Kaego's Richman Gardens

Allegation investigated: Facility staff stole from resident(s) Facility staff spoke inappropriately to resident(s)

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with Administrator (AD) Susan Ruiz and the purpose of the inspection was discussed. Regarding allegation, Facility staff stole from resident(s), interviews were conducted with five facility residents and three staff. Two of five residents interviewed denied having any knowledge of facility staff stealing from residents and three of five residents were unable to confirm or deny allegation. Three of three staff interviewed denied personally stealing from residents or having any knowledge of any other staff stealing from residents. Regarding allegation, Facility staff spoke inappropriately to resident(s), interviews were conducted with five facility residents and three staff. (Cont. LIC9099-C) Unsubstantiated Two of five residents interviewed denied having any knowledge of facility staff speaking inappropriately to residents and three of five residents were unable to confirm or deny allegation. Three of three staff interviewed denied personally speaking inappropriately to residents or having any knowledge of any other staff speaking inappropriately to residents. Based on information gathered, the Department did not find sufficient evidence to support the allegations, “Facility staff stole from resident(s) and Facility staff spoke inappropriately to resident(s)”. 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 above allegations are Unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Sep 23, 2026 · control 22-AS-20240524152538

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kimberly Lyman arrived on September 1, 2026 for an unannounced inspection to follow up on a substantiated complaint investigation. LPA Lyman met with Administrator Susan Ruiz Hidalgo and reviewed the report. On December 23, 2024, the Department concluded a complaint investigation regarding the following allegations: Staff did not provide adequate supervision resulting in resident wandering away from facility and causing resident to sustain multiple fractures and injuries, staff do not respond to facility alarm, staff does not securely lock facility’s exterior gate, and staff did not provide resident’s authorized representative with the correct information of incident. The allegations were substantiated, and the licensee was cited under California Code of Regulations (CCR) § 87464(f)(1) Basic Services, CCR § 87207 False Claims, CCR §87705(j) Care of Persons with Dementia, and CCR §87705(h) Care of Persons with Dementia. At the time of the complaint visit on 12/23/2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation. This is evidenced by the licensee not providing a safe environment, care and supervision that resulted in a CONTINUED ON LIC 809C DATED 09/01/2026 resident sustaining multiple bruises in their body, fracture of alveolar maxilla, a missing tooth (protracted loss), organ injury, cardiac contusion, and a skull fracture, after eloping from the facility. Today, September 1, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on December 23, 2024, the amount of the civil penalty issued today will be $9,500. An exit interview was conducted. A copy of the report was issued. Appeal Rights provided to Administrator Ruiz Hidalgo and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Sep 1, 2026

Allegation investigated: Facility does not have an administrator. Residents’ hygiene needs are not being met. Facility failed to address resident's with scabies. Residents’ medications are not being administered as prescribed. Staff are handeling resident's roughly. Diabetes care is being provided without qualified staff.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegations. LPA arrived at the facility and was greeted at the door and granted entry. LPA spoke with Susan Ruiz Hidalgo, Administrator, and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, facility file review, resident file review, copies of pertinent documents and interviews conducted. It is alleged that staff facility does not have an administrator. Facility record review revealed that Robin Aquino was the Administrator until June 21, 2026, and Susan Ruiz Hidalgo is the new Administrator for Continue on LIC9099-C Unsubstantiated the facility as of June 22, 2026. Both individuals have a valid administrator certificate. LIC500 personnel report reflects facility has an administrator and an on call administrator. Interview with staff stated that administrator generally is at the facility Monday – Friday from 9:00am to 6:00pm and on weekends it is on call. It is alleged that residents’ hygiene needs are not being met, specifically to not have laundry supplies at the facility to do residents laundry. LPA on facility visit toured the physical plant of the facility and observed the laundry unit of the facility to be stocked with laundry detergent, fabric softener and dryer sheets. LPA toured the storage unit and observed additional supplies of laundry detergent, fabric softener and dryer sheets. Interview with staff stated that they are the ones that purchase the laundry supplies to ensure that supplies are always kept. It is alleged that facility failed to address resident’s with scabies. Records review revealed that the facility sent in LIC624 incident reports to the department on February – March of residents having scabies and/or being exposed to scabies. The facility immediately initiated infectious control protocol in accordance with facility policy and public health guidance. Interview with staff stated that residents were placed on isolation and contact precautions and promptly started on physician’s order treatment. All residents were assessed for signs of scabies and were placed under ongoing monitoring. LPA toured the facility and did not observe any residents in the common areas with sign and symptoms of scabies. It is alleged that residents’ medication are not being administered as prescribed, specifically to staff giving double doses of medication and losing medication. Record review for 10 random selected residents reflects MAR from April to June of 2026, medication doses given as prescribed. MAR, PRN and controlled/antibiotic drug records revealed no missed doses. MARs reflect that medication was given at the scheduled time per order indications. Records review indicate staff are following doctor’s orders as prescribed. Interview with 2 of 2 staff revealed that medication is given as prescribed and there is no way staff can fail to administer medication because that would cause a shortage of dosage. Staff indicated this would reflect on MAR, but however dosages are signed off as given as indicated on prescription instructions. Continue LIC9099-C It is alleged that staff are handling residents roughly, specifically to a residents chest being rubbed too rough while having a stroke. Records review revealed that there has not been any resident who has had a stroke at the facility. Interview with staff stated that they did not have any resident at the facility that had a stroke. Staff stated that by observation if there was a resident with a stroke you would be able to see a resident with indications such as left side paralyzes. LPA toured the physical plant of the facility and observed the facility to have four buildings that resident resides in. LPA did not observe any resident with face dropping or with one sided weakness or paralysis in any of the four buildings. Interview with 4 of 4 residents stated that they have not observed any staff treating any resident roughly or any resident having a stroke at the facility. Residents stated that staff treat them good and are not rough at all. It is alleged that diabetes care is being provided without qualified staff. Specifically, to a resident being administered insulin. Record review revealed that there is only one resident at the facility who has prescription for insulin. Interview with 4 of 4 staff stated that there was only one resident (R1) that had insulin at the facility. Staff hand resident their glucose meter and R1 do their own testing. If R1 indicates that they need insulin, then staff get the insulin and hand it to the resident so they can administer it. Staff are aware that they are not allowed to do diabetes care per regulations. Interview with R1 stated that they do their own glucose testing as well as their own insulin shots when needed. R1 stated that facility holds their medication and meter with the locked medication storage and all they do is give them the equipment and medication, staff do not perform any diabetes care. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted with the Administrator, and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Aug 20, 2026 · control 22-AS-20260617093229

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nancy Guillen made an unannounced visit for the purpose of conducting a required annual Inspection. LPA was greeted and granted entry by staff after explaining the purpose of the visit. Administrator (AD) Susan Hidalgo was present and assisted with the visit. LPA observed the Administrator certificate was current with an expiration date of December 20, 2027. This is a Residential Care Facility for the Elderly (RCFE) licensed to twenty- six non-ambulatory residents, of which six may be bedridden, with a hospice waiver for eleven. This is a small commercial facility that consists six different buildings. Two buildings consists of the garage and additional storage space. The remaining four buildings contain thirteen bedrooms, seven bathrooms, kitchen, living areas, dinning room, medication room and multiple storage areas. During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following: LPA observed residents watching television in the living room and resting in their respective bedrooms. LPA was advised twenty two residents were in care and seven staff present. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets with additional linens stored in the linen room located in Building 1. LPA observed bathrooms were clean and equipped with grab bars and non skid floor mats. LPA observed all windows were appropriately screened. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 103.2 and 110.4 degrees Fahrenheit. Continued on LIC809C LPA toured the outside of the facility and observed outdoor passageways were free of obstruction. LPA observed the backyard had a shaded sitting area with furniture for resident use. LPA observed two emergency exits were locked without the proper fire clearance; a deficiency was cited on today's date. LPA observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. LPA reviewed the Fire Safety Inspection report and verified the annual fire alarm report was conducted and passed on January 2, 2026 and the carbon monoxide detectors are maintained monthly. Fire extinguishers were observed to be fully charged with a service date of March 31, 2026 and are located in each building. Gas stove, washer, and dryer were all inspected and observed to be operable. LPA observed knives and sharps to be locked and stored in the kitchen. The four car garage is used for storage which is kept locked and inaccessible to residents in care. Toxic chemicals, cleaning solutions, and disinfectants were observed to be stored in the garage. Medication is locked and centrally stored in a hallway closet in Building 1 however, Memantine was signed as administered to a resident, but pill was observed to be in the residents medication tray during medication review; a deficiency was cited on this date. LPA observed the First Aid Kit had all the required components. LPA observed the facility conducted their last emergency disaster drill on April 14, 2026. LPA began review of the records. LPA reviewed nine resident records. All the required documentation were present and current in the resident files reviewed. LPA reviewed six employee records. All employees present have a criminal record clearance and were associated to the facility. LPA observed records reviewed have a current First Aid certificate. Based on the observations made during today’s inspection, deficiencies are being cited and a civil penalty was assessed. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Aug 10, 2026

The state marks this report as 8 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

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 10/17/2024 and 12/23/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Citation issued on 10/17/2024 and 12/23/2024 regarding Fire Safety, 87203 has been cleared. LPA observed delayed egress has been installed on the exit gate and is operational. Licensee has complied with the POC. Licensee has been advised to remain in compliance with items previously cited. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 15, 2025

Type of visit: Collateral

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced collateral visit in conjunction with complaint 22-AS-20220304102138. LPA Ramirez was allowed entry into the facility and met with Administrator (AD) Magali Sanchez. LPA explained the purpose of the visit. On today's visit LPA Ramirez toured the facility and interviewed staff and a resident. LPA was not able to reviewed and obtained copies of facility, resident, and staff records as facility does not have records from March 2022. An exit interview was conducted with AD Sanchez and a copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, Aug 29, 2025

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Magali Sanchez and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 10:30AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, storage areas, and medication room and observed the following: Structure: this is a small commercial facility. Facility is a 13-bedroom, 7-bathroom, 4-building small commercial facility with multiple storage areas, a kitchen, a dining room, a medication room, and multiple common areas. There is a large back yard with a patio cover for the residents. The entire facility is a memory care unit with a delayed egress alarmed exit at the front gate and exit alarms on the other three gates. LPA tested the delayed egress system, exit alarms, and the call button system. Resident Bedrooms: the 13 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 13 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 and 112 degrees F in the 7 resident bathrooms tested. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the housekeeping closets. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees are paid. At about 11:30AM, LPA reviewed 6 resident files and 6 staff files, interviewed 6 residents and 4 staff, and inspected medications for 6 residents. Facility does not handle resident money. During the inspection, LPA and AD observed the following: based on documents, the licensee did not ensure Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5) had appraisals updated within the past year. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 28, 2025

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

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 12/23/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Citation issued on 12/23/2024 regarding Basic Services, 87464(f)(1) has been cleared. Licensee provided proof of correction. Licensee has complied with the POC. *Citation issued on 12/23/2024 regarding False Claims, 87207 has been cleared. Licensee provided proof of correction. Licensee has complied with the POC. *Citation issued on 12/23/2024 regarding Care of Persons with Dementia, 87705(j) has been cleared. Licensee provided proof of correction. Licensee has complied with the POC. *Citation issued on 12/23/2024 regarding Storage Space, 87705(h) has been cleared. Licensee provided proof of correction. Licensee has complied with the POC. Licensee has been advised to remain in compliance with items previously cited. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 8, 2025

Allegation investigated: Staff did not provide adequate supervision resulting in resident wandering away from facility and causing resident to sustain multiple fractures and injuries. Staff do not respond to facility alarm. Staff does not securely lock facility's exterior gate. Staff did not provide resident's authorized representative with the correct information of incident.

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Rosie Maldonado and explained the reason for the visit. During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation including Physician Report and UCI Medical Records. The purpose of today’s visit is to deliver the findings regarding the above allegations. The investigation conducted revealed the following: Resident 1 (R1) was admitted to the facility on July 14, 2023, and has a diagnosis of Alzheimer’s disease with confusion and sundowning behavior per Physician report dated April 4, 2023. Per Physician report resident is not able to leave the facility unassisted. On August 26, 2024, facility staff informed R1’s family that R1 was put to bed around 8:30 PM and fell in the back patio of the facility. However; surveillance video from the nearby liquor store showed R1 walking outside the facility at 8:28 PM while alone. CONT ON LIC 9099C DATED 12/23/2024 Substantiated The liquor store manager confirmed seeing R1 walking outside of the facility the night of incident. Staff interviewed reported last seeing R1 at around 8 PM and did not see them again until approximately 9:20 PM when R1 was brought back by an unknown stranger. Staff had failed to notice R1 was missing during this time. One of two staff on duty that day admitted staff often turn off the auditory alarm to the emergency exit door located in the building and confirmed the alarm to the door was turned off at the time of R1’s elopement. One of two staff interviewed reported it being difficult to hear alarms due to the noise levels and location of R1’s bedroom. The facility is not approved for a locked perimeter exterior, however, two of two staff interviewed reported observing other staff propping the gates open for easy access in and out of the facility. R1’s family arrived at the facility at approximately 9:30 PM. Upon arriving R1’s family stated R1 had major bruising to their face, chest, hands and arms in addition to having a front right tooth completely knocked out, left front tooth loose and bottom teeth sore and cracked. After consulting with R1’s hospice nurse, 9-1-1 was called. R1 was taken to UCI Medical Center due to the severity of injuries sustained where they were admitted at 11:14 PM and diagnosed with bruising to the chin, tooth avulsion and maxillary ridge fracture of the mouth, blunt trauma to the torso, organ injury and cardiac contusion and a skull fracture. A meeting was held with facility management and R1’s family where it was disclosed that R1 had actually fallen outside of the facility grounds and an unknown man had brought them back to the facility despite initially saying the fall occurred at the facility. Two of two staff confirmed lying to R1’s family and that they were pressured to do so by the facility management. R1’s family reported management admitted to lying regarding the circumstances of R1’s fall during their meeting. Therefore, based on interviews conducted and records reviewed, the preponderance of evidence has been met. The allegations that staff did not provide adequate supervision resulting in resident wandering away from facility and causing resident to sustain multiple fractures and injuries; Staff did not provide resident’s authorized representative with the correct information of incident; Staff do not respond to facility alarm; and Staff does not securely lock facility's exterior gate has been Substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f) An exit interview was conducted, and a copy of this report, 9099-D Page, and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 22-AS-20230906160954

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 24, 2024

Basic Services- Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This req is not being met as evidenced by: Based on interviews conducted, Licensee failed to ensure R1 received appropriate care and supervision resulting in R1 eloping and sustaining multiple injuries including a fractured jaw. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Licensee to provide retraining on basic services and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Dec 24, 2024

False Claims- No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This req is not being met as evidenced by: Based on interviews conducted, Licensee failed to ensure employees did not make false claims regarding R1’s fall. Two caregivers confirmed providing false statements to R1’s family which was which was confirmed by R1’s family. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2024

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

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: Dec 24, 2024

Care of Persons with Dementia- The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: Based on interviews conducted, Two of two staff confirmed auditory alarms are turned off and one staff reported alarms are difficult to hear resulting in R1 elopement and subsequent injuries. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Licensee to conduct an in-service on elopements and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(h) · Plan of correction due date: Dec 24, 2024

Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This requirement was not met as evidence by: Based on interviews conducted, Two of two staff reported observing staff propping open exterior leading gates for ease of access, thus, incapacitating the ability to self close and latch. This poses an immediate risk to safety to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Licensee to provide an in-service to staff regarding resident safety and foward proof to LPA by POC due date.

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 10/17/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Citation issued on 10/17/2024 regarding Maintenance and Operation has been cleared. Delayed egress push lever has been removed. Licensee has complied with the POC. *Citation issued on 10/17/2024 regarding Fire Safety has NOT been cleared. Exit gates are secured with either a lock or keypad. CIVIL PENALTY ASSESSED. Based on the observations made during today's visit, the following violation 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 as well as appeal rights were discussed and provided with facility representative.the state’s words, verbatim · CDSS document, Dec 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Dec 24, 2024

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This req is not being met as evidenced by: Based on observation, Licensee failed to ensure fire safety is being conformed to. Exit gates are secured by either a keypad or key locks prohibiting residents from leaving in an emergency. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSEDthe state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Licensee to ensure exit gates are unlocked and forward proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Kimberly Lyman and William Vanegas conducted an unannounced case management visit in conjunction with complaint visit #22-AS-20230906160954. LPAs were greeted and granted entry into the facility and explained the reason for the visit. Interim Administrator Wendy Cruz arrived during the visit. During the visit, LPAs toured the facility and observed the following: All exit gates are locked. The main exit gate is only accessed by a code. Auxiliary exit gates are secured with locks. Exit gate on north side of property has a delayed egress push lever that is broken. Facility fire clearance does not include delayed egress or locked perimeters. Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.the state’s words, verbatim · CDSS document, Oct 17, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Oct 18, 2024

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This req is not being met as evidenced by: Based on observation, Licensee failed to ensure fire safety in the facility. All exit gates are locked posing an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 17, 2024

Plan of correction: Licensee to ensure exit gate is accesible for exiting without a lock or keypad and forward proof to LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Oct 31, 2024

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This req is not being met as evidenced by: Based on observation, Licensee failed to ensure facility is in good repair. Exit gate on north side of property has a broken delayed egress push lever. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 17, 2024

Plan of correction: Licensee to repair replace push lever and forward proof to LPA by POC due date.

Type of visit: POC

This unannounced POC inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of verifying correction of deficiencies issued during the Required – 1 Year Inspection conducted on August 13, 2024. LPA met with Administrator (AD) Wendy Cruz and discussed the purpose of the inspection. During the inspection, LPA and AD toured the facility and observed the following: Type A Violation cited under California Code of Regulations (CCR) Title 22, Section 87303(e)(2) pertaining to hot water that tested at 126, 138, and 85 degrees F in the Tea Rose, Jasmine, and Calla Lilly buildings, respectively, has been CLEARED. AD stated that the facility adjusted the temperature in the Tea Rose and Jasmine buildings and purchased and installed a new water heater in the Calla Lilly building. During the inspection, LPA and AD tested the water temperatures and observed that the water temperature tested at 111, 120, and 120 degrees F in the Tea Rose, Jasmine, and Calla Lilly buildings, respectively. There were no deficiencies observed in the areas inspected. 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 discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 19, 2024

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Wendy Cruz and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 12:30PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a small commercial facility. Facility is a 13-bedroom, 5-bathroom, 4-building small commercial facility with multiple storage areas, a kitchen, a dining room, a medication room, and multiple common areas. There is a large back yard with a patio cover for the residents. The entire facility is a memory care unit with a delayed egress alarmed exit at the front gate. Resident Bedrooms: the 9 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 9 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 126, 138, 85, and 109 degrees F in the Tea Rose, Jasmine, Calla Lilly, and Apple Blossom buildings, respectively. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees are paid. At about 1:30PM, LPA reviewed 5 resident files and 5 staff files, interviewed 5 residents and 5 staff, and inspected medications for 5 residents. Facility does not handle resident money. CONTINUED During the inspection, LPA and AD observed the following: based on observation, the hot water tested at 126, 138, 85, and 109 degrees F in the Tea Rose, Jasmine, Calla Lilly, and Apple Blossom buildings, respectively. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 13, 2024

Allegation investigated: Facility staff are not providing records to resident's responsible person(s)

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Staff #1 (S1) Rosalba Maldonado, discussed the purpose of the inspection, and explained the allegation. Administrator (AD) Lupe Harvey was not present during the inspection. The investigation into the allegation that facility staff are not providing records to resident's responsible person(s) revealed the following: During the course of the investigation, LPA inspected the facility, interviewed facility staff, and obtained and reviewed copies of the resident roster, staff roster, a witness statement dated June 11, 2024, and a written request for Resident #1’s (R1) Resident File dated December 28, 2023. Substantiated Regarding the allegation that facility staff are not providing records to resident's responsible person(s): it was alleged that on December 28, 2023, R1’s Resident File was requested, the facility did not provide R1’s Resident File, facility staff were contacted by phone on January 31, 2024 and confirmed the request was mailed to the correct address, the request was sent again via certified mail, but as of June 12, 2024, the facility still had not provided R1’s Resident File. LPA reviewed a witness statement dated June 11, 2024, and a written request for R1’s Resident File dated December 28, 2023, which corroborated the allegation. LPA interviewed facility staff who corroborated that the facility had received the request on or before January 9, 2024, and had not provided R1’s Resident File by that date which is more than two business days from the request, but could not provide information on whether R1’s Resident File was ever provided. Based on the information obtained, the facility did not timely provide R1’s Resident File in response to the request. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 22-AS-20240612135214

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Jun 27, 2024

87468.2 Additional Personal Rights… (a) … (19) To have prompt access to review all of their records ... within two (2) business days... This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not ensure R1 had access to their records within two business days of the request dated December 28, 2023, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 20, 2024

Plan of correction: Licensee stated they will properly respond to the request for R1’s Resident File and submit proof to LPA by POC due date.