Care Jordan 2

Allegation investigated: Staff hurt residents

On August 31, 2026, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Staff Julie Cornejo and explained the purpose of today’s visit. The investigation consisted of the following: on February 20, 2026, LPA Kim conducted a tour of the indoor and outdoor physical plant. LPA reviewed and obtained resident records, which include: Identification and Emergency Information, Physician's Report, Needs and Services Plans/Reappraisal, Incident reports, and other pertinent records. LPA Kim requested and obtained resident roster and staff roster. The investigation revealed the following: CONTINUED ON LIC9099C Substantiated Allegation: Staff hurt residents It is alleged caregivers always hurt other residents. Based on record review, Incident report dated January 23, 2026, revealed that S1 pulled R1’s hair due to frustration in middle of an activity This incident occurred outside of the facility where an activity occurred at 12:35 PM. Incident reported showed that there’s a back-and-forth conversation between S1 and R1 about when R1 should be taking their medication A Termination Letter dated January 24, 2026, showed S1 was terminated after the incident on January 23, 2026. Based on interviews conducted four out of five residents and five out five staff, and one out of one witness confirmed the allegation. One out five residents denied the allegation. Five staff, four residents, and one witness confirmed that there was an incident where S1 pulled R1’s hair. S1 stated they had pulled R1’s hair because they were frustrated and fed up with R1’s behaviors. S1 stated they knew what they did was wrong and decided that day to no longer to work at the facility. S1 stated they reached out to R1 and R1’s family to apologize for the incident. R1 confirmed that their hair was pulled and stated that this happened because there was a conversation that led to R1 and S1 being frustrated. S2 stated the facility investigated the incident and it resulted in finding that S1 pulled R1’s hair. S1 and S2 stated the termination letter dated on January 24, 2026, is in regard to the January 23, 2026, incident between R1 and S1. Based on information gathered through interviews and record review, the preponderance of evidence standard has been met, therefore, the allegation Staff hurt residents to be SUBSTANTIATED. An exit interview was conducted, and a copy of this report and appeal rights were provide to Staff Julie Cornejo. Allegation: Staff are verbally abusive to residents. It is alleged caregivers always shout and hurt other residents. Based on interviews conducted, five staff and five residents denied the allegation. One witnessed confirmed the allegation. All staff and residents stated that there has not been any instance where a caregiver would yell or were verbally abusive to residents. S2 stated there are no disciplinary actions or disciplinary records of when a staff verbally abused or yelled at a resident. S2 stated that they have not received any concerns or complaints from residents, residents family, or anybody in concern with verbal abuse or shouting at any resident. On February 20, 2026, and August 31, 2026, LPA Kim did not observe any staff yell or verbally abuse any residents at the facility. Based on observations in facility files and staff files, there are no records of staff verbally abusing or shouting at residents. Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegation that staff are verbally abusive to residents. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Staff Julie Cornejo.the state’s words, verbatim · CDSS document, Aug 31, 2026 · control 22-AS-20260217160619

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Sep 1, 2026

87468.1(a)(3) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This requirement is not met as evidenced by: Based on interviews and resident records, the licensee did not comply with the section cited above. S1 physically abused R1 by pulling R1’s hair. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Licensee shall send a plan for staff training and send proof of completed training and list of participants to CCLD. In addition, the Licensee will review the cited regulation CCR 87468.1 and submit a written statement acknowledging understanding and compliance with the regulation via email to edward.kim@dss.ca.gov by POC due date September 1, 2026.

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 Francis Parilla. Administrator (AD) Julie Cornejo arrived at approximately 12:00 p.m. and the purpose of the inspection was discussed. 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: This is a one-story home, consisting of four resident bedrooms, one staff room, three bathrooms, and attached two-car garage. LPA observed Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) posted in the main entryway of the facility met regulatory 20” x 26” in size requirement. All resident bedrooms had the required furnishings. LPA observed all residents’ beds had linens and blankets. LPA observed three of five residents leaving for mass and observed two of five residents resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew and faucets and toilets were operational. Water temperature tested at 109.9 degrees Fahrenheit. LPA observed the backyard has a shaded sitting area and the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguishers were observed to be fully charged with service tags dated June 30, 2026. Gas stove, microwave, laundry washer and dryer were all observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication was observed to be centrally stored and locked. LPA reviewed five of five resident files and three staff files. Two of five resident files did not include an examination for Communicable tuberculosis; a Deficiency was cited on today’s date. (Cont. LIC809-C) Based on observations made during today’s inspection, one deficiency is 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 was left at the facility.the state’s words, verbatim · CDSS document, Jul 17, 2026

Type of visit: Required - 1 Year

On July 7, 2025, at 1:00 PM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim met with Staff Julie Cornejo and explained the purpose of the visit. The facility is licensed to operate for six (6) non-ambulatory, of which one (1) can be bedridden and has a hospice waiver for six (6) residents. The facility is a single-story building located in a residential neighborhood. It consists of the following: four (4) residents bedrooms, one (1) staff bedroom, three (3) bathrooms, an attached 2-car garage, living area, dining area, kitchen, and an outdoor covered seating area. LPA Kim toured inside and outside of the physical plant. There are no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected: resident room 1, resident room 2, resident room 3, and resident room 4. Bathrooms were found to be clean and operational. The water temperature measured between 110.6 degrees F and 111.9 degrees F. A comfortable temperature of 73 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water and emergency supplies are stored in the garage. All mandated inspection control posters were posted. The facility has smoke detectors and carbon monoxide detectors that were operable. The Certificate of Liability Insurance is effective from August 30, 2024, to August 30, 2025. The facility conducted a Fire/Safety Drill on May 29, 2025, and conducts drills quarterly. One (1) fire extinguisher was mounted in the dining area. First Aid Kit contained all the necessary elements. LPA Kim conducted an audit of four (4) residents (R1-R4) files, and five (5) staff (S1-S5) personnel files, and medication and medication administration records that were all in order and complete. LPA conducted interviews for two (2) residents and two (2) staff. No deficiencies were cited during the inspection visit. An exit interview was conducted, and a copy of this report was provided to staff Julie Cornejo.the state’s words, verbatim · CDSS document, Jul 7, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Applicant Gideon Limpiado and toured the facility. An application for Change of Location (CHOL) to operate a Residential Care Facility for the Elderly (RCFE) was submitted to Community Care Licensing (CCL) on February 15, 2024. The facility is to have a capacity of six, of which five can be nonambulatory and one bedridden. Facility phone number 714-203-1342. LPA observed the following. Structure: The facility is a one-story house with four resident bedrooms, one staff bedroom, three full size bathrooms, a living room, a kitchen, a dining room, and an attached car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall by the dining room. There is one gate in the backyard, which both is self-closing and self-latching. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Air/Heating: Central air/heating system installed with a central panel to control entire house. Resident Bedrooms: There are four resident bedrooms. All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. CONTINUED ON LIC809-C... Bathrooms: All bathrooms are clean and have working plumbing. Hot water measured between 107.8 and 110.1 degrees Fahrenheit. Linens & Hygiene Supplies: A supply of extra linen for each resident was stored in a closet by the resident's bedrooms hallway. Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Sample menu was available in the file. Food Service: There are no residents living in the facility at this time. There is 7-day non-perishable food supply on hand. Smoke Detectors/Carbon Monoxide Detectors: Smoke detectors/carbon monoxide detectors are hardwired and tested operational. There is a fire extinguisher mounted on the wall by the laundry room and one by the dining room. Appliances: There is one, four gas burner stove which lights unassisted, one oven, one microwave, a refrigerator, dishwasher, washer, and dryer. All appliances are clean and operational. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored in a locked cabinet in the garage. Water Temperature: Hot water was measured in all bathrooms. Hot water measured between 107.8 and 110.1 degrees Fahrenheit. Medications, First-Aid Kit & Book: The first aid kit and the first aid manual are stored in the closet by the dining room. The first aid kit has all the required elements. Medications will be stored in a locked cabinet by the dining room. Resident & Staff Files: The Resident and Staff Records will be kept in a locked cabinet by the dining room. Reading Material, Games, Equipment & Materials: Arts and craft, board games, books and puzzles are stored in a central storage in the living room. There is one large screen television in the living room. Fire clearance: Fire Clearance approved by a fire inspector of Orange County Fire Authority on April 24, 2024. Special conditions noted, "As per approved plan." Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements. The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued. Applicant was informed today that the final approval will be processed by CAB (Central Applications Bureau) in Sacramento. Exit interview was conducted and a copy of this report was left with the applicantthe state’s words, verbatim · CDSS document, Jun 7, 2024