Senior Family Home 1

Allegation investigated: Staff admitted a resident without their consent. Staff do not allow resident access to their phone. Staff do not allow resident to have visitors of her own choosing.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint received July 30, 2026. LPA Haley was greeted by staff and explained the reason for the visit upon entry. Regarding the allegation: Staff admitted a resident without their consent. During the investigation it was discovered, Resident 1 (R1) was admitted to the facility December 12, 2023, after moving out of a larger Assisted Living (AL) facility. R1 was admitted by one of their children who has a Power of Attorney (POA). R1’s admission agreement was signed, initialed, and dated by R1’s POA on December 11, 2023. Record review confirmed R1 has a diagnosis of dementia. R1’s diagnosis was confirmed by two family members and two facility staff members, including Administrator Reyanaldo Agustine who claims R1’s dementia is severe. Continued on LIC812C Unfounded Regarding the allegation: Staff do not allow resident access to their phone. During interviews it was discovered that R1 does not have a telephone. R1 does have an iPad, and it was observed on the charger in the residents bedroom. According to a family member of R1, they did try to provide a telephone for the resident; however, it was useless to R1. The family member explained that R1’s dementia got so bad, that R1 could no longer use the phone anymore. The family member explained that R1 would just continue to press numbers on the phone. Facility staff denied taking a phone from R1. During record review, LPA Haley reviewed R1’s personal property inventory and it did not list any cell phone. Regarding the allegation: Staff do not allow resident to have visitors of her own choosing. During the investigation it was discovered R1 is allowed to have visitors. A family member of R1 explained there are serious concerns with another family member of R1 who has come to visit R1 in the past. The family member explained some serious concerns about the other member of and explained there’s a restraining order against the other family member. Record review revealed a restraining order filed in Orange County Superior Court on September 23, 2025. LPA Haley received a copy of the court order. Based on the information gathered during the investigation through interviews, document review, and observations, the allegations are deemed unfounded, meaning the allegations are false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 4, 2026 · control 22-AS-20260730081104

Allegation investigated: Resident sustained multiple bruises while in care Staff do not ensure resident receives adequate care with personal grooming assistance

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to investigate a complaint that was received in the Regional Office. LPA was greeted and granted entry by Staff #1 (S1) at 8am. The facility currently has five residents in care. LPA obtained the following documents for Resident #1 (R1) on March 26, 2026: Identification and Emergency Information, Medical Assessment dated January 23, 2026; Appraisal Needs and Services Plan and Preplacement Appraisal Information dated January 23,2026; Skilled Nursing Facility Discharge Summary; Capacity Assessment Declaration – Probate Conservatorship dated January 9, 2026, Admissions Agreement and Addendum and Admission to Hospice notification. Resident #1 (R1) was admitted to the facility on January 23, 2026, from a Skilled Nursing Facility (SNF). (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) In December 2025, prior to being admitted to the facility, Resident #1 (R1) had a fall in the home and was diagnosed with a right intertrochanteric femur fracture that required surgery which was completed on December 9, 2025. R1 was then admitted to a Skilled Nursing Facility (SNF) on December 12, 2025, and was released to the this facility on January 23, 2026. Per Medical Assessment dated 1/23/2026 R1’s requires orthopedic aftercare and is non-ambulatory. Appraisal Needs and Services Plan and Pre-Appraisal dated 1/23/2026 state R1 has major neurocognitive disorder. On January 9, 2026, a Capacity Assessment was signed by the physician that R1 has major neurocognitive disorder and agitation. It was alleged that Resident sustained multiple bruises while in care. LPA reviewed Medical Assessment dated 1/23/2026, Appraisal Needs and Services Plan dated 1/23/2026 Preplacement Appraisal dated 1/23/2026 and the Skilled Nursing Facility Discharge Summary dated 1/23/2026. Documents reviewed revealed no documentation of bruises on Resident #1 (R1). LPA interviewed three of three staff members who all stated R1 came to the facility with various stages of bruising due to the orthopedic surgery. Three of three staff denied the allegation that bruises occurred while in facility care. Two of three witnesses interviewed also stated R1 had bruises prior to coming to the facility and was prone to bruising and denied that the facility caused the bruises. One of three witnesses could not confirm, nor deny the allegation. Resident #1 was interviewed and was asked if bruises occurred while in care. R1 answered No. Two other residents were asked about care provided at the facility and two of two residents stated they receive good care from the staff. LPA also investigated the allegation that Staff do not ensure resident receives adequate care with personal grooming assistance. R1 has a history of psychosis and refusing medications or personal assistance. Two of three witnesses stated that while R1 had a history of not changing, or showering prior to moving into the facility. Two of three witnesses stated that they do not believe the facility is not offering these services but feel that R1 refuses these services. One of three witnesses could not confirm nor deny the allegation but did state R1 would be a challenging patient but hoped with time that this may change. LPA interviewed three of three staff who all denied the allegation. Staff reported they sponge bathe R1 daily and clean fingernails with wipes daily. LPA interviewed R1 to ask if they were happy with services being provided, which included personal care and R1 answered Yes. (Continued on LIC 9099-C1) (Continued from LIC 9099-C) When asked if there were any problems, R1 answered No. LPA observed R1 was clean and dressed, fingernails were clean and feet were covered with socks. The facility does not maintain a log of personal grooming assistance for residents. Based on LPA’s record review, interviews and observations the allegations that Resident sustained multiple bruises while in care and Staff do not ensure resident receives adequate care with personal grooming assistance is Unsubstantiated meaning the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator (AD) Ahl Agustin and a copy of this report and LIC 811 were provided to the facility.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 22-AS-20260326111843

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 Staff #1 at 1:15pm. LPA met with Administrator (AD) Ahl Agustin and explained the purpose of the visit. The facility is a four bedroom, three bathroom residential home with a fire clearance of six non-ambulatory; of which one may be bedridden in room #4. The facility has a hospice waiver for six and one resident is currently on hospice. During the visit LPA toured the kitchen and observed the refrigerator had more than two days of perishable items and the pantry and freezers had seven days of non-perishable items. LPA observed sharps and knives secured with medications. Hazardous chemicals were secured in the garage. All appliances were in working order and the facility was clean with no odors detected. LPA inspected the smoke and carbon monoxide detectors and all detectors were operational. Two fire extinguishers were charged and serviced on July 31, 2025. A fire drill was conducted on January 13, 2026. The facility temperature was 76 degrees Fahrenheit. LPA tested hot water temperatures in three of three resident bathrooms. Bathrooms had grab bars and non-skid mats. The hot water temperature ranged between 113.5 to 116.7 degrees Fahrenheit. Resident bedrooms were clean with the required linens and furnishings. LPA toured the exterior of the property and observed the exterior gate was self-latching and all pathways were clear of obstructions (Continued on LIC 809-C) (Continued from LIC 9099) LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. The First Aid Kit had all the required elements. The facility has a First Aid manual book was on-site. LPA reviewed three of three staff training and fingerprint records and conducted a complete review of resident records. Annual staff training records were not observed in staff files and a deficiency will be given. 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 January 21, 2027. A Legionnaires' Disease Fact Sheet for Assisted Living Facility Administrators was provided to AD. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Ahl Agustin, Administrator (AD) 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, Apr 22, 2026

Allegation investigated: Staff are not distributing resident's medications 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 Staff #1 (S1) and met with Administrator (AD) Reynaldo "Al" Agustin regarding the purpose of the visit. LPA reviewed and obtained the following documents: Resident #1 (R1's) Medical Assessment, dated 12/05/2025 and hospital medical records. LPA also obtained a resident roster and additional documents for Resident #2 (R2) which include: face sheet and Medical Assessment dated 10/8/2025. On Saturday, December 6 2025, R1 moved into the facility at 1:02pm from the hospital. R1 had a scheduled appointment with their primary care physician (PCP) on December 8, 2025 at 10:30am. The Power of Attorney (POA) requested for a staff member to accompany R1 to the appointment and AD agreed to go with R1. Transportation was coordinated with a private vendor by R1's medical provider. (Continued on LIC 9099-C Unfounded (Continued from LIC 9099) While AD and R1 were in transit to PCP appointment, POA arrived at the facility and asked for R1's whereabouts and medications. Medications were counted and POA then left to meet R1 and AD at the PCP appointment at 10:30am. While at the appointment, POA told AD that POA would handle the PCP appointment and so AD, took the scheduled transport back to the facility. AD later learned from staff that R1 and POA returned to the facility after the appointment and packed R1's belongings and left. AD attempted to communicate with POA regarding why R1 was being moved but was unable to speak with POA. R1 resided at the facility less than 48 hours. LPA interviewed two of two staff members if Staff are not distributing resident's medications as prescribed. Two of two staff members denied this allegation. LPA interviewed two of two alert residents if medications were not being given as prescribed. Two of two residents denied this allegation. LPA interviewed one witness who could not confirm, nor deny allegation and had never met R1. LPA reviewed R1's Medical Assessment from 12/5/2025. R1 has diagnoses of: Family stress, hypertension, hypothyroidism and mild cognitive impairment with unknown etiology, as well as mild anxiety disorder. Per assessment, R1 is unable to administer own prescription medications. While at the facility, LPA counted all of R1's medications that were left at the facility. LPA compared tablet counts to bottle quantities listed. Based on medication count, medications were being given as prescribed. Based on LPA's record review, observations and interviews, the allegation that: Staff are not distributing resident's medications as prescribed is Unfounded. The allegation is false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Administrator (AD) Reynaldo "Al" Augustin and copy of the report and LIC 811, were provided to the facility.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 22-AS-20251208103650

Allegation investigated: Facility does not assist residents with their daily needs. Facility does not accord residents with dignity and respect. Facility does not have night supervision. Residents are not afforded healthy and safe accommodations.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct a complaint investigation regarding the above allegations. LPA met with Administrator (AD) Ahl Augustin and explained the purpose of the visit. LPA reviewed and obtained copies of Resident #1 (R1's): Identification and Emergency Form, Physician's Report, Preplacement Appraisal, Appraisal Needs and Services Plan, and a signed letter dated June 16, 2025 regarding new facility for placement to meet R1's health needs. AD also forwarded email with Care Coordination Agency (CCA) regarding Assisted Living Waiver (ALW) placement. LPA interviewed three of three staff, one outside witness and four of four residents. LPA asked both residents and staff if water is restricted after 6pm. Three of four residents confirmed water is always accessible. Three of three staff and one witness confirmed residents have access to water at all times and that one resident even is able to have snacks in the middle of the night. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) Three of four residents confirmed that the two day caregivers always accommodate their needs. In the evening, there is one staff member and there is always staff in the facility at all times. If a female needs changing, in the middle of the night, the AD, who is the night staff member five days per week, will call and pay a female caregiver who lives nearby to change the female soiled diaper. This has only occurred recently and had not been an issue until a resident's health needs changed. The allegation that there are no staff, in the evening, is false. One of four residents did not confirm, nor deny allegation and stated they, "were fine." LPA spoke with residents to see if they were afforded dignity and respect in their interactions with facility staff. Three of four residents strongly agreed that staff are available for their needs. Staff do not yell at them, although one staff member is hard of hearing and speaks louder. LPA asked if residents' toileting and hygiene needs were being met and three of four residents confirmed they receive assistance, when needed. One of four residents did not confirm or deny allegation but this resident receives daily sponge baths and refuses to take showers due to weakness from a current health condition. Three of three staff confirmed showers are offered to one resident but that the resident states they are, "weak and dizzy" and refuses to shower. Residents were asked if they had safe and sanitary physical accommodations. Three of four residents felt safe and that the facility was clean. LPA did not observe any odors upon touring the facility and checking on the health and safety of the other residents. Resident #2 (R2) stated roommate, R1, requires a higher level of care and demands to have their needs met before others. The example given was that, if R1's appointment gets rescheduled, R1 feels R1's appointment is the priority and that the other five residents' appointments should be rescheduled or canceled. LPA spoke with the outside witness who confirmed that a meeting was held with R1 and AD and that the facility is doing all that they can to accommodate the resident's needs. The witness stated R1 is not consistent in their requests and does not follow things through. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations that: Facility does not assist residents with their daily needs, Facility does not accord residents with dignity and respect, Facility does not have night supervision and Residents are not afforded (Continued on LIC 9099-C1) (Continued from LIC 9099-C) healthy and safe accommodations Based on LPA file review, observations and interviews the allegations are Unsubstantiated. An exit interview was conducted with Administrator, Ahl Augustin, and a copy of this report and LIC 811, Confidential Names, were provided to the facility.the state’s words, verbatim · CDSS document, Jun 16, 2025 · control 22-AS-20250613094107

Allegation investigated: Staff not providing resident with arrangements to meet health needs.

LIcensing Program Analyst (LPA) made an unannounced visit to investigate a complaint received in our Regional Office. LPA was greeted and granted entry by care staff. LPA met with Administrator, Reynaldo "Ahl" Augustin and explained the purpose of the visit. LPA requested files for Resident #1 (R1) which include: Identification and Emergency Information, Physician's Report,Preappraisal Information and Appraisal Needs and Services Plan and Admissions Agreement. LPA interviewed R1 regarding care provided and asked resident if arrangements to meet R1's health needs are being met. R1 showed LPA the health issue requested and LPA observed this was not met. R1 allowed LPA to take photographs for documentation. LPA reviewed LIC 602A which states resident is unable to groom self. Administrator also admitted he did not schedule podiatry appointment. (Continued on LIC 9099-C) ****THIS IS AN AMENDED REPORT**** Substantiated (Continued from LIC 9099) Based on LPA's observations and record review, the preponderance of evidence has been met, therefore the allegation of: Staff not providing resident with arrangements to meet health needs is Substantiated. The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Reynaldo Augustin, Administrator and a copy of this report was given to the facility along with a copy of the LIC 9099-D and Appeal Rights.the state’s words, verbatim · CDSS document, May 6, 2025 · control 22-AS-20250429140446

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: May 7, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care...by:(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not being met as evidenced by: Resident #1 showed LPA physical health issue which poses an immediate health and safety risk for the person in care.the state’s words, verbatim · CDSS document, May 6, 2025

Plan of correction: The Plan of Correction (POC) is that Administrator shall provide LPA with scheduled appointment details for R1 by 5pm on May 7, 2025. LPA also requests follow-up after the appointment with documentation that health need was met.

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 was greeted and granted entry by Staff #1 at 12:15pm. During today’s visit, LPA met with Erlinda Pinkston, Administrator Designee (AD). The facility is a four bedroom, three bathroom, single story residence with an approved fire clearance of six non-ambulatory residents of which one may be bedridden. The facility currently has a census of six residents in care and is approved with a hospice waiver for six. 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 three of three resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 116.0 and 119.8 degrees Fahrenheit and all smoke detectors were operational. The fire extinguisher is charged and was serviced on February 22, 2024. The facility has not conducted a fire drill in this quarter and a deficiency will be 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. Sharps and disinfectants were secured. LPA observed medication storage and reviewed the centrally stored medications. Per review it is not clear if medications are being given as prescribed and a deficiency will be given. LPA observed residents finishing lunch. Five of the residents watched a movie in the living room and one (Continued on LIC 809-C) (Continued from LIC 809) resident played solitaire at the dining room table. LPA observed resident bedrooms and all had the required furnishings and linens. LPA toured the exterior and noted a shaded seating area and one exterior gate door that was self-latching. There were no obstacles or hazards obstructing exterior pathways and there was ample outdoor space for activities. LPA observed the garage is used for laundry and storage purposes only which include emergency supplies and disinfectants. LPA reviewed three of three staff training and fingerprint records and 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 January 21, 2027. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Erlinda Pinkston, Administrator Designee 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, Apr 8, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Staff Elenita "Lenny" Mendoza and explained the purpose of the inspection. Administrator (AD) Reynaldo Agustin was contacted by phone and arrived at the facility at 9:35 a.m. During the inspection, LPA and Staff Mendoza conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following: This is a one-story home with four resident bedrooms, three bathrooms, and attached two-car garage. LPA observed a section of the garage to be cornered off with boxes stacked on top of one another. The area contains a made bed with pillows, linen, and blankets, and also contains staffs' personal belongings. Per pre-licensing inspection conducted on March 23, 2023, there no designated staff bedrooms; a Deficiency was cited on today’s date. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The backyard has a shaded sitting area. LPA observed residents watching television in the living room and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 119.6-120.2 degrees Fahrenheit. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with service tag dated February 22, 2024. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. (Cont. LIC9099-C) Medication cabinet was observed to be locked; however, medication is being pre-poured into a plastic weekly medication organizer for each resident; a Deficiency was cited on this date. LPA reviewed five resident files and three staff files. LPA interviewed three residents and two staff. Based on the observations made during today’s inspection, 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 and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Sep 6, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.