Chestnut Cove

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 Sarah Cruz and the purpose of the inspection was discussed. Staff Dave Sombilon arrived with groceries from the grocery store at approximately 1:00 p.m. and assisted with the inspection. During the inspection, LPA and Staff Cruz conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and observed the following: This is a one-story home with four resident bedrooms, two staff rooms, three bathrooms, the backyard has a shaded sitting area, and LPA observed all windows were screened. Resident bedrooms were observed to have the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed residents resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 105.8-106.7 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. Gas stove, dishwasher, microwave, washer, and dryer were all inspected and observed to be operable. Medication was observed to be centrally stored and locked. LPA reviewed four of four resident files and two staff files. Staff files did not contain any documentation for ten hours of initial training, consisting of six hours of hands-on shadowing training and four hours of other training or instruction. Staff files also did not include eight hours of dementia care training, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care; a Deficiency was cited on today’s date. LPA interviewed two staff and one of four residents, as three of four residents were observed to be sleeping. (Cont. LIC809-C) Based on the observations made during today’s inspection, two 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 was left at the facility.the state’s words, verbatim · CDSS document, Nov 20, 2025

Allegation investigated: Facility staff left resident lying on the floor Facility staff did not assist resident with hygiene as needed Facility staff did not assist resident with incontinence care as needed

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez. LPA met with Staff Dave Sombilon and explained the purpose of the inspection. Regarding the allegation Facility staff left resident lying on the floor, the following was revealed: It is alleged Facility staff left Resident 1 (R1) lying on the floor. During the course of the investigation, interviews were conducted with R1, two additional facility residents, three witnesses, and two staff. Per R1’s Physician Report dated September 19, 2025, R1 can be confused and forgetful due to their medical diagnosis. During their interview, R1 did not disclose any staff neglect but was unable to confirm or deny the allegation.During their interview, Resident 2 (R2) denied having any knowledge of staff leaving any resident lying on the floor and stated R1 has a history of yelling at facility staff and throwing themselves on the floor. (Cont. LIC9099-C) Unsubstantiated During their interview, Resident 3 (R3) denied having any knowledge of staff leaving any resident lying on the floor and stated they were not familiar with, nor did they know R1. Per R3, staff is always available to assist them, and they can use their call button to call for help and staff will almost always come to their aid immediately. During their interview, Staff 1 (S1) denied personally leaving any resident lying on the floor and denied having any knowledge of any other facility staff leaving any resident, including R1 to lying on the floor. Per S1, on August 30, 2025, R1 was upset they had not received a visit from Witness 2 (W2), which lead to R1 throwing themselves on the floor. Per S1, they felt R1 was a threat to themselves and others due to pulling out their own hair and kicking S2. S1 stated they called 911 and R1 was placed on a psychiatric hold. During their interview, Staff 2 (S2) denied personally leaving any resident lying on the floor and denied having any knowledge of any other facility staff leaving any resident, including R1 lying on the floor. Per S2, on August 30, 2025, staff made the decision to call 911 after R1 slipped from their bed onto the floor and refused to allow staff to assist them getting up. S2 stated they attempted to assist R1 but R1 kicked them, and it was then they and S1 no longer felt safe and called 911. During their interview, Witness 1 (W1) denied R1 informing them, or having any knowledge of staff leaving R1 lying on the floor. W1 stated they did not have any concerns regarding the facility staff and denied R1 sharing any concerns regarding the facility or staff. During their interview, Witness 2 (W2) denied having any knowledge of staff leaving R1 lying on the floor. W2 stated they did not have any concerns regarding the facility staff and denied R1 sharing any concerns regarding the facility or staff. During their interview, Witness 3 (W3) stated they did not know any specifics but stated R1 had been complaining about the care at the facility, however, was unable to provide further information. Regarding the allegation Facility staff did not assist resident with hygiene as needed, the following was revealed: It is alleged staff did not assist R1 with hygiene as needed. During their interview, R1 denied the allegation and stated staff assist them with all grooming and hygiene needs. Per R1, at the time of their interview, staff had just assisted them with a bed bath. LPA observed R1 with combed wet hair and a clean appearance. During their interview, Resident 2 (R2) denied having any knowledge of any resident being unkempt and stated facility staff have been and continue to be helpful. Per R2, they initially felt uncomfortable with male caregivers assisting them in the shower, but the staff make them feel safe and they now enjoy and actually look forward to their showers. (Cont. LIC9099-C) During their interview, Resident 3 (R3) denied having any knowledge of any resident being unkempt and stated staff is always available to assist them. During their interview, S1 denied facility staff not assisting R1 or any other resident with hygiene. Per S1, on August 30, 2025, after R1 threw themselves on the floor, R1 removed their bottoms and defecated on their bedroom floor. S1 stated they attempted to clean R1 prior to paramedics arriving but R1 was resistant. Per S1, R1's hair became disheveled due to R1 running their fingers through their hair and pulling it out. During their interview, S2 denied facility staff not assisting R1 or any other resident with hygiene. Per S2, staff always assist R1 with grooming and bathing and stated that upon R1’s admission to the facility, R1’s hair had been matted, and a brush could not be run through their hair. S2 stated staff have been washing R1’s hair regularly and R1’s hair is now soft enough to brush. Per S2, on August 30, 2025, after R1 threw themselves on the floor, R1 removed their bottoms and defecated on their bedroom floor. S2 stated they attempted to clean R1 but R1 was resistant and kicked them. During their interview, Witness 1 (W1) denied witnessing or having any knowledge of R1’s appearance being unkempt and stated they did not have any concerns regarding the facility staff and denied R1 sharing any concerns regarding the facility or staff. During their interview, Witness 2 (W2) denied witnessing or having any knowledge of R1’s appearance being unkempt and stated they did not have any concerns regarding the facility staff and denied R1 sharing any concerns regarding the facility or staff. During their interview, Witness 3 (W3) stated they did not know any specifics but stated R1 had been complaining about the care at the facility, however, was unable to provide further information. Regarding the allegation Facility staff did not assist resident with incontinence care as needed, the following was revealed: It is alleged staff did not assist R1 with incontinence care as needed. During their interview, R1 denied the allegation and stated staff always assist them with incontinence care. During their interview, Resident 2 (R2) denied having any knowledge of R1 or any other resident sharing any concerns regarding staff or staff being unwilling to help them with incontinence care. R2 denied witnessing R1’s or any other residents' appearance to be unkempt. R2 stated facility staff have been and continue to be helpful. During their interview, Resident 3 (R3) denied having any knowledge of any resident sharing any concerns regarding staff or staff being unwilling to help them with incontinence care and denied witnessing any other residents' appearance to be unkempt. During their interview, S1 denied facility staff not assisting R1 or any other resident with incontinence care. Per S1, on August 30, 2025, after R1 threw themselves on the floor, R1 removed their bottoms and defecated on their bedroom floor. S1 stated they attempted to clean R1 prior to paramedics arriving but R1 was resistant. (Cont. LIC9099-C) During their interview, S2 denied facility staff not assisting R1 or any other resident with incontinence care. Per S2, on August 30, 2025, after R1 threw themselves on the floor, R1 removed their bottoms and defecated on their bedroom floor. S2 stated they attempted to clean R1 but R1 was resistant and kicked them. During their interview, Witness 1 (W1) denied witnessing or having any knowledge of staff not assisting R1 with incontinence care. Per W1, they have no concerns regarding the facility and R1 has never shared any concerns with them. W1 stated that as far as they are aware R1 is well taken care of. During their interview, Witness 2 (W2) denied witnessing or having any knowledge of staff not assisting R1 with incontinence care. Per W2, R1 had been asked if they were okay with returning to the facility following their hospitalization and R1 had no objections. During their interview, Witness 3 (W3) stated they did not know any specifics but stated R1 had been complaining about the care at the facility, however, was unable to provide further information. Due to allegations being uncorroborated during interviews conducted, the Department is unable to determine if Facility staff left resident lying on the floor, iff Facility staff did not assist resident with hygiene as needed, or if Facility staff did not assist resident with incontinence care as needed. Although the above 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 at this time 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 30, 2025 · control 22-AS-20250910164026

Allegation investigated: Staff did not provide 60-day notice prior to rent increase.

Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced Complaint Investigation regarding the allegation mentioned above. LPA met with Staff Dave Sombilon. Licensee Representative (LR) Janice Jabonero was contacted by phone at arrived at approximately 1:45 p.m. During the course of the investigation, LPA conducted a record review for four of four resident files. One of four resident admission agreements was observed to have basic service fee of $4,000 a month and the following handwritten statement was on the first page: “Rent for basic services will increase to $4,500 a month as of 9/01/202[5]." At the bottom of the first page of the agreement the following handwritten statement was observed: “June 2024 rent will be $3000 due to overcharge collect by Chestnut Cove worth $1,000." Interviews were conducted with LR, Resident 1 (R1), and R1’s responsible party, Witness 1 (W1). During their interview, R1 stated they default to W1 on most personal and financial matters. (Cont. LIC9099-C) Unfounded For this reason, R1 stated they did not negotiate the terms and conditions of the admission agreement and left it to W1 to “sort out.” During their interview, W1 stated it had all been “an innocent mistake” and provided a written statement which read in part: “The issue was due to an error in the paperwork for my husband’s assisted living fees. I hope that my ability to clear up this misunderstanding allows the Department of Social Services to also clear up the issue.” During their interview, LR stated that the original agreed upon basic service fee was $4,500, however, the amount had originally been left blank at the time that the admission agreement was signed. LR stated that once W1 informed them they were being overcharged, a meeting was held with all parties involved and the handwritten statements were added to the first page of the admission agreement, in order to honor W1’s believe that basic service fee was that of $4,000 and allow the proper 60-day notification for rent increase to take place. The Department has investigated the complaint alleging Staff did not provide 60-day notice prior to rent increase. Based upon resident file review, written statements provided, and interviews conducted, We have 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, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 22-AS-20250528163140

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced Case Management inspection in conjunction with investigation into complaint number 22-AS-20250528163140. LPA met with Staff Dave Sombilon and explained the purpose of the inspection. During the course of the investigation, deficiencies were observed. During their interview, Licensee Representative (LR) Janice Jabonero stated that the original agreed upon basic service fee for Resident 1 (R1) was $4,500, however, the amount had originally been left blank at the time that the admission agreement was signed. Per California Code of Regulations Title 22, 87507(g)(3)(A) The licensee shall complete an individual written admission agreement and include payment provisions, including rate for all basic services which the facility is required to provide in order to obtain and maintain a license. Based on observations made during this 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, Jun 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(3)(A) · Plan of correction due date: Jun 18, 2025

(g) Admission agreements shall specify the following: (3) Payment provisions, including... (A) Rate for all basic services which the facility is required to provide in order to obtain and maintain a license. This requirement is not met as evidenced by: Based on staff interview, the Licensee did not comply with the section cited above as basic service fee amount for R1 was originally left blank at the time that the admission agreement was signed.the state’s words, verbatim · CDSS document, Jun 4, 2025

Plan of correction: Admission agreement was updated to include basic service fee amount. LR stated staff training regarding proper documentation will be completed and proof provided to LPA via email by POC date.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with Licensee Macrina Jabonero. An application to operate a Residential Care Facility for the elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by CCL on June 13, 2024. Structure: The facility is a one-story house with four resident bedrooms, two staff rooms, three bathrooms, one living room, one kitchen, and one dining room. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard with an exit gate each side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. Signal system There is a signal system. Signal system generates an audible sound and identifies the bedroom of each resident. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked underneath the kitchen sink. Resident & Staff Files: Records will be kept in a locked cabinet. Medications, First-Aid Kit & Book: Medication will be stored in a locked cabinet. First aid kit is stored in one of the staff rooms and has all the required elements. Pool/Jacuzzi: No bodies of water were observed. Fire Extinguisher: Fire extinguisher is fully charged. Reading Material, Games, Equipment & Materials: The facility has reading books, board games, and other recreational materials for resident use stored in a cabinet in the dining room. Fire clearance: Was approved by a fire inspector of the Anaheim Fire Department on July 18, 2024. Special conditions noted, “Bedridden in room #4.” Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements. Bedrooms Staff: There are two staff rooms. Bathrooms: All bathrooms have working plumbing. Hot water measured between 115.1- and 120.1-degrees Fahrenheit. Linens & Hygiene Supplies: A supply of extra linen was stored in a closet. Emergency Phone Numbers, Exit Plan & Menu: Posted and available, means of exiting, and emergency phone numbers. Food menu is available for review in menu binder stored with resident activity supplies. Food Service: A supply of 2-day perishable and 7-day of non-perishable food will be maintained on hand. Smoke Detectors: Smoke detectors and carbon monoxide detectors tested operational. Appliances: Gas burner stove, dishwasher, refrigerator, microwave oven, washer, and dryer are operational. The Licensee was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of this report was provided to Licensee.the state’s words, verbatim · CDSS document, Dec 17, 2024

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for the Elderly (RCFE) Application Type: Initial Capacity: 6 Census (if any clients in care): none COMP II Participants: Janice Jabonero, Applicant Macrina Jabonero, Applicant Myrna Bugasto, Administrator Interview Method: Telephone interview On November 22, 2022 at 9:00 AM, Applicants and Administrator participated in COMP II. Identification of the Applicants and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicants and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with Applicants and Administrator. Report sent via email and informed to return signed copy to CAB by end of business day today.the state’s words, verbatim · CDSS document, Nov 22, 2024