Citrus Gardens

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Allegation investigated: Staff does not ensure comfortable temperatures for residents Facility is in disrepair

Licensing Program Analyst (LPA), Ivashia Wright, conducted an unannounced visit to conduct a investigation regarding the above allegations. LPA Ivashia met with Administrator Liliana Moreno and explained the purpose of the visit. On September 11, 2026 Community Care Licensing Division (CCLD) received a complaint alleging Staff does not ensure comfortable temperatures for residents and Facility is in disrepair. During the investigation, the LPA toured the facility, made observations, and conducted interviews with the Staff and Residents. Regarding the allegations Staff does not ensure comfortable temperatures for residents and the Facility is in despair, It was reported that the facility doesn't have air conditioning that works properly in the rooms and has not function properly for five years. LPA tour all five villas and observed the ac thermostats to be running and reading between 71-73 degrees. Continued on LIC 9099-C Unsubstantiated Interview with Administrator, Liliana Moreno reported every villa in the facility has ac except the garage.Liliana reported the facility has not had any issues with the ac units not working properly recently. Liliana reported the ac unit in villa 2 went out months ago and was serviced and repaired immediately. Liliana reported there hasn't been any issues with the conditions of any villas. Information obtained from Staff corroborated the information obtained from Administration. Staff reported the facility has no problems with the air conditioner units cooling properly in any of the villas. Additional interviews with residents reported they have not experience their rooms temperatures being hot or uncomfortable. Based on staff interviews, resident interviews, and LPA observations, the allegations Staff does not ensure comfortable temperatures for residents and the Facility is in despair is deemed unsubstantiated. This means that although the allegations may have happened or are valid, the preponderance of evidence requirement has not been met to prove that the alleged violations did or did not occur. An exit interview was conducted and a copy of this report and 9099 C were reviewed and provided to Administrator Liliana Moreno.the state’s words, verbatim · CDSS document, Sep 15, 2026 · control 18-AS-20260911130609

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Ivashia Wright conducted an unannounced annual required visit. Upon entry, LPA was greeted by staff, and informed them of the purpose of the visit. LPA met with Executive Director Valeria Garcia and Administrator Liliana Moreno. Facility Overview: The facility consists of five (5) building structures. The facility has a kitchen, dinning area, laundry room, and a courtyard and with sufficient seating and space for activities. There is no bodies of water and there are no firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents inside the kitchen. The hot water temperature was measured at 109F, meeting the department requirements. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors are a combined single unit and were tested by the fire department on 4/8/2026. Fire extinguishers were previously serviced on 9/23/25. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Continued on LIC809-C.... Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The Executive Director holds a current administrator’s certificate which expires 12/12/2026 and CPR which expires 9/9/2028. Record Review and Resident/Staff Files: LPA reviewed files for (6) six staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. (8) eight resident files were reviewed and contained all required documentation. LPA observed first aid kit to be stored in the medication room inaccessible to residents. Health-Related Services/Incidental Medical Services: Medication are centrally stored. There is a locked room in villa four allocated for medication storage. Centrally stored medication and destruction logs are maintained. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire/earthquake drill conducted on 8/18/2026, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided to the Executive Director Valeria Garcia and Administrator Liliana Morenothe state’s words, verbatim · CDSS document, Sep 9, 2026

Allegation investigated: Staff abandoned resident at hospital. Staff are not answering the resident representative’s communications promptly.

Licensing Program Analyst (LPA), Ivashia Wright, conducted an unannounced visit to conduct a investigation regarding the above allegations. LPA Ivashia met with Administrator Liliana Moreno and explained the purpose of the visit. On August 13 ,2026 Community Care Licensing Division (CCLD) received a complaint alleging Staff abandoned resident at hospital and Staff are not answering the resident representative’s communications promptly. During the investigation, the LPA inspected the facility, reviewed R1's records, and conducted interviews with the Staff. LPA also interviewed R1's responsible party and witness to obtain additional information. Regarding the allegation Staff abandoned resident at hospital, it was reported that the facility refused to accept R1 back after being discharged by the hospital. Continued on LIC 9099-C Unsubstantiated Interview with Administrator, Liliana Moreno reported the facility didn't refuse to accept R1 after being discharged. Liliana stated that the facility is aware of needing to follow the proper guidelines on having a resident relocated from the facility. Information obtained from the interview with the witness corroborated the information obtained from Administration. Additional interviews with R1's responsible party stated the facility did accept R1 back into the facility and that R1 is currently residing there. Regarding the allegation that Staff are not answering the resident representative’s communications promptly, It was reported that multiple attempts have been made to reach the Executive Director however calls have not been returned. Interview with Administrator, Liliana Moreno reported the facility has been in constant communication with both R1's responsible party and the hospital. Information obtained from interviews with the witness corroborated the information obtained from Administration. Additional interviews with R1's responsible party revealed that she has spoke to both the Executive Director and Administrator on multiple occasions. Based on staff interviews, witness interviews, and interviews with R1's responsibly party; the allegations that Staff abandoned resident at hospital and Staff are not answering the resident representative’s communications promptly is deemed unsubstantiated. This means that although the allegations may have happened or are valid, the preponderance of evidence requirement has not been met to prove that the alleged violations did or did not occur. An exit interview was conducted and a copy of this report and 9099c were reviewed and provided to Administrator Liliana Moreno.the state’s words, verbatim · CDSS document, Aug 17, 2026 · control 18-AS-20260813101240

Allegation investigated: Staff refused to accept resident back to the facility.

On April 27, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Antonine Richard, conducted an unannounced complaint visit. The LPA, Richard, met with the Executive Director (ED), Valerie Garcia, and the Administrator (A1), Liliana Moreno, and explained the purpose of the visit. The investigation consisted of collecting records and touring the facility. On April 16, 2026, the Department obtained various documents, including the Personnel Report LIC 500 (dated 04/16/26) and the Resident Roster (dated 04/16/26). The Department reviewed and collected the following documents for residents R1. The residents' Admission Agreements, the physician's report, the Medical Assessment, the facility's eviction notice, Affidavit of Service, the Unusual Incident Report, and the facility notes. The Department also interviewed the Administrator (A1), the Executive Director (ED), four staff members (S1-S4), and six residents (R2-R7 The department was unable to interview resident R1 because R1 no longer lives at the facility. Unsubstantiated Allegation #1: Staff refused to accept resident back to the facility. The complaint alleged that the resident was sent to the hospital and, upon being transported back to the facility, the facility refused to allow the resident in. On April 16, 2026, the department interviewed the Executive Director (ED) and the Administrator (A1), both of whom denied the allegation. The facility would accept a resident after a hospital visit. The Administrator also stated that, even with an eviction notice, the facility must admit residents after a hospital visit. Four staff members (S1-S4) were interviewed, all of whom denied the allegations against the facility. They also stated that they had not witnessed or heard of any instance where a resident was refused reentry after a hospital visit. The department subsequently interviewed six residents (R2-R7). Among these six residents, four reported that they had gone to the hospital and returned without any issues. The department attempted to contact the responsible party and family members, but did not receive any responses. Additionally, the department reviewed a facility note indicating that R1 left for the hospital on March 23, 2024, and did not return. Unfortunately, the department was unable to interview R1, as their current whereabouts are unknown. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to Administrator Liliana Moreno.the state’s words, verbatim · CDSS document, Apr 27, 2026 · control 18-AS-20240325141120

Allegation investigated: Staff will not return residents belongings.

On April 27, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Antonine Richard, conducted an unannounced follow-up complaint visit. The LPA met with the Executive Director, Valerie Garcia, and the Administrator (A1), Liliana Moreno, and explained the purpose of the visit. The investigation included collecting records and touring the facility. On April 16, 2026, the Department obtained various documents, including the Personnel Report LIC 500 (dated 04/16/26) and the Resident Roster (dated 04/16/26). The Department reviewed and collected documents for the resident (R1) Admission Agreement, physician Report, Medical Assessment, and Shower Schedule. The Department also interviewed the Administrator (A1), the former Executive Director (ED1), and the current Executive Director (ED), four staff members (S1-S4), six Residents (R2-R7), and the representative of Helping Hands Room and Board (HHRB). Unsubstantiated Allegation #1: Staff will not return residents' belongings. The complaint alleged that the resident left Citrus Gardens and currently resides at Helping Hands Room and Board, where the resident is having difficulty retrieving the resident's (R1) belongings. On June 6, 2024, the department interviewed the former Executive Director (ED1), who stated that they helped R1 pack most of their belongings, medications, and all items given to the Helping Hands Room and Board (HHRB). ED1 also stated they went back a second time to bring R1 the remaining belongings. On April 20, 2026, the department interviewed the Executive Director (ED), who denied the allegation. The ED stated that when a resident moved out of the facility, staff ensured that all belongings and medications were given to the resident and to the HHRB. The department also interviewed the Administrator (A1), who denied the allegation. A1 explained that before any resident leaves the facility, we must ensure that all medications, the doctor's orders, and the resident's belongings are given to the resident or their family members. Additionally, the department interviewed four staff members (S1-S4), all of whom denied the allegation. They also stated that the facility would ensure residents took their belongings. They further stated that even when a resident goes out over the weekend, the facility would ensure the resident's medications are with them, so they don’t miss any. The department also interviewed six residents (R2-R7), all of whom said they like living here. On April 21, 2026, the department interviewed the representative of (HHRB), who stated that the facility gave R1 all of R1's belongings. However, after R1's medications were almost running out, the HHRB called the facility to ask about refilling them, and the facility stated that R1 needed to see the doctor and call the pharmacy for a refill. The department was unable to interview R1 because R1 moved out of HHRB in December 2024. On April 20, 2026, the department reviewed the facility's admission agreement dated 09/30/2023, which stated that all resident personal property would be removed from their rooms within fifteen (15) days. And the facility shall have the right to dispose of such abandoned property in accordance with California Law. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An Exit interview was conducted, and a copy of this report was provided to Administrator Liliana Moreno.the state’s words, verbatim · CDSS document, Apr 27, 2026 · control 18-AS-20240614120546

Allegation investigated: Staff did not prevent resident from causing injuries to another resident in care.

On April 20, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Antonine Richard, conducted an unannounced complaint visit. The LPA Richard met with the Executive Director, Valerie Garcia, and the Administrator (A1), Liliana Moreno, and explained the purpose of the visit. The investigation consisted of collecting records and touring the facility. On April 16, 2026, the Department obtained various documents, including the Personnel Report LIC 500 (dated 04/16/26) and the Resident Roster (dated 04/16/26). The Department reviewed and collected the following documents for residents R1 and R2: the residents' Admission Agreements, the physician's report, the Medical Assessment, the Weekly Scheduled Shower, the facility's menu, the Unusual Incident Report, and the facility notes. The Department also interviewed the Administrator (A1), the Executive Director (ED), four staff members (S1-S4), and six residents (R1-R6). The Department was unable to interview residents R1 and R2 because they no longer live at the facility. Unsubstantiated Allegation #1: Staff did not prevent resident from causing injuries to another resident in care. The complaint alleged that the resident was physically assaulted by another resident and sustained injuries to the resident's eyes. On April 16, 2026, the department interviewed the Executive Director (ED) and the Administrator (A1), both of whom stated that they try to have more staff around residents who are aggressive toward other residents. The Administrator noted that the caregivers are aware of which residents require more supervision and who are likely to act aggressively. Additionally, four staff members (S1-S4) were interviewed, all of whom denied the allegation. They also stated that they are very alert and proactive around residents to prevent any residents from causing injuries to others. The department then interviewed six residents (R3-R8). 6 out of the six residents denied ever being hurt by other residents. However, the department was unable to interview R1 and R2 because they no longer reside at the facility. On April 16, 2026, the department reviewed the facility's notes dated 09/06/24 through 09/13/24, which documented that the facility assigned a one-on-one caregiver to R1 due to aggressive behavior and altercations with others. On 09/11/24, during the incident, the caregiver intervened and called Medical Emergency Services (MES), which transported residents R1 and R2 to the hospital. R2 was placed on a 51/50 hold. Both were discharged on 09/12/24. The department also reviewed the Unusual Incident Report dated 09/12/24, which was sent to Community Care Licensing and the Ombudsman. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to Administrator Liliana Moreno.the state’s words, verbatim · CDSS document, Apr 20, 2026 · control 18-AS-20240912155637

Allegation investigated: Due to lack of supervision, resident was physically attacked by another resident. Staff hit resident. Staff serve food that is not of good quality.

On April 20, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Antonine Richard, conducted an unannounced follow-up complaint visit. The LPA met with the Executive Director, Valerie Garcia, and the Administrator (A1), Liliana Moreno, and explained the purpose of the visit. The investigation included collecting records and touring the facility. On April 16, 2026, the Department obtained various documents, including the Personnel Report LIC 500 (dated 04/16/26) and the Resident Roster (dated 04/16/26). The Department reviewed and collected documents for the resident (R1) Admission Agreement, physician Report, Medical Assessment, Shower Schedule, and Weekly Menu. The Department also interviewed the Administrator (A1), the Executive Director (ED), four staff members (S1-S4), six Residents (R1-R6), and one witness (W). Unsubstantiated Allegation #1: Due to lack of supervision, resident was physically attacked by another resident. The complaint alleged that one resident attacked another by hitting the other and throwing the victim's TV against the wall. On April 16, 2026, the department interviewed the Executive Director (ED), who denied the allegation. The ED stated that when a resident exhibits aggressive behavior, they are typically removed from the situation and redirected to their seats or rooms. The department also interviewed the Administrator (A1), who also denied the allegation. A1 explained that this is a memory care facility, where they are aware of a resident who may have shown signs of aggressive behavior. However, they have sufficient staff to help redirect residents, and staff are always present near them. Additionally, the department interviewed four staff members (S1-S4), all of whom denied the allegation. They stated they are familiar with their residents and emphasized that such incidents are rare. The department also interviewed six residents (R1-R6), all of whom reported that no other residents had hit them. On April 16, 2026, the department reviewed the facility's daily notes for residents; none indicated that any residents were struck by others. No Unusual Incident Report was submitted to the Community Care Licensing Department. On April 17, 2026, the department interviewed the witness (W), who stated that whenever they visit the facility, they see many caregivers around the residents' rooms or nearby, supervising the residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. Allegation #2: Staff hit resident. The complaint also alleged that a staff member hit the resident on multiple occasions, and there may have been bruising on the resident's arm. On April 16, 2026, the department interviewed the Executive Director (ED), who denied the allegation and stated that staff would not hit any residents because they knew they would be fired and reported to Law Enforcement. At the same time, the department interviewed the Administrator (A1), who also denied the allegation and stated that they would fire the staff and send an Unusual Incident Report to Community Care Licensing, the Ombudsman, family members, and Law Enforcement. The department interviewed four staff members (S1-S4), all of whom denied the allegation and stated that they had never witnessed any staff member hitting a resident or that the resident had told them a staff member had hit them. The department interviewed six residents (R1-R6), all of whom denied being hit by staff members. On April 16, 2026, the department reviewed the facility's daily notes for residents, which did not document any incidents of staff members hitting residents. Additionally, no Unusual Incident Reports have been submitted to the Community Care Licensing Department. (CCLD) On April 17, 2026, the department interviewed a witness (W), who also denied the allegations. The witness (W) stated that this facility is the best place for R1 and expressed confidence that no staff member would harm R1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. Allegation #3: Staff serve food that is not of good quality. The complaint alleged that a resident has not been properly fed, receives cold, unappetizing food, and must beg for meals. On April 16, 2026, the department interviewed the Executive Director (ED), who denied the allegations. The ED stated that the facility employs a dietitian with 10 years of service and that the facility provides a weekly menu, serving residents three meals a day. During the same time, the department also interviewed the Administrator (A1), who likewise denied the allegations. A1 stated that the facility serves a variety of high-quality meals to residents. The department then interviewed four staff members (S1-S4), all of whom also denied the claims. S1 explained that when preparing food, they accommodate residents' dietary needs as directed by doctors. S1 also noted that the weekly menu offers a diverse selection of dishes. If a resident doesn't like what is served, they can request an alternative. The department interviewed six residents (R1-R6), all of whom described the food positively. Four of the six reported that they had requested a second plate because they enjoyed the food, and they were always provided with one. On April 16, 2026, the department toured the kitchen while lunch was being prepared. The department also observed a variety of dishes, including Vegetable Medley Soup, Ham and Cheese Macaroni Bake, a green salad, fresh fruit, and Blueberry French Toast. On April 17, 2026, the department interviewed a witness (W) who stated that when visiting R1, (W) observed that the meals served were very good. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An Exit interview was conducted, and a copy of this report was provided to Administrator Liliana Moreno.the state’s words, verbatim · CDSS document, Apr 20, 2026 · control 18-AS-20240828094816

Allegation investigated: Staff do not ensure residents are provided feeding assistance.

On April 17, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Antonine Richard, conducted an unannounced complaint visit. The LPA Richard met with the Executive Director, Valerie Garcia, and the Administrator (A1), Liliana Moreno, and explained the purpose of the visit. The investigation consisted of collecting records and touring the facility. On April 16, 2026, the Department obtained various documents, including the Personnel Report LIC 500 (dated 04/16/26) and the Resident Roster (dated 04/16/26). The Department reviewed and collected the following documents for the residents (R1-R2): the residents' Admission Agreement, the Physician's Report, the Medical Assessment, the Weekly Scheduled Shower, and the facility's Menu. The Department also interviewed the Administrator (A1), the Executive Director (ED), Four Staff members (S1-S4), and six Residents (R1-R6). Unsubstantiated Allegation #1: Staff do not ensure residents are provided feeding assistance. The complaint alleged that residents in memory care are not fed because staff are slacking off. During lunch, three residents returned their full plates to the kitchen because the staff did not assist. On April 16, 2026, the department conducted interviews regarding an allegation about meal assistance. The Executive Director (ED) and the Administrator (A1) denied the allegation. The Administrator noted that the caregiver is aware of which residents require meal assistance and is present to help during mealtimes. Additionally, four staff members (S1-S4) were interviewed, all of whom also denied the allegation. They stated that only two residents need help with feeding, and that the caregiver is consistently available at every meal to assist them. The department then interviewed six residents (R1-R6). Four of the six residents denied the need for assistance with feeding. Although the department attempted to interview R1, R1 was unable to answer the questions. R2, another resident, confirmed that they had not been unassisted during mealtimes and stated that staff assisted R2 with feeding at all times. Report Continue on LIC9099C Finally, the department reviewed the facility's resident Physician Report LIC602A, which indicated that only two residents needed assistance with feeding. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to the Executive Director, Valerie Garcia.the state’s words, verbatim · CDSS document, Apr 17, 2026 · control 18-AS-20240604090938

Allegation investigated: Staff do not meet residents' incontinence needs. Staff do not ensure residents are bathed. Staff do not maintain the facility in clean and sanitary condition.

On April 17, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Antonine Richard, conducted an unannounced follow-up complaint visit. The LPA met with the Executive Director, Valerie Garcia, and the Administrator (A1), Liliana Moreno, and explained the purpose of the visit. The investigation consisted of collecting records and touring the facility. On April 16, 2026, the Department obtained various documents, including the Personnel Report LIC 500 (dated 04/16/26) and the Resident Roster (dated 04/16/26). The Department reviewed and collected documents for the resident (R1) Admission Agreement, physician Report, Medical Assessment, Shower Schedule, and Weekly Menu. The Department also interviewed the Administrator (A1), the Executive Director (ED), four Staff Members (S1-S4), and six Residents (R1-R6). Unsubstantiated Allegation #1: Staff do not meet residents’ incontinence needs. The complaint alleged that residents' briefs were changed late and that this caused rashes. On April 16, 2026, the department interviewed the Executive Director (ED), who denied the allegation and stated that the caregiver changed residents' diapers every two hours and as needed. At the same time, the department interviewed the Administrator (A1), who also denied the allegation and stated that caregivers changed residents' diapers every two hours and as needed. A1 also stated that if a resident needed to be changed sooner, the caregiver or any staff member would do so. The department interviewed four staff members (S1-S4), all of whom denied the allegation and stated that they know their residents and how often they need to be changed. Additionally, the department interviewed 6 residents (R1-R6), 4 of whom wear diapers, and none reported that the caregiver took too long to change them. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. Report Continue on LIC9099C Allegation #2: Staff do not ensure residents are bathed. The complaint also alleged insufficient time for showers and that residents are not receiving them when they should. On April 16, 2026, the department interviewed the Executive Director (ED), who denied the allegation and stated that the facility maintains a shower schedule for all residents, including those in hospice. At the same time, the department interviewed the Administrator (A1), who also denied the allegation and stated that residents are showered three times a week, with some showering every day if they choose. The department interviewed four staff members (S1-S4), all of whom denied the allegation and stated that residents have scheduled showers, with some showering three times a week or every day. Additionally, the department interviewed 6 residents (R1-R6), all of whom reported showering regularly but sometimes not wanting to shower. On April 16, 2026, the department reviewed the facility’s residents' weekly shower schedules, which showed that most residents are scheduled three times a week, and hospice residents are scheduled three times a week as well. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. Report Continued on LIC9099C Allegation #3: Staff do not maintain the facility in clean and sanitary condition. The complaint alleged that there are no housekeeping services on weekends and that, upon arrival, visitors often report that the facility is generally not clean. On April 16, 2026, the department interviewed the Executive Director (ED), who denied the allegation and stated that the facility has caregivers and housekeepers on weekends. At the same time, the department interviewed the Administrator (A1), who also denied the allegation and stated that the facility schedules three to four housekeepers on weekends. The department interviewed four staff members (S1-S4), all of whom denied the allegation and stated that the facility schedules housekeepers on weekends because residents' rooms need to be cleaned then. Additionally, the department interviewed 6 residents (R1-R6), all of whom stated that their rooms are cleaned on weekends as well. They also stated that if they spill something, the housekeeper cleans it right away. On April 16, 2026, the department toured the facility and some residents' rooms. The rooms were clean, and the facility did not appear to be in disrepair. The department observed that the housekeeper was mapping the residents' floor while the residents were outside. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An Exit interview was conducted, and a copy of this report was provided to the Executive Director, Valerie Garcia.the state’s words, verbatim · CDSS document, Apr 17, 2026 · control 18-AS-20240311143426

Type of visit: Case Management - Incident

On Wednesday April 8, 2026 at 1:25PM Licensing Program Analyst (LPA) Tremayne Barra made an unannounced visit to the facility and met with Executive Director, Valeria Garcia and Administrator, Liliana Moreno, to conduct a case management incident. LPA informed them of the purpose of the visit. During the visit, LPA toured the facility and made observations pertaining to the incident. LPA conducted staff interviews, requested and received pertinent documents and conducted record reviews. LPA observed resident Joy McCarroll in her room in villa #5 laying in her bed with an oxygen machine connected to her nose. Joy granted permission to speak with her. LPA conducted a health, safety and welfare check of the resident in care. LPA did not observe any health and safety concerns at the time of the visit. An exit interview was conducted, a copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Apr 8, 2026

Allegation investigated: Lack of supervision/neglect resulting in Resident #1 sustaining injuries. Lack of supervision/neglect resulting in Resident #1 developing a wound with an infection. Staff do not maintain resident’s hygiene.

Licensing Program Analysts (LPA), Armando Perez and Tremayne Barra, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director, Valeria Garcia and Administrator Liliana Moreno, and explained both the purpose of the visit and the details of the allegations. LPA was unable to interview R1 due to R1 passing away. On June 19, 2025, the Community Care Licensing Division (CCLD) received a complaint alleging lack of supervision and neglect resulting in Resident #1 sustaining injuries and staff do not maintain resident’s hygiene. Regarding the lack of supervision and neglect resulting in Resident #1 sustaining injuries, it was alleged staff were not preventing R1 from falling. Interview with Additional Witness 1 revealed they observed injuries to R1’s right cheek bone and head. AW1 reported that the injuries were caused by staff not providing sufficient assistance to prevent R1 from falling. Continued on LIC 9099-C. Unsubstantiated Interview with ED reported that R1 was identified as a fall risk and staff were made aware to provide increased and sufficient supervision. ED noted R1 began to have a cognitive and communication decline, contributing to the falls. Interview with Staff 1 (S1) reported R1 had a care plan that included the use of a Geriatric Chair and bed railings to help prevent falls. Interview with R1’s responsible party confirmed facility staff communicated fall incidents and when R1 was transported to the hospital in a timely manner. A review of medical hospital records obtained did not reference injuries resulting from falls. Additionally, a review of incident reports submitted to Community Care Licensing identified four fall-related incidents involving R1. Facility staff appropriately documented responses, such as arranging medical transport and notifying responsible parties and hospice agencies. Regarding the allegation of lack of supervision/neglect resulting in Resident 1 (R1) developing a wound with an infection, it was alleged that R1 was not receiving adequate wound care which caused the condition of the wound to worsen. Interview with AW1 indicated that R1 appeared to have a severe infection and AW1 was unsure how often wound care was being provided. AW1 stated that their observations of R1’s condition, were the result of inadequate care by staff. Interview with S1 revealed that R1 was on hospice and experiencing a decline in health. S1 reported that R1 had a diagnosis of cognitive impairment and a form of cancer that resulted in a wound on R1’s left hand. S1 emphasized that a body check completed during admission on February 26, 2026, documented a skin tear and a bump on R1’s left hand. A review of R1’s medical records confirmed a cancerous growth on the left hand. Additionally, the growth was described as an open wound; however, it was noted on the medical record to be non-infected and did not develop while R1 was in care at the facility. Interview with Resident 2 (R2) indicated that staff attended to R1 daily and R2 observed the bandage on R1’s left arm changed regularly. Interview with Responsible Party (RP), reported visiting R1 a couple times a week and reported staff provided good care for R1. RP emphasized they had no concerns neglect or abuse had occurred at the facility. A police report dated June 24, 2025 was obtained and revealed a case related to the allegations regarding neglect and abuse of R1 at the facility was investigated and closed with no evidence of suspected abuse or neglect by facility staff. Regarding the allegation that staff do not maintain residents’ hygiene, it was reported that on June 18, 2025, R1 was observed to have a foul odor, with maggots and flies on R1's left arm. An interview with Additional Witness 1 (AW1) indicated they were visiting R2 when they noticed a foul odor coming from R1. AW1 stated that upon approaching R1, they observed a maggot on R1’s left arm. Interview with ED reported that they had not seen or been made aware of maggots on R1. ED denied the allegation and noted a bathing log was maintained by hospice and staff would assist with cleaning the bandage in between hospice visits. Interview with AW2 reported that staff often attended to R1 and maintained the cleanliness of R1’s room. It was also denied that AW2 observed maggots on R1. Interview with 5 of 5 staff corroborated denying observing maggots on R1. Interview with R1’s Responsible Party reported they had no concerns regarding R1’s care and observed R1’s room to be clean and organized during visits. A review of June and July 2025 hospice records revealed R1 was bathed on 6/5, 6/10, 6/12, 6/17, 6/19, 6/24, 6/26, 7/1, 7/3, 7/8, 7/15 and 7/17. Additionally, documentation showed that multiple wound care visits had been completed. Based on interviews, record reviews, and observations, the allegations of lack of supervision and neglect resulting in R1 sustaining injuries and a wound infection, and staff do not maintain resident’s hygiene has been deemed UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report was provided to Executive Director Valeria Garcia.the state’s words, verbatim · CDSS document, Mar 20, 2026 · control 18-AS-20250619155106

Allegation investigated: Staff chemically restrained resident(s) in care.

Licensing Program Analysts (LPAs), Armando Perez and Tremayne Barra, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Executive Director, Valeria Garcia and Administrator Liliana Moreno, and explained both the purpose of the visit and the details of the allegation. On June 19, 2025, the Community Care Licensing Division (CCLD) received a complaint alleging facility staff chemically restrained resident(s) in care. It was reported during a visit on June 18, 2025 residents were observed to be over-medicated. Interview with Additional Witness 1 (AW1) reported that they observed residents to be walking around the facility, banging on doors, making odd noises, and acting as “walking zombies.” AW1 reported they were not made aware of any medication distribution issues by staff or residents, emphasizing it was based on observations. Continued on LIC 9099-C. Unfounded AW1 could not provide any additional information to support the allegation. Interview with Executive Director (ED), Valeria Garcia, noted the facility is a memory care and various residents have cognitive diagnosis that may result in unpredictable behavior. ED reported that staff have not reported, nor are they aware of, any issues involving residents being overmedicated. Interview with 5 of 5 staff corroborated the statement made by ED. Information obtained from staff reported that they have not observed or been made aware of any issues with over-medicating residents. Interview with 5 of 5 residents did not reveal medication concerns or provide further information supporting the reported allegation. An interview with R1 could not be conducted due to their passing. Interview with Responsible Party reported that facility staff responded to R1's medical needs and would receive updates when R1 was sent out for medical intervention. LPA conducted a review of Special Incident Reports submitted and did not find any incidents related to the allegation reported. Based on interviews, research, and record review, the allegations facility staff chemically restrained resident(s) in care is unfounded. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, this complaint is dismissed. An exit interview was conducted. A copy of this report was provided to Executive Director Valeria Garcia.the state’s words, verbatim · CDSS document, Mar 20, 2026 · control 18-AS-20250619155106

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Tremayne Barra and Armando Perez conducted an unannounced visit for the purpose of confirming the recent changes to the capacity of the facility. LPA received an updated approved fire clearance and updated facility sketch. The facility has applied to go from a licensed capacity of Fifty Nine (59) Non-Ambulatory of which 5 may be Bedridden, to the new requested capacity at Sixty Four (64) Non-Ambulatory in which 5 may be bedridden. LPAs were greeted and granted entry by Executive Director; Valeria Garcia. LPAs conducted a tour of the interior and exterior of the compound that consists of 5 structures. Each structure is labeled as such on the submitted facility sketch. LPAs observed changes in the structures to accommodate the additional clearance. According to Administrator, no new structures were added, the request was to reflect the new approved capacity of Sixty Four (64) Non-Ambulatory in which 5 may be bedridden. On March 17 2026, the Riverside County Fire Department approved the capacity change. LPA observed each resident bedroom to have the required furnishing. LPA observed the facility to be clean and in good repair. All outdoor and indoor passageways are free of obstruction. No health and safety concerns were observed during today's visit. An exit interview was conducted, and a copy of this report was provided to facility representative.the state’s words, verbatim · CDSS document, Mar 20, 2026

Allegation investigated: Staff did not prevent resident in care from leaving the facility unsupervised Staff did not report incident to appropriate parties in a timely manner

Licensing Program Analysts (LPA), Armando Perez and Robert Cambpell , conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director, Valeria Garcia and Administrator Liliana Moreno, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and witnesses, and file reviews. On July 18, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that staff did not prevent resident in care from leaving the facility unsupervised and staff did not report incident to appropriate parties in a timely manner. Regarding the allegation that staff failed to prevent a resident from leaving the facility unsupervised, it was reported that on July 12, 2025, Resident 1 (R1) went on absent without leave (AWOL) status. Continued on LIC 9099-C. Substantiated It was indicated that it was unknown how R1 left the facility, possibly by following a visitor out. Furthermore, it was noted that R1 has had multiple elopements at the facility. Interview with Executive Director (ED), Valeria Garcia, revealed that R1 did elope from the facility noting it was before her start date. It was stated that it was believed R1 followed a visitor through several secured doors. ED stated that facility care staff received training on the supervision of clients in care on two recent occasions prior to R1’s elopement incident and policies were implemented. Information obtained from additional staff (S1) revealed that elopement procedures were followed once R1 was reported missing. Furthermore, S1 noted R1 was assessed for injuries and documented not observing any injuries. An interview was attempted with R1 resulting in LPA concluding interview for inadequate information. Interview with Additional Witness 1 (AW1) revealed a primary concern regarding the ongoing lack of adequate supervision at the facility, citing constant incidents related to supervision. AW1 noted that the lack of information surrounding R1’s elopement exemplified staff failure to provide adequate supervision. Through Records review, information obtained confirmed training regarding resident supervision was conducted on May 21, 2025 and July 3, 2025, corroborating statements made by ED. Additionally, a medical assessment dated March 25, 2025, was reviewed and revealed R1 is not capable of leaving facility unsupervised. Review of incident reports submitted to CCLD showed no documentation of preventive measures, such as redirecting the resident was conducted. The documentation reviewed identified the cause of R1’s elopement as unknown, only providing an assumption. Regarding the allegation that staff did not report incident to appropriate parties in a timely manner, it was alleged facility staff failed to report the elopement to all proper agencies. Interview with Administrator Liliana Moreno confirmed submitting an incident report to the Community Care Licensing Division (CCLD) and the Long-Term Care Ombudsman, noting that the CCLD report was filed on July 14, 2025, and the Ombudsman report on July 15, 2025. Administrator clarified that an SOC 341 form was not completed, as it was her understanding that elopement or AWOL incidents do not meet the criteria for that report without physical harm. Liliana added that R1 was assessed with no bodily injury observed and emphasized that she believed all required documentation was submitted to the appropriate agencies in compliance with regulatory requirements. Interview with AW1 revealed that a SOC 341 Report of Dependent Adult/Elder Abuse was Abuse (SOC341) was never submitted to Long Term Care Ombudsman failing to comply reporting requirements under Neglect. Continued on 9099-C. Information obtained through interview with ED revealed they believed a proper response was followed and emphasized an incident report was submitted to CCLD, Law Enforcement and LTCO. ED could not provide confirmation if SOC341 was submitted. Interview with Responsible Party (RP) verified they were notified and kept updated on the elopement incident with R1 on July 12, 2025. RP confirmed one other elopement at the facility, noting that R1 also had elopement incidents at the previous facility R1 resided in. RP noted they do not have any further concerns about the supervision and care provided to R1 by the facility staff. A record review confirmed that a special incident report was submitted to Law Enforcement, Community Care Licensing, and the Long-Term Care Ombudsman (LTCO). Additional information obtained that an SOC 341 was not submitted to these agencies. Further research revealed the elopement incident with R1 included unknown factors that classified the incident under neglect guidelines. Contributing factors included the unknown circumstances of how R1 eloped from a secure facility, the lack of any attempted staff intervention to redirect, and the medical determination that R1 was not permitted to leave the facility unassisted. Based on interviews and record reviews, the allegation that staff did not prevent resident in care from leaving the facility unsupervised and staff did not report incident to appropriate parties in a timely manner is Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. This is a potential risk to clients in care. The facility will be cited. An exit interview was conducted. A copy of this report was provided to Executive Director Valeria Garcia, along with a copy of the LIC9099-C, LIC9099D, and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Dec 5, 2025 · control 18-AS-20250718133105

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Jan 9, 2026

Reporting Requirements 87211(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). Welfare and Institutions Code section 15630(b)(1) provides in pertinent part: Any mandated reporter who… has knowledge of an incident that reasonably appears to be…neglect…shall report the known or suspected instance of abuse by telephone … a written report shall be sent, or an Internet report shall be made through the confidential Internet reporting tool established in Section 15658, within two working days.the state’s words, verbatim · CDSS document, Dec 5, 2025

Plan of correction: Executive director will provide in house training on requirements to submitting SOC 341 form. Training will include the telephone resource for CCLD and LTCO to submit within 24 hours when applicable. ED will submit an updated weekend procedures to be in compliance with SOC 341 reporting requirements. This requirement was not met as evidenced by: Based on interviews and record reviews, it was determined that the facility failed to submit properly submit incident under the SOC 341 Elder Abuse requirements. This poses a potential health safety or personal rights risk to residents in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(3) · Plan of correction due date: Dec 26, 2025

87705 Care of Persons with Dementia (3) Facility staff shall attempt to redirect a resident at risk for elopement who may be attempting to leave the facility without violating Section 87468.1, Personal Rights of Residents in All Facilities. This requirement was not met as evidenced by: Based on interviews and record reviews, it was determined that the facility staff failed to intervene with resident elopement and is unaware on how they eloped. This poses a potential health safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2025

Plan of correction: Executive Director will provide me their security clearance procedures. Additionally, in house training will be provided to all staff on proper supervision procedures for residents in care and intervention procedures when observing potential elopement.

Allegation investigated: Staff did not ensure resident had adequate sleeping accommodations. Facility’s Administrator is not on the premises a sufficient number of hours.

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director Valeria Garcia and Business Office Manager Judine Ramirez, where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of interviews with staff and witnesses and file reviews. On June 4, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that staff did not ensure resident had adequate sleeping accommodation and Facility’s Administrator is not on the premises a sufficient number of hours. In response to concerns regarding inadequate sleeping accommodation, it was reported that a resident had been observed sleeping on a broken bed and staff failed to take corrective action.Interview with ED stated that no reports of a broken bed had been brought to their attention. Cpntinued on LIC 9099-C. Unsubstantiated Interviews with six of six staff members corroborated that no observations of a broken bed had been reported. On June 4th, 2025, LPA toured the facility documenting observations. LPA inspected 14 rooms, noting that no inadequate sleeping arrangements were observed. LPA noted proper bed accommodation in 14 of 14 rooms with proper bed frames and mattresses. Through resident interviews, 3 of 3 revealed no issues with their sleeping accommodation or aware of any reported broken beds. Multiple interview attempts were made with Additional Witness 1 (AW1) to gather further information, however, AW1 did not respond to the interview request. Through record review, no special incident reports or maintenance orders documenting a broken bed were reported. In response to the allegation that the Facility Administrator is not present on the premises for a sufficient number of hours, it was reported that AW1 attempted to speak with management regarding a resident’s inadequate sleeping accommodations, but management was unavailable. Information obtained from an interview with ED, stated they are regularly on-site Monday through Friday from 8:00 AM to 5:00 PM. It was also advised that an additional Administrator is present during similar hours to provide support. Interviews with all six staff members corroborated that both the ED and Administrator are consistently available in person to assist staff and visitors. Staff further indicated that both administrators are accessible by phone when not physically present at the facility. Information obtained from interviews with residents stated that Administrator is available during weekday hours. A review of records confirmed that both the ED and Administrator hold valid Administrator certificates. Additionally, Title 22 regulations do not specify a required number of on-site hours, but indicated the importance of fulfilling the responsibilities associated with the role. The regulations also permit the use of designated substitutes who possess adequate qualifications to be responsible and accountable for the facility’s management and administration. Staff schedules reviewed, verified that both the ED and Administrator are scheduled to be on-site Monday through Friday, from 8:00 AM to 5:00 PM documenting compliance with regulation. Continued on LIC 9099-C. Based on interviews, record reviews, and observations the allegations staff did not ensure resident had adequate sleeping accommodation and Facility’s Administrator is not on the premises a sufficient number of hours has been deemed UNSUBSTANTIATED. A finding that the allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted. A copy of this report was provided to Executive Director Valeria Garcia and Business Office Manager Judine Ramirez.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 18-AS-20250604100237

Allegation investigated: Staff are abusive to resident in care.

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Executive Director Valeria Garcia, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff, witnesses and file reviews. On April 10, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that facility staff are abusive to resident in care. It was alleged that Resident 1 (R1) was being mistreated by staff and experiencing abusive behavior due to nonpayment of rent. Interview with Executive Director, Valeria Garcia, revealed that R1 was unable to pay their rent, but eviction proceedings had not been initiated. It was also stated that R1 had not made any allegations to management of staff abuse. Interview with 2 of 2 staff corroborated that they neither heard R1 report any abuse by staff nor witnessed any staff engaging in abusive behavior toward R1. Continued on LIC 9099-C. Unfounded Information obtained from interview with R1 indicated that they experienced a financial issue, resulting in a delay in their monthly rent payment. It was confirmed that no eviction procedures had been initiated and that an arrangement was made to accept payment upon receipt of the new bank card. Despite these challenges, R1 stated they had no issues with the treatment provided by the staff and expressed overall satisfaction with living at the facility. Interview with Witness (W1), stated they visited R1 approximately once a week, reported observing no abusive behavior from staff. W1 noted that staff treated R1 well and stated that R1 had not mentioned any mistreatment. A review of facility records, including incident reports, revealed no documented incidents of staff abuse involving R1. Additionally, there was no documentation of an eviction notice, as no such action had been initiated. Based on interviews, research, and record review, the allegation that facility staff are abusive to resident in care is unfounded. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, this complaint is dismissed. An exit interview was conducted. A copy of this report was provided to Executive Director Valeria Garcia.the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 18-AS-20250410091938

Allegation investigated: Facility does not have adequate staffing to meet resident's care needs.

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Executive Director Valeria Garcia, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and file reviews. On May 05, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that facility does not have adequate staffing to meet resident's care needs. It was alleged that facility only has 3 caregiver staff to supervise five villas, resulting in two villas not staffed and unable to provide proper care and supervision for. Information obtained from interview with Executive Director Valeria Garcia stated that the facility made recent staffing adjustments that are sufficient to meet the care needs of residents. ED noted the facility has increased night shift coverage from three to four caregivers between 10:00 PM and 6:00 AM to enhance supervision and response times. Continued on LIC 9099-C. Substantiated Additionally, ED added staff are now required to conduct resident checks every 10 to 15 minutes throughout the night. Information obtained from interviews with residents stated there were many incidents that required immediate attention and did not receive a response from staff in a timely manner. Further information obtained stated there was an incident where Resident #1 (R1) fell and required staff assistance. The information provided was corroborated by Witness 1 (W1), who stated they activated R1’s call pendant and verbally called out for help. W1 further noted that when staff eventually arrived, they explained the delay was due to assisting another resident with an emergency. Additional information obtained stated there was an incident where a physical altercation occurred between two residents. Staff was requested, but no staff responded. As a result, residents contacted law enforcement for assistance. Additionally, there were two documented incidents in which medications were not administered due to inadequate staffing. On February 1, 2025, the Night Operations Shift (NOC) lacked an assigned MedTech, resulting in at least two residents missing their scheduled medications, including any Pro Re Nata (PRN) requests. A second occurrence took place on Saturday, April 26, 2025, when an unexpected staff call-out prior to the evening shift, which left the facility without MedTech coverage. As a result, scheduled medications were not dispensed to residents. Interviews with the Executive Director and staff confirmed that attempts were made to secure coverage; however, due to emergencies, existing staff commitments, and the short notice, a qualified replacement could not be arranged for that shift. A review of the facility’s staffing schedule from January through May 2025, there are three shifts. During this period, the AM and PM shifts consistently maintained six to seven staff members who actively provide resident care, excluding office and kitchen personnel. In contrast, the NOC (overnight) shift, operating from10:00 PM to 6:00 AM, was inconsistently staffed with only three to four caregivers. The NOC shift was responsible for approximately 54 residents. The shortage in staff, compromised both the safety and the level of supervision provided to residents in care. This poses as a potential health & safety risk to residents in care. Based on interviews and record reviews, the allegation that facility does not have adequate staffing to meet resident's care needs. is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was provided to Executive Director Valeria Garcia, along with a copy of the LIC9099-C, LIC9099D, and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 18-AS-20250505091658

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 17, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1…elderly shall have …the following personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers…to meet their needs. This requirement was not met as evidenced by: Based on interviews and records review, the facility is not staffed sufficiently at night from 10pm to 6am to meet night supervision needs.the state’s words, verbatim · CDSS document, Oct 17, 2025

Plan of correction: The Licensee has corrected the issue. On 10/13/25 an updated LIC 500 and Staffing schedule was submitted to satisfy the plan of correction. The staff rotational procedure for supervision and the reported active residents during the night led to an altercation that staff did not witness or intervene. This poses a potential health safety or personal rights risk to residents in care.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Seo Jeon made an unannounced visit to the facility to conduct a Case Management visit regarding a complaint report number 18-AS-20250303133359. LPA spoke with the Executive Director, Valeria Garcia, and informed them of the purpose of the LPA's visit. LPA conducted a health, safety and welfare check of residents in care. LPA did not observe any health and safety concerns at the time of the visit. There are no deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22. An exit interview was conducted, a copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Sep 30, 2025

Allegation investigated: Staff did not prevent a physical altercation between residents Staff did not respond to resident's calls for assistance

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director Valeria Garcia and Administrator Liliana Moreno where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of interviews with staff and witnesses, and file reviews. On August 08, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that staff did not prevent a physical altercation between residents and staff did not respond to residents’ calls for assistance. It was alleged that on August 1, 2025, Resident 1 (R1) was involved in a physical altercation with R2 and staff failed to respond to verbal and telephone calls for intervention and assistance. Interview with Additional Witness 1 (AW1) disclosed that R1 observed R2 in the incorrect room and asked R2 to exit the room. Continued on LIC 9099-C. Substantiated AW1 reported that R2 became agitated and responded with physical aggression towards R1. AW1 reported R1 yelled for staff assistance and called the facility number with no response, leading to calling law enforcement for assistance. Additionally, AW1 reported that the altercation resulted in injuries to R1 and medical transport for both residents. Interview with Executive Director, Valeria Garcia stated she was made aware of the incident and clarified that NOC staff are assigned to supervise the villas on a rotational basis. Executive Director stated the altercation occurred while staff were actively following protocol during their scheduled rounds. Valeria added that proper assessments, additional care plans, and staff monitoring have been adjusted for R2. Through interviews, 4 of 4 staff reported that they did not observe or hear of the altercation between R1 and R2. Additionally, they did not hear the facility phone ring and were made aware of the altercation when paramedics and law enforcement arrived at the facility. A review of facility records confirmed that the NOC shift operates from 10:00 PM to 6:00 AM and is staffed with three to four personnel responsible for the care of 54 residents. Through supplemental interviews, it was further corroborated that several residents remain active during these hours, often engaging in mobility throughout the facility. Additional information obtained indicated that frequent calls for assistance are common during NOC shift, which presents ongoing challenges in maintaining adequate supervision and ensuring consistent quality of care under the current staffing levels. Based on interviews and record reviews, the allegation that staff did not prevent a physical altercation between residents and staff did not respond to resident's calls for assistance is Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The facility will be cited. An exit interview was conducted. A copy of this report was provided to Executive Director Valeria Garcia, and Administrator Liliana Moreno along with a copy of the LIC9099-C, LIC9099D, and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Sep 22, 2025 · control 18-AS-20250808101937

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 13, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in 87468.1…elderly shall have …personal rights:(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers…to meet their needs. This requirement was not met as evidenced by: Based on interviews and records review, the facility is not staffed sufficiently at night from 10pm to 6am to meet night supervision needs.the state’s words, verbatim · CDSS document, Sep 22, 2025

Plan of correction: The licensee agreed to submit an updated LIC500 and updated Staff Calendar showing adequate staffing at night to meet the proper care, supervision and services for the residents in care. The staff rotational procedure for supervision and the reported active residents during the night led to an altercation that staff did not witness or intervene. This poses a potential health safety or personal rights risk to residents in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87415(a) · Plan of correction due date: Oct 13, 2025

Night Supervision: 87415 (a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures… to assist in caring for residents in the event of an emergency. This requirement was not met as evidenced by: Based on interviews and record reviews, it was determined that staff failed to assist during an emergency involving a physical altercation between two residents. Staff were unavailable to provide timely intervention, resulting in injuries to both residents.the state’s words, verbatim · CDSS document, Sep 22, 2025

Plan of correction: The licensee agreed to submit an updated LIC500 and updated Staff Calendar showing adequate staffing at night to meet the proper care, supervision and services for the residents in care. The lack of sufficient overnight supervision from 10:00 p.m. to 6:00 a.m. contributed to the incident occurring without staff presence or response. This poses a potential health safety or personal rights risk to residents in care.

Allegation investigated: Staff do not prevent resident to resident altercations while in care. Staff did not properly report incidents involving the residents.

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director (ED), Valeria Garcia and Administrator Liliana Moreno where the LPA explained the purpose of the visit and the elements of the allegations. The investigation consisted of interviews with staff and witnesses, and file reviews. On March 04, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that staff did not properly report incidents involving residents and staff do not prevent resident to resident altercations while in care. It was alleged that between January and March 2025, multiple resident on resident altercations were not reported to Long Term Care Ombudsman Program (LTCO), in accordance with the guidelines outlined in California Assembly Bill 1411 and Title 22 regulations. Additionally it was noted that staff was not preventing resident to resident altercations due to the influx of cases. Continue on LIC 9099-C. Substantiated In regards to the allegation that staff did not properly report incidents involving residents, information obtained from interview with Additional Witness 1 (AW1) disclosed that several incidents involving resident on resident altercations were advised of by witnesses not associated to the facility. Interview with AW2 stated mandatory reporting requirements were discussed with ED on two separate occasions. AW2 further reported that they had provided staff with resources outlining the LTCO reporting guidelines. Information obtained from interview with ED, revealed that 6 of 6 incidents were reported to CCLD, however, the same reports were not provided to LTCO. ED explained that there was a lack of understanding regarding LTCO reporting requirements. ED reported that clarification was provided to facility staff. Interview with additional staff (S1) shared that they were assigned responsibility for incident reporting beginning in January 2025. S1 confirmed that incident reports were submitted to CCLD in accordance with regulatory requirements, but not to LTCO. Through a review of records, LPA observed that 6 out 6 incidents that occurred during January 2025 through March 2025, which met LTCO reporting requirements, were not cross-reported to the LTCO. This poses as a potential health & safety risk to residents in care. For the allegation that staff do not prevent resident to resident altercations while in care, LPA interviewed staff and witnesses, and obtained supportive documentation to aid in determining the findings of the noted allegation. During an interview with ED, it was reported that incidents involving memory care residents can be unpredictable due to behavioral factors. ED added that staff receive initial training, as well as ongoing in-service trainings, to ensure they are equipped to understand and appropriately respond to behavioral incidents. LPA reviewed facility in-service training records which revealed staff received training on various topics, including resident observation, dementia redirection techniques, responding to call buttons, hydration practices, monitoring physical changes, and conducting resident reappraisals. LPA noted that in-house training records commenced in May to August 2025 and subsequently requested documentation covering the period from January to March 2025. Interview with ED stated that those were the records available at this time. A review of facility records between the period of January 2025 through March 2025 was conducted. The record review revealed a total of 6 incidents that met the criteria of resident on resident altercation. LPA observed that 6 out of 6 incidents documented staff intervened by separating the involved residents, redirecting behavior, and/or conducting assessments for potential injuries. Documentation also revealed that there were four residents who were repeatedly involved in the identified 6 altercations. Continued LIC 9099-C. ED reported the facility’s response included several interventions to manage these behaviors, which included requesting revised physician orders, adjusting medications, and conducting resident reassessments. LPA also examined the facility’s activities calendar, which provides a structured daily schedule of programs available to residents under care. Interviews conducted with 6 of 6 staff members revealed inconsistencies regarding the ED statement on implementation of training and behavioral interventions during the period of January through March 2025. Through interviews it was revealed that no in-house training was provided on preventing resident-to-resident altercations during the time frame. Additionally, staff consistently reported that the practice of redirecting residents was insufficient as a standalone method for managing individuals with behavioral challenges. Concerns were also advised regarding staffing levels, which were described as inadequate for effective resident supervision. Examples were cited, including concerns with Villa 2, which accommodates up to 18 residents. Staff noted that at times, only one employee was assigned to this unit, significantly limiting the ability to respond promptly to incidents while simultaneously attending to other residents. An additional concern identified was the lack of staffing coverage resulting from last-minute call-outs. Staff interviews indicated that these absences were not consistently backfilled, leading to inadequate staff-to-resident ratios. This shortage compromised both the safety and the level of supervision provided to residents in care. This poses as a potential health & safety risk to residents in care. Based on interviews and record reviews, the allegation that staff did not properly report incidents involving the residents and staff do not prevent resident to resident altercations while in care is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The facility will be cited. An exit interview was conducted. A copy of this report, along with a copy of the LIC9099-C, LIC9099D, and Appeal Rights were provided to Executive Director Valeria Garcia.the state’s words, verbatim · CDSS document, Aug 29, 2025 · control 18-AS-20250304094204

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 19, 2025

Personnel Requirements: 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met, as evidenced by:the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: Executive Director to come up with the staffing and implementation plan to rectify the staffing issue and submit to CCL on or before the POC date. Based on LPAs record review and interviews, licensee did not ensure that the facility has sufficient staffing to provide the necessary services and supervision, this poses an immediate health and safety risk to the residents in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Sep 12, 2025

REPORTING REQUIREMENTS: (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman... licensing agency, & the local law enforcement agency within 24 hours as required by 15630(b)(1). This requirement was not met, as evidenced by: Based on a record review, 6 out 6 incidents, that met LTCO reporting requirements, were not cross reported by facility staff, per Title 22. This poses a potential health and safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: Administrator will conduct in-service training on LTCO mandated reporting requirements under AB1411, including guidance on completing and submitting Form SOC 341 to ensure compliance.

Allegation investigated: Staff did not administer prescribed medications to residents in care.

Licensing Program Analyst (LPA), Armando Perez, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Executive Director Valeria Garcia, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and file reviews. On May 05, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that staff did not administer prescribed medications to residents in care. It was alleged that occasionally on the weekends, the facility would not staff a Medical Technician (MedTech) to be scheduled. The inability to cover the shift resulted in medication not being dispensed to residents. In regards to the allegation, LPA, in collaboration with Executive Director (ED) Valeria Garcia and two of two staff members responsible for employee scheduling, conducted interviews and reviewed documentation including electronic Medication Administration Records (MAR), paper PRN logs, and employee timecards. Continued on LIC 9099-C. Substantiated A comprehensive review of facility records was conducted and uncovered inconsistencies in the scheduling of Medical Technicians (MedTechs) on the staff calendar. LPA identified 16 instances where MedTech coverage appeared to be missing for at least one shift, prompting concerns regarding the administration of medications. The investigation confirmed that a qualified MedTech was present during 14 of the 16 shifts in question, thereby negate there was inappropriate coverage. Information obtained from an interview with S2, it was determined that abrupt changes were made to the schedule and the staff schedule was not updated. On February 1, 2025, no MedTech was assigned during the Night Operations Shift (NOC), resulting in an estimated two residents not receiving their scheduled medications and any PRN requests by the residents in care. Additionally, on Saturday April 26, 2025, an unexpected staff call-out before the PM shift left the facility without MedTech coverage, leading to a failure in dispensing scheduled medications to the facility residents in care. Interviews with ED and staff members confirmed that efforts were made to secure coverage; however, due to emergencies, pre-existing schedules, and the short notice, a qualified replacement could not be arranged on that Saturday shift. Based on interviews and record reviews, the allegation that staff did not administer prescribed medications to residents in care is Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where a copy of this report was provided to Executive Director Valeria Garcia, along with a copy of the LIC9099-C, LIC9099D, and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Aug 25, 2025 · control 18-AS-20250505105846

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 25, 2025

87465 Incidental Medical and Dental Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility…(4)The licensee shall assist residents with self-administered medications as needed. This requirement was not met, as evidenced by: Based on observation, interview and record review, Medication was not administered as prescribed by physician, on two of two occasion to residents, which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 25, 2025

Plan of correction: Administrator will provide LPA with a planned procedure in place to properly dispense medication in the case of a call out by a MedTech. The plan must include weekend and NOC shift instructions on how coverage and medication dispensing will be followed. Administrator must provide training on the procedure with management and MedTechs. An email will need to be provided to LPA by POC date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Armando Perez conducted an unannounced visit for the purpose of confirming the recent changes to the capacity of the facility. LPA received an updated approved fire clearance and updated facility sketch. The facility has applied to go from a licensed capacity of Fifty Five (55) Non-Ambulatory of which 5 may be Bedridden, to the new requested capacity at Fifty Nine (59) Non-Ambulatory in which 5 may be bedridden. LPA was greeted and granted entry by Administrator; Valeria Garcia, who also has a current administrator certificate that expires on 12/12/2026. LPA conducted a tour of the interior and exterior of the compound that consists of 5 structures. Each structure is referred to as a Villa and is labeled as such on the submitted facility sketch. According to Administrator, no new structures were added, the request was to reflect the new approved capacity of Fifty Nine (59) Non-Ambulatory in which 5 may be bedridden. On August 1 2025, the Riverside County Fire Department approved the capacity change. LPA observed each resident bedroom to have the required furnishing. LPA observed the facility to be clean and in good repair. All outdoor and indoor passageways are free of obstruction. LPA observed for the facility food supply to meet the minimum requirements of having a 2-day supply of perishable and 7 day supply of non-perishable food items. LPA reviewed the storage and dispensing of medications and observed for them to be locked and inaccessible to residents. No health and safety concerns were observed during today's visit. An exit interview was conducted, and a copy of this report was provided to facility representative. .the state’s words, verbatim · CDSS document, Aug 14, 2025

Allegation investigated: Facility staff not regularly providing observations to residents physical changes.

Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to the facility to conclude the investigation of and deliver findings to the above mentioned complaint. LPA was greeted and granted entrance into the facility by Jessenia Rubalcaba, Activity Director. Jessenia informed the Administrator of my arrival. LPA later met with Administrator, Valeria Garcia who was informed of the reason for today's visit. The investigation consisted of interviews with staff, and review of records. The investigation revealed that on September 15, 2022, Witness three (W3) conducted a physical examination of Resident 1(R1) and noted an acute stage 2 ulcer on the sacral area. The ulcer had been present for 11/12 weeks. The patient care plan was to turn every 2 hours or as needed, change diaper often, continue air mattress, home health for wound care, continue applying skin protectant, and zinc ointment twice a day and as needed, apply nonadherent dressing to area and change twice a day and as needed, and monitor. Although staff reported following the care plan for R1, interviews revealed that facility staff did not document written observation of R1 change in condition. ***Continued on LIC9099C*** Substantiated Interviews with S2, S3, and S5 reported providing verbal communication to staff on changes of condition and new procedures. It was reported after R1 conditioned worsen staff started a daily log or charting changes in R1 condition. This new procedure required caregiver to chart resident’s daily activities or behaviors such as showers, food intake, bowel movements, behaviors, complete a shower check list, and skin condition. It was found that R1 was diagnosed with Stage 1 pressure injury and required assistance with all daily living activities. There was no charting or log to identify changes in R1 condition. Based on the evidence gathered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 18-AS-20221223121913

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(1)(E) · Plan of correction due date: Aug 12, 2025

87463(1)(E) ReappraisalsSignificant changes in condition, as...Definitions, include,...limited, (E)Illness or injury...ignificant change in the health care or dietary needs of the resident. Based on the evidence the Administrator did not comply with the section cited above by staff not properly reporting, observing and or documenting the changes in R1's condition which resuled in a stage 3 wound, which imposes an immediate health, safety and personal risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Licensee agrees to educate all staff on the proper procedure for residents developing pressure injury and reporting requirements. Administrator will submit an email with a statement knowledging the regulation cited.Proof of staff reading over section 87463(1)(E) and completion of training to LPA Farlow by Plan of Correction (POC) due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Armando Perez made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was granted entry by staff to conduct the inspection and met with Executive Director Valeria Garcia and Administrator Liliana Moreno. The LPA informed Valeria and Liliana of the purpose for the visit. The inspection included the following: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility consists of five (5) building structures. The facility has a kitchen, dinning area, laundry room, and a courtyard and with sufficient seating and space for activities. The five villas are maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured within regulation at multiple tested locations. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. An Activities calendar and menu is available and posted at the facility. The LIC 610, emergency disaster plan and infection control plan is maintained. There are no firearms at this facility and no bodies of water observed. LPA began review of client records. eight (8) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. LPA observed two out of eight files to be missing the Admissions agreement, medical consent form and personal rights. A deficiency will be cited. Continued on LIC 809-C. LPA began review of employee records- eight (8) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date of 12/12/2026. LPA observed 3 out of eight employee records missing the health screening and TB test. A deficiency will be cited. LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. Medication are centrally stored. There is a locked room in villa four allocated for medication storage. Centrally stored medication and destruction logs are maintained. Medications reviewed appear to have been dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. Smoke detectors and carbon monoxide detectors are a combined single unit and were tested and found to be operational. Fire extinguishers were previously serviced on, 09/05/2024. Fire drills are conducted quarterly at the facility with the last drill on 07/09/2025. LPA observed the emergency drill record to be missing the time it was conducted and appeared to not include all staff. A technical violation will be documented. Based on the information received during this visit today in the areas reviewed, there are deficiencies that are being cited per Title 22, Division 6 of The California Code of Regulations. This LIC 809 report was reviewed with the facility representatives and a copy was provided.the state’s words, verbatim · CDSS document, Jul 22, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Resident developed a Stage 3 pressure injury due to neglect.

Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Liliana Moreno, Med-Tech Supervisor/ Administrator and explained the purpose of the visit. The investigation conducted by Department staff consisted of staff interviews, resident interviews and document review. Evidence shows that on 9/15/2022 a nurse came to the facility to assess R1’s wound on the coccyx which was assessed as a stage 2. The nurse recommended home health care for the wound and the plan was to keep the wound clean, reposition every 2 hours, apply ointment, and dress. On 10/5/2022 the first visit was made by Home Health Registered Nurse (RN1) for wound care and nurse observed the wound was not dressed when R1’s wet diaper was changed, and the nurse documented the wound as a stage 3 open wound with no drainage. The LVN checked on R1 3 times a day but did not always look at the wound. Instead, she checked to make sure the caregivers repositioned R1 every 2 hours. The wound went from a stage 2 to a stage 3 from 9/15/2022 – 10/5/2022. Substantiated Interviews show staff reported assisting R1 during varies stages of R1 wound treatment. Staff confirmed there were steps in place to reposition R1. However, R1 had a medical condition that caused stiffness, so repositioning was difficult. Staff S2 and S5 indicated they were trained to provide wound care to R1 on the days no skilled nurses were scheduled. The procedure required staff to clean, pat dry, and dress the wound. However, staff never dressed the wound which caused the wound to worsen. Staff only applied ointment, repositioned R1, and attempted to keep R1 dry. There was no documentation of dressing being applied to the wound. In addition, the facility staff did not maintain a chart or log for R1’s plan of care or change of condition as it worsened. The facility only implemented charting changes after R1 condition changed after 12/2022. Based on the evidence gathered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence standard has been met. An immediate civil penalty is assessed for $500.00, per Health and Safety Code. An additional civil penalty may be imposed per Health and Safety Code 1569.49 (f).the state’s words, verbatim · CDSS document, Apr 18, 2025 · control 18-AS-20221223121913

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 19, 2025

87466 The licensee shall ensure residents are regularly observed ..changes in physical, mental, emotional and social... appropriate assistance...bservation reveals unmet needs...changes such as unusual weight gains or losses or deterioration of mental ability..physical health condition are observed..licensee shall ensure that such changes are documented and attention of the resident's physician and the resident's responsible person Based on the evidence the licensee did not comply with the section cited above by staff not properly caring for R1's wound resulting in a stage 3 wound, which imposes an immediate health, safety and personal risk to persons in care.the state’s words, verbatim · CDSS document, Apr 18, 2025

Plan of correction: Licensee agrees to educate all staff on the proper procedure for residents developing pressure injury and reporting requirements. Licensee will submit an email and statement of documentation of proof of staff reading over section 87466 and completion of training to LPA Farlow by Plan of Correction (POC) due date.

Allegation investigated: Staff threatened resident.

Licensing Program Analyst (LPA) Armando Perez conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Executive Director Valeria Garcia and explained the purpose of the visit and the details of the allegation. The investigation included observations, interviews with staff members and residents, and a review of records. On February 14, 2025, Community Care Licensing received a complaint alleging that a staff member threatened a resident in care. It was reported that Staff 1 (S1) verbally threatened Client 1 (C1) and Client 2 (C2), stating that the facility was their home and the clients would be evicted if they did not follow the rules. Information obtained from interview with Executive Director, (ED) Valeria Garcia stated that she was made aware of the incident and conducted an internal investigation with the alleged staff and residents involved. ED stated the investigation did not find evidence that S1 made the alleged statement. ED explained that C1 was upset because they had an incident which required C1 to have increased supervision. Continued on 9099-C Unsubstantiated Information obtained from staff corroborated that C1 was upset regarding the change in supervision. Information obtained from interview with S1 stated denied threatening clients with evictions or that the facility was their home. Additional interviews conducted with staff denied that they heard S1 make any inappropriate statement regarding eviction or that the facility was their home. Additional witnesses were interviews and it was stated they never observed any staff being verbally threatening to residents. Based on observations, record reviews, and interviews with clients and staff, this allegation is deemed Unsubstantiated. A finding of "Unsubstantiated" means that the allegation may have occurred or is valid, but there is insufficient evidence to prove the alleged violation. An exit interview was conducted, and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 18-AS-20250214110735

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Armando Perez conducted a case management visit to the facility for the purpose of issuing deficiencies. LPA met with Executive Director Valeria Garcia and explained the purpose of the visit. During interviews and a record review on February 21, 2025, LPA became aware of an incident involving two clients in care. It was advised that on February 11, 2025, multiple staff members reported observing Client #1 inappropriately touching Client #2. Administration was informed of the incident. Information obtained from Executive Director, Valeria Garcia, stated that immediate action was taken. Executive Director stated staff separated the clients, notified their responsible parties, and develop a plan pertaining to increased supervision. Interviews with staff, residents, and additional witnesses corroborated the information. However, the incident was not reported to Community Care Licensing Division (CCLD) as required. Per CCLD guidelines, a special incident report must be submitted within seven days from the occurrence. LPA reviewed Special Incident Reports pertaining to the facility and did not find any documentation referencing the observations made regarding the behavior between C1 and C2. As a result, a deficiency will be cited. This violation of regulations may pose as a potential health and or safety risk to clients in care. An exit interview was conducted. A copy of this report, LIC 809-D , and Appeal rights was reviewed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Apr 3, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Apr 25, 2025

1. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. (D) Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by: Based on observation, interview, and record review, the facility administration did not comply with the section cited above in one out of one incident between two clients, which posses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: Administrator will conduct a staff training on mandating reporting, guidelines, and the resources available for reporting. Administrator will email proof of completion of training and attendance sheet for all staff.An SIR will need to be submitted to CCLD for incident.

Allegation investigated: Facility doesn't have a qualified administrator.

Licensing Program Analysts (LPAs) Javina George and Ferrer Sabarias made an unannounced visit to deliver findings for the allegation listed above. LPAs met with Administrator Valeria Garcia where LPAs explained the purpose of the visit and the elements of allegation. The Allegation was investigated, the investigation consisted of observations, interviews, records review. On 11/06/2024 Community Care Licensing received a complaint alleging that the facility doesn't have a qualified administrator, as they do not possess a valid administrator certificate. Per an interview conducted with Valeria Garcia, whom confirmed that she has been the Administrator since 10/30/24, administrator certificate number 6022084740, which expires 12/12/24. This was verfied by a records review of the personnel record and criminal record transfer request form. Upon conducting a tour of the interior of the physical plant LPAs observed for there to be a valid administrator certificate posted in the entryway. In addition per the file review conducted revealed the certificate renewal documents were sent on 11/05/24. Unfounded Based on records review and observation the allegation of the facility doesn't have a qualified administrator is unfounded. A finding that the complaint is unfounded means that the allegation is 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 to Valerie Garcia Administrator.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 18-AS-20241106142616

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. On today’s visit the LPA met with Onsite Administrator, Diana Ramirez. She was notified of the purpose for the visit. PHYSICAL PLANT: The Licensee appears to be operating the facility within the conditions and limitations specified on the license. Residents appear to be protected against immediate hazards. The interior and exterior areas of the facility were observed to be clean and safe. No pool or body of water was observed on the property. According to the Onsite Administrator, there are no weapons kept on the property. Disinfectants, cleaning solutions, and poisons were inaccessible to residents in care. A comfortable temperature was being maintained in each building on the property. There was sufficient lighting in resident bedrooms to ensure the comfort and safety of residents. Other than seating, each resident bedroom had the required furniture. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. Additional equipment for physically handicapped residents is available. The fire panel was inspected and observed to be in a 'normal' status. Several carbon monoxide detectors were tested throughout the facility and found to be operable. LPA observed missing call buttons for multiple resident bedrooms used for the facility's signal system. The LPA observed no signal system device set up for building two. According to staff, it was unknown where the device was moved to. A citation will be issued. FOOD SERVICE: There was a variety of food which appeared to be selected and stored in a safe and healthful manner. Food supply of nonperishable and perishable foods was sufficient. Sufficient supplies for resident's dinning use was observed to be available. RECORD REVIEW: Staff files had required training; including, but not limited to, First Aid/CPR and Suspected Abuse training. Hospice Care Plans were observed on file for residents in care. Staff present had the required criminal record clearances. Admission Agreements, Medical Assessments (Physician's Reports), and Service Plans were observed on file for residents in care. Onsite Administrator Ramirez's Administrator's certificate is currently pending review. Administrator Tracy Langendoen has an active Administrator's certificate. The facility currently has 12 residents in care receiving hospice services; which is within their Hospice Waiver limit. MEDICATION: Two of three medication carts were inspected. Medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be organized, safe, locked, and inaccessible to residents in care. PRN Authorization letters were observed on file. Centrally Stored Medication and Destruction Records were observed on file. This report was reviewed with Onsite Administrator Ramirez and a copy was provided, along with the LIC 811, LIC 9098 and instructions on appeal rights.the state’s words, verbatim · CDSS document, Jul 26, 2024

Type of visit: Case Management - Deficiencies

On 1/25/2024, Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit for a separate unrelated matter. LPA met with Medical Technican, Judine Ramirez, who was informed of the purpose of the visit. During the visit, LPA conducted conducted a walk through and conducted records reviews. LPA requested resident records and was informed both individuals with access to the files were not on the premises and could not provide the files to the LPA. A plan of correction was created with the staff and documented on deficiency page. A health and safety check was conducted on the facility residents. No immediate health or safety concerns were observed during the visit. An exit interview was conducted with Medical Technican, Judine Ramirez, where this report along with appeal rights and deficiency pages were reviewed and provided to them.the state’s words, verbatim · CDSS document, Jan 25, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jan 31, 2024

(a) The licensee shall ensure that a...record is maintained for each resident in the facility or in a central administrative location readily available...to licensing agency staff. This requirment was not met as evidenced by: Based on interview, the facility did not have file for R1 readily avaible for licensing review. This poses a potential health, saftey or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: The administrator agreed over the phone to send the documents to the LPA's email by the POC due date.

Allegation investigated: Facility staff are not ensuring that resident has access to a phone while in care.

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit to conclude and deliver findings to an investigation regarding the allegation listed above. LPA was granted entry and met with Buisness Office Manager Ashlee Theus. The allegation was investigated and consisted of observation, interviews, and record review. Regarding the allegation “Facility staff are not ensuring that resident has access to a phone while in care”, it was alleged a telephone is not accessible to Resident One (R1) who is bedridden. LPA conducted an interview with Business Office Manager Ashlee Theus regarding residents’ accessibility to a telephone at the facility. Theus stated there is a telephone accessible to every resident in each villa at the facility. Residents who do not have a cellphone with an ambulatory status of bedridden can request to use the administrative staffs’ cellphone while on duty to make outgoing calls or receive calls. Unsubstantiated Reporting Party (RP) stated they tried multiple times to contact R1 via telephone and whenever RP called the facility requesting to speak to R1, a staff member would inform RP that Theus was not available and to call back later in the day when Theus is at the facility so they could speak to R1. Interview with R1 revealed if they requested a telephone to make or receive a phone call, staff would make a telephone accessible for R1. During LPA’s initial visit on 12/27/23, LPA observed a working telephone accessible to residents in each villa and a telephone available for use in the front office. LPA called the facility on 01/03/2024 and LPA spoke to Executive Director Diana Ramirez. LPA requested to speak to R1 and Ramirez informed LPA that R1 is bedridden and LPA would need to call Ramirez’s cellphone to communicate with R1. Ramirez gave LPA their cellphone number so R1 could have access to a telephone while in care. Therefore, based on interviews, record review, and observations, the allegation “Facility staff are not ensuring that resident has access to a phone while in care” has been deemed UNSUBSTANTIATED at this time. A finding that the allegation(s) are unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. An exit interview was conducted where a copy of this report was discussed and provided to Theus, along with a copy of LIC811-Confidential Names.the state’s words, verbatim · CDSS document, Jan 23, 2024 · control 18-AS-20231219181442