The Senior's Retreat of Brea

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit for an Annual Continuation visit. LPA was greeted and granted entry by Staff at 4pm. LPA met with Administrator (AD) Lorna Smith and explained the purpose of the visit. LPA reviewed three of three staff training and fingerprint records. Staff have yearly in-services on various topics which include: hospice, dementia, postural supports and restricted health conditions. The last fire drill was conducted on March 30, 2026. The Emergency Disaster Plan is updated. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Lorna Smith, Administrator and a copy of the report was given at the time of the visit.the state’s words, verbatim · CDSS document, May 29, 2026

Allegation investigated: Licensee does not ensure visitor policy is posted in the facility

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office. LPA was greeted and granted entry by Lorna Smith, Administrator (AD) and explained the purpose of the visit. Currently there are two residents in care. The facility has an approved fire clearance for six non-ambulatory with a hospice waiver for six. LPA obtained the following documents for Resident #1 (R1): Identification and Emergency Information form, Preplacement Appraisal Information, Functional Capability Assessment, Appraisal Needs and Services Plan, Physician's Report dated 1/28/2026, Personal Rights, House Rules with stated visiting hours from 10am - 6pm, Admissions Agreement signed on 2/5/2026 which states visiting hours are from 10a-6p, Medication Administration Records (MARs) from Feburary through May 2026, Facility Progress Notes and Facility handwritten Incident Report. LPA also received a copy of the Power of Attorney (POA) documents via email. LPA also received a copy of the 30-day eviction notice for R1. (Continued on LIC 9099-C) Substantiated (Continued from LIC 9099) It was alleged that Licensee does not ensure visitor policy is posted in the facility. LPA toured the facility and observed visiting hours were not posted in the facility. LPA reviewed paperwork removed from the bulletin board during the week of May 18th, due to dry wall construction work being done on the wall. No visiting hours were posted. File review did show that visiting hours were stated in both the House Rules policy and Admissions Agreement signed on 2/5/2026. LPA interviewed two of two residents who stated they are allowed visitors and can come and go as needed. Two of two residents had no issues with the visiting policy. LPA interviewed two of two staff who stated visiting hours were verbally shared with visitors. Staff stated they accommodate visitors, even if they go past visiting hours; where visitors have remained in the facility through 8pm or 9pm. Staff also stated they provide visiting hours for consistency for the residents and staff routines and request visitors abide by the rules. Based on LPA's observations, file review and interviews, the allegation that: Licensee does not ensure visitor policy is posted in the facility is Substantiated. A Technical Violation will be given and visiting hours were posted by the end of the visit. An exit interview was conducted with Administrator, Lorna Smith, and a copy of this report, LIC 811 and LIC 9102-TV was provided to the facility.the state’s words, verbatim · CDSS document, May 26, 2026 · control 22-AS-20260520155155

Allegation investigated: Licensee does not ensure required posted signs are placed prominently in the facility Staff does not ensure medications are dispensed as prescribed

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office. LPA was greeted and granted entry by Lorna Smith, Administrator (AD) and explained the purpose of the visit. Currently there are two residents in care. The facility has an approved fire clearance for six non-ambulatory with a hospice waiver for six. Resident #1 (R1) moved into the facility on February 5, 2026 with a diagnosis of hemiplegia and hemiparesis per medical assessment on January 28, 2026. R1 is non-ambulatory and has mild forgetfulness. LPA interviewed two of two residents. Two of two residents stated they are being provided care by the staff and that they do not have any issues at this time. It was alleged that Licensee does not ensure required posted signs are placed prominently in the facility. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) LPA observed the poster for the Long Term Care Ombudsman (LTCO) with ombudsman's contact information. Currently contractors are working on the dry wall for an extended patio; thus the posters were taken down from the bulletin board for contractors to do work. The posters were taken off the bulletin wall during the week of May 18, 2026. LPA interviewed two of two residents who stated they have no issues with their care and were not aware of the posters on the wall. Two of two staff members confirmed the posters were on the bulletin board prior to contract work of the dry wall. One witness confirmed the posters were posted, a second witness could not confirm nor deny that the posters were posted. Thus, the allegation that Licensee does not ensure required posted signs are placed prominently in the facility is Unsubstantiated. It was alleged that Staff does not ensure medications are dispensed as prescribed. LPA reviewed two of two resident Medication Administration Records (MARs) and made copies of Resident #1 (R1)'s MAR, Identification and Emergency Information Form, Physician's Report dated January 28, 2026. R1 takes three routine medications but one of the medications has not been refilled per a family member's request. The facility and Power of Attorney (POA) have requested the prescription for the behavior medication to be refilled. The next doctor's appointment for R1 is scheduled on June 5, 2026. None of the medications on the MAR cause drowsiness. LPA interviewed two of two staff members regarding a resident being over medicated and two of two staff members denied the allegation and were not aware of which resident had this incident. Two of two witnesses interviewed also denied this allegation. LPA interviewed two of two residents and both stated they are happy with the care being provided and that they did not have any issues with medications. Based on LPA's observations, record review and interviews, the allegations that: Staff does not ensure required posted signs are placed prominently in the facility and Staff does not ensure medications are dispensed as prescribed are Unsubstantiated. The allegations may have happened or are valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator, Lorna Smith, and a copy of this report and LIC 811 were provided to the facility.the state’s words, verbatim · CDSS document, May 26, 2026 · control 22-AS-20260520155155

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Lorna Smith, Administrator (AD) and explained the purpose of the visit. The facility is a four bedroom, two bathroom residential home with an approved fire clearance for six non-ambulatory residents and a hospice waiver for six. The facility has been undergoing construction for a permitted extended patio and bedroom so the entrance through the patio is not accessible at this time. There are currently two residents in care and neither resident receives hospice services. AD recently completed the Department's Technical Support Program (TSP) on May 18, 2026. The facility was 72 degrees Fahrenheit, was clean and no odors were detected. The smoke and carbon monoxide detectors were inspected and were operational. The fire extinguisher was charged and inspected on May 26, 2026. The hot water temperatures were measured in two of two resident bathrooms. The temperatures ranged from 105.9 to 107.6 degrees Fahrenheit. Bathrooms had non skid mats and covered trash cans. Four of four bedrooms had the required furnishings and linens. LPA toured the kitchen and appliances were in working order. Fresh fruits were observed on the countertop. Sharps and knives were secured in a locked drawer and cleaning supplies and chemicals were locked beneath the kitchen sink. The refrigerator had two days of perishable food supplies and the pantry and freezer had seven days of non-perishable items on hand. Additional food items were in the garage with a washer and dryer and staff refrigerator. (Continued on LIC 809-C) (Continued from LIC 809) LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. The First Aid kit had the required elements. LPA conducted a complete review of resident records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on August 16, 2026. An annual continuation visit will be conducted to complete the Annual Required Evaluation at a further date. An exit interview was conducted with Lorna Smith, Administrator and a copy of the report and files reviewed (LIC 858) were given at the time of the visit.the state’s words, verbatim · CDSS document, May 26, 2026

Allegation investigated: Staff is physically forcing resident to take medication

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint received in the Regional Office. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Lorna Smith and explained the purpose of the visit. It is alleged that Staff is physically forcing resident to take medication. Resident #1 (R1) recently moved into the residence on November 28, 2025 after a week's stay in the hospital. LPA reviewed hospital discharge records and Medical Assessment dated 11/28/2025. R1 has multiple diagnoses; which include: bipolar disorder, paranoid schizophrenia and psychosis. Resident is alert, non-ambulatory and uses a motorized wheelchair. LPA requested and reviewed a Medication Administration Record for R1. LPA interviewed two of two residents, two of two staff members and three of three witnesses. Based on interviews conducted, it is confirmed that the resident was physically forced to take medications. (Continued on LIC 809-C) Substantiated (Continued from LIC 809) Based on LPA's observations, interviews conducted and record review, the preponderance of evidence standard has been met. Therefore the allegation that Staff is physically forcing resident to take medication is Substantiated and a deficiency will be cited per Title 22, California Code of Regulations. An exit interview was conducted with Administrator, Lorna Smith, and a copy of this report, LIC 9099-D, LIC 811 and Appeal Rights were provided to the facility.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 22-AS-20251203112100

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5)(D) · Plan of correction due date: Dec 5, 2025

87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility... :(5) Facility staff...may assist persons with self-administration..: (D) Assistance with self-administration does not include forcing a resident to take medication, ... or otherwise infringing upon a resident's right to refuse to take a medication. This requirement is not met as evidenced by: Based on LPA's interviews and record review this was not met for R1 which poses an immediate health and safety risk to persons in carethe state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: Administrator (AD) will provide LPA with a written Memo of Understanding regarding regulations 87465 and 87468 and will email signed documenation by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(3) · Plan of correction due date: Dec 5, 2025

87608 Postural Supports. (a) Based on the individual's preadmission appraisal... Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record... This requirement was not met as evidenced by: Based on LPA observations, interview and record review this was not met in one of one residents which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: AD will obtain documentation for postural supports at a medical appointment on 12/04/25 with any additional documentation and will email physician's orders for bed rails to LPA by 12/05/2025.

Type of visit: POC

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced Plan of Correction (POC) visit. LPA was greeted and granted entry by Lorna Smith, Administrator (AD) at 2:30pm and explained the purpose of the visit. AD and LPA walked the facility and AD pressed the fire/ carbon monoxide alarm; which is electrical and is interconnected with other alarms throughout the home. LPA observed detectors to be operational throughout the residence and cleared this deficiency with the POC visit. AD also provided video documentation to LPA on Friday, May 9, 2025 showing the alarms were working at time of LPA's annual required visit but that the button had not been pressed long enough to activate the auditory alarms. The appeal process was discussed with AD. LPA toured four of four bedrooms and all bedrooms have beds, mattresses, linens, lamps and dressers. LPA has cleared this deficiency with the POC visit. AD has requested an extension until Wednesday, May 14, 2025 to obtain a medical assessment for one of one residents. Based on LPA observations, two of three deficiencies were cleared during this visit. An exit interview was conducted with AD Lorna Smith and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 12, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA met with Lorna Smith, Administrator. The facility is a four bedroom, single- story home with an approved fire clearance of six non-ambulatory residents with a hospice waiver for six. The facility currently has a census of one resident in care. During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in one of one resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured 105.6 degrees Fahrenheit. The fire extinguishers are charged and were serviced on October 20, 2022. The facility’s last fire drill was conducted on March 22, 2025. The facility fire alarms and carbon monoxide detectors were not operational and a deficiency was given. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand for one resident. All appliances in the facility are operational. Knives and sharps were secured in a locked cabinet. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. LPA observed the First Aid Kit had all the required elements. Three of four vacant resident rooms did not have the required beds or linens. Chairs, drawers and lamps were observed in all bedrooms and window screens were maintained and rooms were clean. (Continued on LIC 809-C) (Continued on LIC 809) LPA toured the exterior of the facility. Recently the home had solar panels installed and an area was demolished for permitting purposes. There are two exterior self-latching gates. One exterior gate has solar debris and construction material stored for construction but residents and staff have a clear exterior exit on the north side of the house. The one resident socializes and engages in activities with the Administrator's facility, Senior's Retrea,t during the day. Resident has visitors that takes the resident out in the community. Resident was watching the baseball game in their room during the visit and was waiting for family to visit. LPA reviewed three of three staff training and fingerprint records and reviewed one of one resident record. Resident did not have a medical assessment on file and a deficiency was given. LPA interviewed the resident regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on August 16, 2026. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. LPA has requested an informal meeting to discuss the Technical Support Program (TSP). An exit interview was conducted with Lorna Smith, Administrator and a copy of this report was given to the facility along with a copy of the LIC 858, LIC 859; LIC 809-D and Appeal Rights.the state’s words, verbatim · CDSS document, May 9, 2025

Allegation investigated: Wrongful Eviction

LIcensing Program Analyst (LPA) Rose Ruppert made an unannouced visit to conduct a complaint investigation, received by our Regional Office on January 10, 2025, regarding a wrongful eviction of a resident. Upon arrival, LPA was told by contractors, who were installing solar panels on the home, that the residents and staff were at the home across the street. LPA spoke with Lorna Smith, Administrator, and confirmed the resident does not live at this location and was never a resident of this facility. Resident resided at Senior's Retreat #306005914. LPA requested copies of the resident's file, including the signed Admissions Agreement; which reflects the address of #306005914. The Department has investigated the complaint alleging the resident was wrongfully evicted. The agency has found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Lorna Smith, Administrator and a copy of this report was provided to the facility. ****This is an amended report**** Unfoundedthe state’s words, verbatim · CDSS document, Jan 17, 2025 · control 22-AS-20250110110403