the facility. AD Mai understood and said that he will have his sister, Quy "Anna" Mai an on-call caregiver come to facility within in half an hour. LPA observed there is not enough staff to care for residents, especially when AD Mai is away. Based on this inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for the deficiencies. An exit interview was conducted with Caregiver staff Quy "Anna" Mai and Administrator Nick Mai over the phone a copy of this report LIC809 and LIC809D and appeal rights were provided at exit.the state’s words, verbatim · CDSS document, Sep 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: Sep 27, 2024

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Based on LPA's observation, new staff does not have background clearance to be at the facility. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Licensee will have proof that staff obtain fingerprint and be background cleared in order to work and be at the facility by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(a) · Plan of correction due date: Sep 27, 2024

Administrator - Qualifications and Duties ... facilities shall have a qualified and currently certified administrator. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. This requirement is not met as evidenced by: Based on LPA's observation, facility lacks enough staffing and back up administrator while away, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Licensee to provide a written statement of understanding of the regulation and forward to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1) · Plan of correction due date: Sep 27, 2024

Reporting Requirements ... (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to ... This requirement is not met as evidenced by: Based on LPA's observation, licensee can not recall if the incident on 02/01/2023 was reported to CCLD. LPA searched past SIRs during the time of incident and there is no LIC624 reporting the incident from the facility.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Licensee to provide a written statement of understanding of the regulation and forward to LPA by POC due date.

Type of visit: Case Management - Deficiencies

On today's date, Licensing Program Analyst (LPA) Michael Tea conducted this case management in conjunction with the continued Complaint visit Control #:22-AS-20230203140953. LPA Tea met with Administrator (AD) Ngoc "Nick" Mai and discussed purpose of today's case management visit - Deficiencies visit. During the visit LPA Tea while reviewing resident records discovered Resident 1(R1) Physician report to be outdated and has a diagnosis of dementia. Residents with dementia are suppose to have updated physician's report annually. Based on this inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for the deficiency. An exit interview was conducted with Administrator Nick Mai a copy of this report LIC809 and LIC809D and LIC811 and appeal rights were provided at exit.the state’s words, verbatim · CDSS document, Sep 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Oct 2, 2024

"Care of Persons with Dementia" ... Each resident with dementia shall have an annual medical assessment ... done at least annually ... of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidence by: Based on LPA's review of resident records, LPA discovered outdated Physician Report sign and dated by Physician 02/17/2023.the state’s words, verbatim · CDSS document, Sep 11, 2024

Plan of correction: Licensee will obtain updated physician's report by COB of POC due date 10/02/24.

Allegation investigated: Resident left in soiled diapers on multiple occassions. Resident left in soiled diaper for an extended period of time.

Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of delivering the findings into the above allegations. LPA met with Licensee/Administrator Ngoc Mai and was advised of the visit and the allegations. On September 1, 2020, the Department received the complaint. The complaint investigation was initiated by LPA Ruth Martinez on September 9, 2020, via a tele-visit due to Coronavirus 2019 precautionary measures. During the tele-visit, LPA Martinez conducted an interview with staff and obtained pertinent records via email. On April 24, 2024, LPA Cho made an unannounced subsequent visit to continue the investigation from 9:20am-11:10am. LPA Cho conducted interviews with the staff and residents; however, interviews were terminated prematurely for three out of the three residents due to language barriers and/or their refusal to participate. Additional interviews were conducted via telephone with the exception of Resident #1 (R1). The following was revealed during the course of the investigation: Unsubstantiated It is alleged that the resident was left in soiled diapers on multiple occasions. Three out of the three staff indicated that R1 was provided incontinent care such as diaper changes. All staff expressed that R1’s diaper was changed as needed and at their request by calling their name or using the buzzer. R1 was cognitively “sharp” and was able to express their needs which aligned with the Physician’s Report dated May 14, 2020. The family member who also corroborated with the statement was unable to recall details to R1’s care. It is alleged that the resident was left in soiled diaper for an extended period of time. Three out of the three staff denied the allegation and the family member was unable to provide further information. Therefore, based on the interviews and the record review, 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 following allegations: Resident was left in soiled diapers on multiple occasions and Resident was left in soiled diaper for an extended period of time are deemed UNSUBSTANTIATED. An exit interview was conducted with Licensee/Administrator Ngoc Mai, and a copy of this report including the LIC9099C and the LIC811 were provided at exit.the state’s words, verbatim · CDSS document, Apr 29, 2024 · control 22-AS-20200901153600

Allegation investigated: Facility failed to pay electricity bill timely

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA Mendivil was greeted and granted entry into the facility by Licensee/Administrator Ngoc Mai and explained the reason for the visit. The department received a complaint on 03/08/2024, and LPA Mendivil conducted initial 10 day visit same day. LPA Mendivil interviewed Licensee/Administrator Ngoc Mai and obtained copies of electronic payment receipt. Regarding the allegation facility failed to pay electricity bill timely, the investigation revealed the following: Per interview with Licensee/Administrator Mai the electricity was on auto pay and the card linked to the account had expired in October 2023. Licensee Mai stated that he was not aware as he does not often check his emails linked to the electricity account and did not receive anything in the mail or calls regarding the late payments. On 03/01/2024 a door tag was left on the front door of the facility indicating a payment was due by 03/01/2024 in order to ensure electricity was not shut off. Substantiated Based on interview with Licensee Mai he stated that a partial payment was made on 03/01/2024 and the remaining balance was paid on 03/08/2024. LPA Mendivil received a copy of receipt of both payments from 03/01/2024 and 03/08/2024 while at the facility. It was confirmed by Anaheim Public Utilities if the balance was paid then there would not be a disruption in service. Therefore, based on the preponderance of evidence through records reviewed and interviews the allegation facility failed to pay electricity bill timely is determined to be 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. An exit interview was conducted and a copy of this report and appeal rights was provided to the facility representative.the state’s words, verbatim · CDSS document, Mar 8, 2024 · control 22-AS-20240308085205

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87205(a) · Plan of correction due date: Mar 9, 2024

(a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement was not met as evidence by faciltiy received a notice to pay electricity bill or face a disruption in service. This poses an immediate health and safety risks to persons in care.the state’s words, verbatim · CDSS document, Mar 8, 2024

Plan of correction: Licensee has since paid the remaining balance of the electricity bill. Licensee has setup a auto pay with updated credit card to avoid rejected payments in the furture.