Flowers Family Care

Allegation investigated: Staff do not provide adequate supervision to resident, resulting in multiple unobserved falls Staff do not follow resident's care plan Staff do not ensure resident intakes adequate fluids, resulting in mild dehydration Staff do not meet resident's hygiene needs

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff, resident and witnesses as well as reviewed and obtained pertinent documentation such as hospice records. Regarding the allegation that Staff do not provide adequate supervision to resident, resulting in multiple unobserved falls, the investigation revealed the following: Per physician report dated 04/22/2026, Resident 1 (R1) is at increased risk of falls due to weakness and impaired balance and is diagnosed with Dementia. R1 admitted into hospice care on 02/12/2026. Two out of two staff state resident had a fall in which the resident was sent out to the hospital resulting in no injuries. The department is in receipt of an incident report dated 05/05/2025 outlining the incident. Administrator indicates R1 has slid onto the floor from the bed with no injuries noted and staff deny other falls. Three out of three staff state checking on facility CONTINUED ON LIC 9099C DATED 07/31/2026 Unsubstantiated residents constantly and Administrator indicates an expectation of hourly checks. Resident interviewed confirmed staff are attentive to needs. Regarding the allegation that staff do not follow resident's care plan, the investigation revealed the following: R1 is equipped with a glucose monitoring device. Staff indicate monitoring and inserting the device. Facility was cited on 05/08/2026 for having a non-skilled staff inserting the device. Staff state checking the blood sugar on the device app and advising hospice of the reading daily. LPA obtained documentation of the readings. Staff indicate family requested this process and LPA is unable to find any written order requesting the reading from hospice or a physician. Regarding the allegation that staff do not ensure resident intakes adequate fluids, resulting in mild dehydration, the investigation revealed the following: Three out of three staff state water and fluids are offered to all residents. Facility staff cannot force a resident to drink but only encourage. LPA observed residents with water cups at meal time and staff encouraging hydration. Regarding the allegation that staff do not meet resident's hygiene needs, the investigation revealed the following: Interview with hospice bath aide indicated resident has been receiving baths three times a week from hospice for a couple months. The bath aide stated that when the service commenced, the fungal infection was already being treated and has since cleared. Facility staff state baths were being given and the infection was reported and treated once it was discovered. Hospice narrative indicate the resident was treated with Nystatin for 14 days and the infection was resolved. Due to conflicting information, LPA is unable to corroborate allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 31, 2026 · control 22-AS-20260504105402

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on citations issued on 05/08/2026. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87411(h) pertaining to Personnel Requirements has been cleared. Facility provided proof of correction. Licensee has complied with the POC. *Licensee has been advised to maintain compliance in all previously cited items. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 31, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on citations issued on 04/07/2026. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to Care of Persons with Dementia has been cleared. During today's visit, exit gate is unlocked. Licensee has complied with the POC. *Deficiency cited under Title 22 Regulation 87307(e)(1)(A) pertaining to Personal Accommodations and Services has been cleared. LPA observed covers on cook top knobs. Licensee has complied with the POC. *Deficiency cited under Title 22 Regulation 87463(h) pertaining to Medical Assessments has been cleared. Licensee provided proof of correction.. Licensee has complied with the POC. *Licensee has been advised to maintain compliance in all previously cited items. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 8, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint #22-AS-20260504105402. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation interviews conducted revealed staff are inserting the Libre 3 (Glucose monitoring) device into Resident 1's (R1) arm. Staff employed at the facility are not licensed professionals. Based on the observations made from today's visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided to Administrator as well as Appeal Rights.the state’s words, verbatim · CDSS document, May 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(h) · Plan of correction due date: May 9, 2026

All services requiring specialized skills shall be performed by personnel qualified by training or experience in accordance with recognized professional standards. This req is not met as evidenced by: Based on observation and interviews conducted, the licensee failed to ensure a licensed professional inserted resident's glucose monitoring device which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 8, 2026

Plan of correction: Licensee states hospice will be inserting the device moving forward. Licensee to submit a detailed plan on how to address the situation should the resident come off hospice and forward proof to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Flowers Family Care. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and met with Caregiver Dominga Santillian. Facility is licensed for 6 non-ambulatory residents, one of which may be bedridden. Facility has an approved hospice waiver for 6 residents and the home currently has 5 residents. There are 3 residents on hospice care during today's visit. Administrator/ Licensee Jonathan Martinez arrived during the visit. Administrator Martinez has an administrator certificate expiring on 03/08/2027. LPA Lyman along with Caregiver Dominga Santillian toured the facility at 11:47 AM. LPA toured the physical plant, checked food service, facility records and the first aid kit. Facility appears to be clean, safe, and sanitary. The home consists of three resident bedrooms, two shared bathrooms, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed three residents with full rails and one resident with half rails. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured at 106.3 degrees F in facility restroom. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. LPA observed a locked storage area for cleaning supplies in the kitchen. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. CONTINUED ON LIC 809C DATED 04/07/2026 LPA observed three out of five cook top knobs have protective mechanisms. LPA toured the outside grounds and there is a fenced pool. LPA observed emergency food and water supply in the garage. LPA observed the exit gate is locked with a padlock. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provides activities in the form of games and exercise. LPA reviewed five resident files and three staff files. Resident files contained required documents including admission agreements and physician reports. Four out of five residents do not have updated physician reports. Staff files reviewed contained required documentation of criminal record clearance, required annual training, CPR and health screens/ TB. LPA reviewed medication storage and administration. Medications appear to be administered per physician order and are stored in a locked cabinet. Based on the observations made from today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided to Administrator as well as Appeal Rights.the state’s words, verbatim · CDSS document, Apr 7, 2026

Allegation investigated: Staff physically abused resident in care causing a fracture.

On 04/13/25, Donna Gurriere, Licensing Program Analyst (LPA) contacted the administrator via phone to deliver final findings regarding a complaint that was received on 05/09/23. LPA Gurriere spoke with Jonathan Martinez, Administrator and explained the purpose of the call. Staff physically abused resident in care causing a fracture. During the interview process, the licensee, the resident (Resident 1), a staff person and several others were interviewed. In addition, documents were reviewed and obtained to include medical records, Personnel Report, Physicians Report, Emergency Information, Admission Agreement and the Resident Facility Roster. Unsubstantiated During the investigation of a complaint received on 05/09/23, it was reported that the resident (Resident 1) suffered a fractured hip while at the facility due to abuse by a staff person. During the interview process, the resident was inconsistent with her statements and at times reported that her injury was due to a fall. In addition, there was no medical evidence or supporting witness statements to substantiate an allegation of physical abuse. No actionable evidence was gathered during the investigation. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated. Licensee was advised a copy of this report will be sent via certified mail. Two copies of the report will be sent. The Licensee is to sign and return a copy to the Orange County Regional Office.the state’s words, verbatim · CDSS document, May 13, 2025 · control 22-AS-20230509165028

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on citations issued on 04/09/2025. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87608(a)(5) pertaining to Postural Supports has been cleared. During today's visit, full rails have been removed. Licensee has complied with the POC. *Deficiency cited under Title 22 Regulation 87456(a)(2) pertaining to Pre-Appraisals has been cleared. Licensee provided proof of correction. Licensee has complied with the POC. *Deficiency cited under Title 22 Regulation 87608(a)(5) pertaining to Postural Supports has been cleared. During today's visit, Licensee obtained orders for half rails. Licensee has complied with the POC. LPA observed protective mechanisms on stove top as well as emergency packets for residents. *Licensee has been advised to maintain compliance in all previously cited items. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Flowers Family Care. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and met with Caregiver Dominga Santillian. Facility is licensed for 6 non-ambulatory residents, one of which may be bedridden. Facility has an approved hospice waiver for 6 residents and the home currently has 5 residents. There are no residents on hospice care during today's visit. Administrator/ Licensee Jonathan Martinez arrived during the visit. LPA Lyman along with Caregiver Dominga Santillian toured the facility at 7:54 AM. LPA toured the physical plant, checked food service, facility records and the first aid kit. Facility appears to be clean, safe, and sanitary. The home consists of three resident bedrooms, two shared bathrooms, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. At 7:59 AM, LPA observed two residents with full rails and two residents with half rails. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105.4 and 106.8 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. LPA observed a locked storage area for cleaning supplies in the kitchen. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is a fenced pool. LPA observed emergency food and water supply in the garage. LPA reviewed the CONTINUED ON LIC 809C DATED 04/09/2025 emergency disaster plan and infection control plan during the visit. Plans are thorough and complete. Facility provides activities in the form of games and exercise. At 9:00 AM, LPA reviewed five resident files and three staff files. Resident files contained required documents including admission agreements and physician reports. Staff files reviewed contained required documentation of criminal record clearance. Three out of three staff do not have proof of required annual training. At 9:30 AM, LPA reviewed medication storage and administration. Medications are being administered per physician order and are stored in a locked cabinet. Based on the observations made from today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided to Administrator as well as Appeal Rights.the state’s words, verbatim · CDSS document, Apr 9, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on citations issued on 04/10/2024 and 04/24/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications has been cleared. During today's visit, medications are secured in the medication closet. Licensee has complied with the POC. *Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to Care of Persons with Dementia has been cleared. During today's visit, supplements are secured. Licensee has complied with the POC. *Licensee has been advised to maintain compliance in all previously cited items. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, May 7, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on citations issued on 04/10/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications has NOT been cleared. During today's visit, medications are unsecured in the medication closet. Licensee has NOT complied with the POC. CIVIL PENALTY ASSESSED. *Deficiency cited under Title 22 Regulation 87628(a) pertaining to Diabetes has been cleared. Licensee provided a plan for glucose checks. Licensee has complied with the POC. *Deficiency cited under Health and Safety Code 1569.695(c) has been cleared. Licensee provided proof of emergency drill. Licensee has complied with the POC. Licensee obtained CPR certification for additional staff. During the plan of correction visit, LPA observed unsecured supplements in Resident #4's room. Based on the observations made from today's visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided to Administrator as well as Appeal Rights.the state’s words, verbatim · CDSS document, Apr 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Apr 25, 2024

The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins.. cleaning supplies and disinfectants. This requirement is not being met as evidenced by: Based on observation, Licensee failed to ensure vitamins/ supplements are secured. LPA observed vitamins/ supplements unsecured in R4's room. This poses an immediate health and safety risk to resident's in care.the state’s words, verbatim · CDSS document, Apr 24, 2024

Plan of correction: Licensee to secure noted items and forward proof to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Flowers Family Care. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and met with Caregiver Dominga Santillian. Facility is licensed for 6 non-ambulatory residents, one of which may be bedridden. Facility has an approved hospice waiver for 6 residents and the home currently has 4 residents. There are no residents on hospice care during today's visit. Administrator/ Licensee Jonathan Martinez arrived during the visit. LPA Lyman along with Caregiver Dominga Santillian toured the facility at 10:05 AM. LPA toured the physical plant, checked food service, and the first aid kit. Facility appears to be clean, safe, and sanitary. The home consists of three resident bedrooms, two shared bathrooms, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. At 10:15 AM, LPA observed unsecured supplements in resident room. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 108.6 and 109.4 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. LPA observed a locked storage area for cleaning supplies in the kitchen. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. At 10:25 AM, LPA observed the medication cabinet is unlocked and medications are unsecured. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is a fenced pool. LPA observed emergency food and water supply in the garage. LPA reviewed the CONT ON LIC 9099C DATED 4/10/24 emergency disaster plan during the visit. Plan is thorough and complete. Facility provides activities in the form of games and exercise. At 11:00 AM, LPA reviewed four resident files and three staff files. Resident files contained required documents including admission agreements and current physician reports. Staff files reviewed contained required documentation of annual training, health screen/TB, and criminal record clearance. At 11:30 AM, LPA reviewed medication storage and administration. Medications are being administered per physician order. LPA observed facility is performing finger sticks on Resident 3. Based on the observations made from today's visit, deficiencies is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided to Administrator as well as Appeal Rights.the state’s words, verbatim · CDSS document, Apr 10, 2024