Corona Residential Care Center

Allegation investigated: Staff did not administer medication as prescribed.

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegation listed above. LPA met with Assistant Administrator Mary Gonzalez and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews, a medication audit, and a records review. For the allegation, Staff did not administer medication as prescribed: During staff interviews, three out of three staff members confirmed that they did not administer R1’s medication as prescribed. In addition, two out of the three staff stated they were unaware that R1’s medication required a refill. During resident interviews, four out of seven residents stated that medication is not always administered on time and that staff members sometimes forget. LPA also conducted interviews with outside agencies involved with R1, which indicated that R1’s test results showed medication was not detected. Substantiated During the medication audit, LPA Rico observed three loose pills inside the medication carts and noted that staff had documented that R1 received medication even though the facility did not have the medication available. Staff members were unable to identify which resident the loose pills belonged to. Based on the evidence gathered during today’s investigation, the allegation listed above is deemed SUBSTANTIATED. A finding of SUBSTANTIATED means the allegation is valid because the preponderance of evidence standard has been met. During today’s visit, one (1) deficiency was cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D were discussed and provided to Assistant Administrator Mary Gonzalez, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, May 22, 2026 · control 56-AS-20251212130158

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(4) · Plan of correction due date: May 22, 2026

87465(4) Incidental Medical and Dental Care (4) The licensee shall assist residents with self-administered medications as needed. This requirement wasn't met as evidenced by: Based on interviews, record review, and medication audit, which poses an immediate health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, May 22, 2026

Plan of correction: The Administrator has agreed to conduct an in-service training on medication to staff. A copy will be provided to LPA Rico. POC due date 5/26/2026

Allegation investigated: Staff did not ensure medications were inaccessible to residents. Staff yelled at residents. Staff did not ensure the facility was kept clean.

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced complaint visit to initiate and deliver findings regarding the above-mentioned complaint allegations. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Assistant Administrator Mary Gonzalez. On March 6, 2026, it was alleged that staff did not ensure medications were inaccessible to residents, staff yelled at residents, and staff did not ensure the facility was kept clean. According to the allegations received, residents who self-administer their medications were storing their medications under their bed and leaving them accessible to other residents, staff yelled at residents in front of everyone, and staff did not clean residents’ bedrooms. The Department’s investigation consisted of an unannounced facility visit, LPA observations, records review, and staff and resident interviews. [CONTINUED ON LIC9099-C] Unsubstantiated Interviews and review of facility records revealed three (3) residents who are capable of storing and administering their own medications. During LPA’s visit on March 12, 2026, LPA inspected a sample of resident bedrooms, including those who store and administer their own medications. LPA did not observe accessible medications, LPA observed residents’ who stored their own medications to have their medications locked in their closets and inaccessible to other residents. Interviews with residents, staff and LPA’s observations did not reveal that residents’ bedrooms were not cleaned. Interviews with residents and staff did not reveal that staff yell at residents. Based on LPA observations, interviews, and record review, the investigation did not yield a preponderance of evidence to conclude that staff did not ensure medications were inaccessible to residents, staff yelled at residents, and staff did not ensure the facility was kept clean. Based on the foregoing, the allegations are unsubstantiated. These findings mean that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Assistant Administrator Mary Gonzalez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Mar 12, 2026 · control 56-AS-20260306133236

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Hannah Rodgers conducted an announced case management visit to follow up on an incident observed during a complaint visit that is unrelated to the complaint allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Assistant Administrator Mary Gonzalez. During the unrelated complaint visit, LPA observed a resident with a fracture boot on their right ankle. On October 20, 2025, the Department received an incident report that described that on October 16, 2025, R1 requested to be sent out to the hospital and was diagnosed with a right leg fracture. During today’s visit, LPA briefly toured the facility, observed residents in care, reviewed and obtained copies of facility records, and interviewed staff and residents. There were no deficiencies cited during today's visit. However, this incident may require further follow-up visits. An exit interview was conducted with Assistant Administrator Mary Gonzalez, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to.the state’s words, verbatim · CDSS document, Mar 12, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Assistant Administrator Mary Gonzalez. The facility's license shows a maximum capacity of one hundred twenty-five (125) non-ambulatory residents. Hospice waiver for ten (10). During today’s inspection there were ninety-one (91) residents in care. LPA with Assistant Administrator Gonzalez toured the interior and exterior of the facility and inspected a sample of rooms. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were stored in locked areas. LPA observed multiple prescription labels with writing. Interviews revealed that facility staff write the start date of the medications on the prescription labels. No pools or bodies of water exist on the premises. Per Assistant Administrator Gonzalez, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. One deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A plan of correction was jointly formulated, and an exit interview was conducted with Assistant Administrator Mary Gonzalez, to whom a copy of this report, LIC809-C, LIC809-D and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.the state’s words, verbatim · CDSS document, Oct 24, 2025

Allegation investigated: Staff are not providing adequate care and supervision of a resident.

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver the findings on the allegation listed above. LPA met with Assisted Living Coordinator Sonia Hernandez and explained the purpose of today’s visit. The investigation consisted of staff interviews, resident interviews and record review. For the allegation, Staff are not providing adequate care and supervision of a resident. During staff interviews, 5 out of the 5 staff stated they provide adequate care and supervision for residents. During resident interviews 7 out of the 7 residents stated they receive assistance with care and supervision. Based on the evidence found during the investigation, the one (1) allegation listed above are deemed UNSUBSTANTIATED. A finding that the complaint are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Assisted Living Coordinator Sonia Hernandez. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 8, 2025 · control 56-AS-20250702145624

Allegation investigated: Staff neglect resulted in a resident to be hospitalized. Staff is over medicating a resident.

On 05/29/2025 at 03:00 PM, Licensing Program Analyst (LPA), Melody Brown, met with Assistant Administrator Mary Gonzalez at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) San Bernardino (SB) Regional Office to deliver the complaint investigation findings for the above allegations. After introducing and identifying self, LPA Brown met Assistant Administrator Mary Gonzalez and explained the purpose of the requested Office Visit. The investigation was conducted by LPA Melody Brown. The investigation consisted of file review and interviews with relevant parties. The first allegation indicates staff neglect resulted in a resident to be hospitalized. During the investigation, LPA Brown was not able to obtain sufficient evidence to support that staff neglect resulted in a resident to be hospitalized. LPA Brown unable to interview Resident #1 (R1) as R1 moved out at the facility on 10/01/2025. Interview with seven (7) of seven (7) residents indicated that staff at the facility are checking on them multiple times in a day. Staff interviewed reported that they are checking on all their residents every two (2) hours, ***Continuation in LIC9099C*** Unsubstantiated every hour or every 30 minutes. Six (6) of six (6) staff interviewed revealed that they are checking on R1 at least every two (2) hours or more often if needed. All staff interviewed denied that R1 was neglected. Interview with Staff #1 (S1) indicated that R1 was sent out to the hospital in 09/12/2024 due to shortness of breath and mumbling words. Medical Records review revealed that the facility sent out R1 to the hospital after a staff observed R1 change of condition. Moreover, R1 was treated at the hospital for complaints and symptoms that are not keeping R1 with R1 overall wellness and condition. R1 was discharged to skilled nursing facility for continuation of care. In addition, records review revealed that on 06/23/24, R1 was diagnosed and being treated for a medical condition that can cause skin breakdown with possible bleeding in R1 lower extremity. It was noted that R1 has monthly follow-up appointments with R1 physician. The second allegation indicates staff is over medicating a resident. During the investigation, LPA Brown did not find any evidence to corroborate the allegation. LPA Brown was unable to interview R1 due to resident no longer living at the facility. Interview with seven (7) residents indicated that staffs are dispensing their medications as prescribed and there's no incident that staff over medicated a resident. Six (6) staff interviewed reported they have not witnessed or heard of an incident that a staff over medicating a resident. Two (2) Medication Technician (MedTech) staffs added that they are utilizing electronic Medication Administration Record (MAR) to ensure that they are giving the residents medications as prescribed. Both MedTechs denied over medicating R1. LPA Brown reviewed R1’s MAR and confirmed that staffs are dispensing R1's medications per R1’s physician orders and there was no evidence that staff overmedicated R1. Based on the evidence, the allegation that Staff neglect resulted in a resident to be hospitalized (Allegation #1), and Staff is over medicating a resident (Allegation #2) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report, LIC9099, was discussed and provided to Assistant Administrator Mary Gonzalez.the state’s words, verbatim · CDSS document, May 29, 2025 · control 56-AS-20240912101826

Type of visit: Case Management - Deficiencies

On 05/29/2025 at 03:00 PM, Licensing Program Analyst (LPA), Melody Brown, met with Assistant Administrator Mary Gonzalez at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) San Bernardino (SB) Regional Office to initiate a case management deficiency. The investigation consisted of observation, interviews ,and a review of pertinent documentation. During Department staff investigation, the discrepancies were noted regarding the dates of Resident #1 (R1) fall which caused the ankle injury: the facility incident report stating it occurred on 7/25/2023; R1's primary physician records appearing to state it occurred on 7/23/2023; and the report by the orthopedic physician's assistant stating the injury occurred on 7/21/2023. Moreover, Department staff records review indicated that R1 went to the Emergency Room (ER) on 7/25/2023 which is multiple days after R1 fell out of R1’s wheelchair and an apparent delay in seeking medical attention. During the Office Visit today, 05/29/2025, Assistant Administrator Gonzalez was informed that deficiency will be issued. An exit interview was conducted where this report (LIC809), LIC809D) and Appeal Rights were discussed and provided to Assistant Administrator Mary Gonzalez.the state’s words, verbatim · CDSS document, May 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 30, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more...This requirement was not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not ensuring that staff seek immediate medical attention for Resident #1 (R1) after a fall which pose immediate health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: Licensee stated to train all staff on CCR 87411(a) and submit proof of all staff training log to LPA Brown by the Plan of Correction (POC) due date.

Allegation investigated: Staff did not ensure that a resident received medical and dental services.

On 05/20/2025, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to deliver complaint investigation findings for the above allegation. After introducing and identifying self, LPA Brown met Assistant Administrator Mary Gonzalez to discuss the findings. The investigation was conducted by LPA Melody Brown. The investigation consisted of file review and interviews with relevant parties. The allegation indicates that staff did not ensure that a resident received medical and dental services. LPA Brown obtained evidence to corroborate the allegation. Interview with Resident #1 (R1) on 12/30/2024 indicated that since R1 moved in at the facility in 2017, R1 did not see a dentist or have an appointment with a dentist. in addition R1 stated that R1 has an upcoming dentist appointment scheduled on 01/23/2025 which is R1 first dentist appointment since moving in at the facility in 2017. Interview with R1 Public Guardian confirmed that R1 has not seen a dentist since moving in at the facility in 2017 and discussed R1 unmet dental care needs to the facility on 12/2024. **Cont. in LIC9099C** Substantiated Interview with six (6) of eight (8) residents revealed that they are not receiving dental services as they were not informed that they can see a dentist and they were never provided assistance to make an appointment to see a dentist since they moved in at the facility. On 12/30/2024, Staff #1 (S1) informed LPA Brown that R1's Health Insurance requires them to set-up their own appointment that's why R1 has not seen a dentist since moving in in 2017. Moreover, Staff #7 (S7) reported that when R1 has a dental appointment scheduled, R1 will not go to the scheduled appointment but there was no documentation available to prove that R1 refused to go to R1's scheduled appointment. In addition, records review revealed that R1 has a mental health condition that makes R1 unable to advocate and decide for own medical and dental care and although the facility has a plan that encourage and provide assistance in medical care to R1, LPA Brown noted that the facility does not have a plan to encourage routine dental care and provide assistance in obtaining such care to meet R1 needs. Overall, the preponderance of evidence supports that staff did not ensure that a resident received dental services. It was found that R1 was diagnosed to have mental health condition that makes R1 unable to advocate and decide for own medical and dental care and there is lack of support to identify that the facility has a plan to encourage routine dental care and provide assistance in obtaining such care to meet R1 needs. As a result, R1 was not able to receive dental services since moving in at the facility in 2017 and investigations revealed that on 01/23/2025 was R1 first dentist appointment since moving in at the facility in 2017 after R1 Public Guardian reported to the facility R1 unmet dental care needs. The above allegation is found to be SUBSTANTIATED. A deficiency is being issued per California Code of Regulations, Title 22. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met. An exit interview was conducted where this report, LIC9099, LIC9099D, and Appeal Rights were discussed and provided to Assistant Administrator Mary Gonzalez.the state’s words, verbatim · CDSS document, May 20, 2025 · control 56-AS-20241223134640

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: May 27, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by... The plan shall encourage routine medical and dental care and provide for assistance...(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs...This requirement was not met as evidenced by: Based upon interviews and records review, R1 did not receive dental care since moving in at the facility on 2017 nor R1 assisted with receiving dental care as needed due to R1 mental health condition which pose a potential health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: Licensee stated to train all staff on CCR 87465(a)(1) and submit proof to LPA Brown by the Plan of Correctio (POC) due date. Licensee stated that R1 had a dentist appointment on 01/23/2025.

Allegation investigated: Staff did not reappraise resident as necessary. Facility did not have enough staff to meet the needs of resident in care.

On 05/29/2025 at 03:00 PM, Licensing Program Analyst (LPA), Melody Brown, met with Assistant Administrator Mary Gonzalez at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) San Bernardino (SB) Regional Office to amend the complaint investigation findings for the above allegations delivered on 05/20/2025.LPA Brown explained the purpose of the requested Office Visit to Assistant Administrator Gonzalez. After introducing and identifying self, LPA Brown met Assistant Administrator Mary Gonzalez to discuss the findings. The investigation was conducted by Department staff. The investigation consisted of file review and interviews with relevant parties. The first allegation indicates staff did not reappraise resident as necessary. The Department staff investigation revealed that Resident #1 (R1) had an ankle fracture suffered in 07/2023 after R1 fell out of R1's wheelchair. ***Continuation in LIC9099C*** ***This is an amended report for the Complaint Investigation Report (LIC9099) issued on 05/20/2025*** Unsubstantiated Therefore, based on the evidence obtained during the Department's investigation, the allegation of resident died due to staff neglect is UNSUBSTANTIATED at this time. Although the allegation resident died due to staff neglect may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted where this report (LIC9099), was discussed and provided to Assistant Administrator Mary Gonzalez. Medical records review dated 7/25/2023 confirmed R1 diagnosis and treatment of a fractured ankle. In addition, Department staff investigation revealed that R1 was placed in a splint and R1 physician requested skilled nursing placement on 07/28/2023. The Department staff investigation indicated that reappraisal was not required for R1 as staff at the facility reported the incident to R1's physician and requested for R1 to be seen after R1's fall. The second allegation indicates facility did not have enough staff to meet the needs of resident in care. The Department staff interview with Staff #1 (S1) confirmed that R1 needs two-person transfer. Department staff reviewed R1 Individual Service Plan (ISP) completed on 9/26/2023 for the Assisted Living Waiver Program (ALW) stating R1 has a history of falling, uses a wheelchair and needs two-person transfer. Department staff investigations revealed that on 01/17/2024, R1's call light was on and S3 had gone to R1's room alone for assistance and arrived at the doorway to enter the room and heard R1 say, "diaper change" and could see R1 already moving to a standing position from R1's wheelchair and fell to the floor. S3 reported to Department staff that S3 had no time to try to catch or grab R1. Though the Department staff investigation revealed that it was only S3 who responded to R1's call light that resulted to R1's fall as R1's assigned caregiver Staff #4 (S4) was on lunch break, there was no indication that S3 attempted to assist and transfer R1. In addition, interview with S3 indicated that the incident happened so quickly that S3 did not even have time to put rubber gloves on. Department staff investigations revealed that S3 did not attempt to assist or transfer R1 as S3 reported knowing that R1 needs two-person assist. The Department staff interview with S2 indicated that S3 called for a Medication Technician (MedTech) to help with an emergency in R1's room and asked for 911 to be called after R1's fall and S2 did not provide information that S3 attempted to assist or transfer R1. Therefore, based on the evidence obtained during the Department staff investigation, the allegation of staff did not reappraise resident as necessary (Allegation #1), and facility did not have enough staff to meet the needs of resident in care (Allegation #2) are UNSUBSTANTIATED at this time. Although the allegation staff did not reappraise resident as necessary (Allegation #1) and facility did not have enough staff to meet the needs of resident in care (Allegation #2) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted where this report (LIC9099) was discussed and provided to Assistant Administrator Mary Gonzalez. ***This is an amended report for the LIC9099 report issued on 05/20/2025***the state’s words, verbatim · CDSS document, May 20, 2025 · control 56-AS-20240213165029

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: May 21, 2025

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs...This requirement was not met as evidenced by: Based on interview and records review, R1 sustained ankle fracture at facility which were not observed nor was R1 assisted with receiving care as needed which pose immediate health, safety, and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: Licensee stated to train all staff on CCR 87466 and submit proof of all staff training log to LPA Brown by the Plan of Correction (POC) due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 21, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient...This requirement was not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not ensuring that there are sufficient number of staffs to provide the services necesary to R1 needs which poses an immediate health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: Licensee stated to submit Personnel Report/Staff Schedule showing sufficient number of staffs working at the facility to provide the services necessary to meet residents that require two person assist and two person transfer to LPA Brown by the POC due date.

Type of visit: Required - 1 Year

On 10/29/2024 at 12:50 PM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. Assistant Administrator Mary Gonzalez was informed of the visit and met with LPA Brown. At the time of the visit there were 90 residents present. The facility is a seventy-five bedroom and eighty (80) bathrooms with a kitchen/dining area, living room, beauty shop, laundry room. The facility is a Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of one hundred twenty-five (125) non-ambulatory residents and with an approved hospice waiver for ten (10) and the current census is 90 residents. LPA Brown was accompanied by Assistant Administrator Mary Gonzalez to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean with a water temperature of 107 degrees Fahrenheit and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide detectors were observed. Fire extinguishers were also observed at the facility. Posters such as personal rights, ombudsman poster, labor laws, and the disaster plan were posted in a common area. However, LPA Brown did not observe the CCLD complaint poster. Technical Violation will be issued. During the visit, Assistant Administrator Gonzalez posted the required CCLD poster. LPA Brown tested the call button/pull cord on five (5) residents room and observed the call button/pull cord in good working condition. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. ***Continuation in LIC809C *** There is a Medicine Room with the resident’s medications locked. LPA Brown observed complete first aid kit with first aid book maintained at the facility. During the tour of the facility, LPA Brown observed Resident #5 (R5) and Resident #6 (R6) with half bed rail but no written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. However, LPA Brown observed two (2) kitchen staff - Staff #6 (S6) and Staff #7 (S7) with expired food handler certification. Deficiency will be issued. Care & Supervision: The facility has a certified Administrator present during the visit with the required hours to effectively manage the facility. The facility has a sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA Brown reviewed five (5) resident files for admission agreements, physician reports, pre-placement appraisals, Centrally Stored Medication List, and Preplacements Needs and Services plans/Care Plan. LPA Brown observed that Resident #3 (R3) does not have a completed Pre-Admission Appraisal. Deficiency will be issued. Also, LPA Brown observed that Resident #1 (R1), Resident #2 (R2) and Resident #5 (R5) do not have the required Preplacement Needs and Services Plan/Care Plan. Deficiency will be issued. Moreover, LPA Brown observed Resident #2 (R2) Physician Report was incomplete because it does not have the required physician signature date. Deficiency will be issued. Furthermore, LPA Brown observed Resident #5 (R5) Admission Agreement was not signed by the Licensee/Administrator/Designee. Deficiency will be issued. LPA Brown reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown observed that files reviewed were complete. During medication audit, LPA Brown observed that staffs at the facility did not assist Resident #1 (R1) and Resident #4 (R4) with their two (2) medications. Deficiency will be issued. Per records review, the facility were cited for the same regulations within 12-month period for California Code of Regulation (CCR) 87465(a)(4) and civil penalty will be issued today, 10/28/2024 with the amount of $1,000.00 for third offense within 12-month period. ***Continuation in LIC809C*** Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), LIC809D, LIC9102, LIC421IM and Appeal Rights were discussed and provided to Assistant Administrator Mary Gonzalez.the state’s words, verbatim · CDSS document, Oct 29, 2024

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Staff is financially abusing residents in care.

Licensing Program Analysts (LPAs) Beena Singh and Paola Guerrero conducted an unannounced visit to this facility for the purpose of delivering findings for the above allegation. For Allegation, Staff is financially abusing residents in care. During interviews with residents, 5 out of 5 residents denied being financially abused by staff or staff managing residents’ finances. LPA conducted an interview with Resident #1 who reported to LPA that resident has possession of debit card and denied staff managing their finances or having possession of debit card. Based on the evidence found during the investigation, LPA Beena Singh found the allegation listed above to be Unsubstantiated. Unsubstantiated: A finding that the complaints are Unsubstantiated means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Administrator Assistant Maria "Mary" Gonzalez. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 21, 2024 · control 56-AS-20240923101716

Allegation investigated: Licensee does not ensure that facility grounds are free from hazards to residents in care. Staff did not adequately supervise resident in care resulting in resident sustaining an injury while in care. Staff did not provide assistance to resident in a timely manner.

On 12/30/2024 at 09:15 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility to amend the report issued on 09/22/2024 regarding the findings of the above allegations. LPA Brown explained the purpose of the visit to a staff. Staff contacted Assistant Administrator Mary Gonzalez and informed of the visit. LPA Brown explained the purpose of the visit to Assistant Administrator Mary Gonzalez. The investigation consisted of file review, interviews with staffs and residents as well as observation. The investigation was conducted by LPA Brown. The investigation consisted of file review and interviews with relevant parties. The first allegation indicates Licensee does not ensure that facility grounds are free from hazards to residents in care. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with seven (7) of seven (7) residents indicated that staffs at the facility ensure that the facility grounds are free from hazards and ***Continuation in LIC9099C*** **This an amended Complaint Investigation Report (LIC9099) that was issued on 09/22/2024*** Unsubstantiated there's no incident that the staffs at the facility did not ensure that the the facility grounds/backyard/ courtyard are free from hazards. LPA Brown unable to interview three (3) residents as Resident #1 (R1) passed away on 12/29/2023, and Resident #7 (R7) and Resident #9 (R) were sleeping. Interviews with nine (9) of nine (9) staffs indicated that they all ensure that the facility grounds/backyard/courtyard are free from hazards to residents. Interviews with nine (9) of nine (9) staffs revealed that no incident happened at the facility that they did not make sure that the facility grounds/backyard and courtyard are free from hazards. Six (6) of six (6) staffs interviewed stated that no incident happened at the facility that they did not ensure that the facility grounds/ backyard/courtyard are free from hazards to R1. Moreover, all staff interviewed reported that the facility grounds/backyard/courtyard were always maintained clean. During the facility visit on 11/30/2023 and 07/30/2024, LPA Brown observed the facility grounds/backyard/courtyard are free from hazards to residents and no potholes observed. The second allegation indicates that Staff did not adequately supervise resident in care resulting in resident sustaining an injury while in care. Interviews with seven (7) of seven residents indicated that staffs at the facility are checking on them multiple times in a day. Seven (7) of seven (7) residents interviewed reported that staffs at the facility always checks on them and there's no incident that staffs at the facility did not check on them. LPA Brown unable to interview three (3) residents as R1 passed away on 12/29/2023, and R7 and R9 were sleeping. Interviews with nine (9) of nine (9) staffs indicated that they are checking on their residents every two (2) hours, more frequent if needed. Interviews with five (5) of six (6) staffs indicated that on 09/08/2023, staffs at the facility adequately supervise R1 and they all reported that R1 has a habit of arriving late at the facility after a night out with friends as during that time, R1 has his own vehicle which R1 parks at the facility back alley way. Interview with Staff #8 (S8) indicated that S8 was working at the facility on 09/08/2023 and S8 was informed by a skilled nursing staff that a resident was at the back alley of the facility and they both approached the resident observed and S8 stated that it was R1 that was at the back alley of the facility at around 12:00 AM. Moreover, S8 stated that S8 checked on R1 and R1 said that R1 wants to stay at the back alley and refused to go back to R1's room. S8 added that S8 checked back on R1 at around 01:30 AM and saw R1 fell from R1's motorized wheelchair and S8 immediately attended to R1 and S8 contacted Staff #9 (S9) for assistance to help R1 back on R1's motorized wheelchair. S8 stated that they observed bruises on R1 and informed R1 that they have to checked R1's bruises but R1 refused with aggressive and combative behavior and that's when S9 called the paramedics for R1. Interview with S9 indicated that S9 was working at the facility on 09/08/2023 and S9 reported that S9 assisted S8 to transfer R1 back on R1's motorized wheelchair and they both observed bruises on R1 and informed R1 that they have to checked R1's bruises but R1 refused with aggressive and combative behavior. Interviews with S8 and S9 revealed that due to R1's observed bruises, *Continuation in LIC9099C*** they called for medical emergency for appropriate medical care. During the facility visit on 11/30/2023 and 07/30/2024, LPA Brown observed staffs at the facility are adequately supervising their residents as LPA Brown noted that staffs are checking on their residents on their scheduled rounds of at least every two (2) hours. The third allegation indicates that staff did not provide assistance to resident in a timely manner. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with seven (7) of seven residents indicated that all staffs at the facility are assisting them in a timely manner. Interviews with seven (7) of seven (7) residents revealed that staffs at the facility are always ready to help them and it takes about five (5) minutes for a staff to arrive and the longest would be ten (10) minutes. LPA Brown unable to interview three (3) residents as R1 passed away on 12/29/2023, and R7 and R9 were sleeping. Interviews with nine (9) of nine (9) staffs indicated that they all provide assistance to all the residents at the facility in a timely manner. Seven (7) of seven (7) staffs interviewed reported that it usually takes them three (3) to five minutes to assist a resident. Five (5) of six (6) staffs interviewed revealed that there's no incident that happened at the facility that a staff did not provide assistance to R1 in a timely manner. Interview with S8 indicated that when S8 saw R1 fell from R1's motorized wheelchair on 09/08/2023, S8 immediately attended to R1 and contacted S9 for assistance to help R1 transfer back to R1's wheelchair. S8 stated that they observed bruises on R1 and informed R1 that they have to check R1's bruises but R1 refused their assistance with aggressive and combative behavior and that's when S9 called the paramedics for R1. Interview with S9 confirmed that S9 helped S8 transfer back R1 to R1' s motorized wheelchair and both S8 and S9 reported to LPA Brown that R1 refused their help to check and assess R1's bruises and S8 and S9 both stated that R1 exhibited aggressive and combative behavior on 09/08/2023. Interview with S8 and S9 revealed that they both observed that R1 sustained bruises on R1's fall, and they promptly contacted medical emergency for appropriate medical treatment to R1. During the facility visit on 07/30/2024, LPA Brown observed that staffs at the facility are assisting residents at the facility in a timely manner as it took them two (2) to three (3) minutes to arrive at a resident room when pressing residents pull cord. Based on the evidence, the allegations that Licensee does not ensure that facility grounds are free from hazards to residents in care (Allegation #1), Staff did not adequately supervise resident in care resulting in resident sustaining an injury while in care (Allegation #2), and Staff did not provide assistance to resident in a timely manner (Allegation #3) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Assistant Administrator Mary Gonzalez. as prescribed by R1 physician as evidenced of R1's 11/2023 electronic MAR showed multiple medications were not given to R1 on multiple days as LPA Brown observed blank entry on R1's MAR and staffs at the facility did not indicate why R1's medications were not given per R1's physician's directions. In addition, per R1's MAR review, LPA Brown noted seven (7) of R1's medications were recorded by a staff as unknown. In addition, during the facility visit on 09/16/2024, LPAs Brown and Howell-Small inquired to Staff #1 why R1's 11/2023 electronic MAR have multiple days blank entries per R1's eMAR Review and why seven (7) medication were recorded by a staff as unknown, and S1 informed LPAs Brown and Howell-Small that S1 will review R1's 11/2023 electronic MAR to provide the requested information. On 09/18/2024, LPA Brown received an email message from S1 with new R1 11/2023 MAR attachment and indicated that the attached R1's electronic MAR was given to previous LPA of the facility and no other explanation provided. LPA Brown reviewed R1's new 11/2023 electronic MAR received, the observed multiple days with blank entries from R1's 11/2023 electronic MAR received on 07/30/2024 now has handwritten entries of staffs initials. LPA Brown noted that the facility was utilizing electronic MAR on R1's 11/2023 MAR and on 09/18/2024, R1's 11/2023 electronic MAR was observed with staffs handwritten initials. Also, the reported R1's seven (7) medications were still recorded by a staff as unknown in new R1's 11/2023 MAR received on 09/18/2024. Furthermore, during the visit today, Staff #3 (S3) reported to LPA Brown that the blank entries on R1's 11/2023 electronic MAR's unacceptable and also added that the handwritten initials in R1's 11/2023 electronic MAR is not S3's handwriting. Based on LPA Brown’s observations and records review, the preponderance of evidence standard has been met, and therefore the above allegation of Staff do not ensure that resident is administered their medication(s) as prescribed while in care is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC9099D. Furthermore, LPA Brown reviewed compliance history and observed that the facility was issued the same deficiency 87465 Incidental Medical and Dental Care (a)(4) for not assisting residents with self administered medications on 04/15/2024. Civil Penalty was assessed for repeat violation within a 12-month period with the amount of $250.00 per citation and will continue to be assessed of $100.00 per day per citation until corrected. ***Continuation on LIC9099C*** An exit interview was conducted with MedTech/Caregiver Marco Navarro where a copy of this report, (LIC 9099) along with LIC9099D, LIC421FC and Appeal Rights were discussed and provided.the state’s words, verbatim · CDSS document, Sep 22, 2024 · control 56-AS-20231122161045

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 23, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... (4) The licensee shall assist residents with self-administered medications... This requirement is not met as evidenced by:Based on interview and records review, the Licensee did not comply with the section cited above by not ensuring that staff are providing the required medication assistance to Resident #1 (R1) as prescribed by R1 physician which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 22, 2024

Plan of correction: Licensee has agreed to conduct Medication Training on CCR 87465(a)(4) to all staffs dispensing medications to residents and submit proof to LPA Brown on Plan of Correction (POC) due date.

Allegation investigated: Resident sustained a fall due to obstructions in the hallway Facility staff not appropriately assisting resident with meals Staff using inappropriate language with resident

Licensing Program Analyst (LPA), Yolanda Delgado made an unannounced visit to the facility to deliver findings for a complaint investigation into the allegations listed above. During the investigation, LPA interviewed eight (8) staff members and ten (10) residents. LPA reviewed pertinent documents pertaining to the allegations. On February 23, 2021, Community Care Licensing received a complaint alleging resident sustained a fall due to obstructions in the hallway, facility staff not appropriately assisting resident with meals, and staff is using inappropriate language with resident. Regarding the allegation that Resident #1 (RI) sustained a fall due to an obstruction in the hallway. (Continued on Page 2) Unsubstantiated (Continued from Page 1) It was reported that R1 fell in July 2020 because staff left walkers and wheelchairs in the hallway. It was reported that R1 roams the facility at night. During that time, the lights in the facility are low and R1 tripped over a walker. It was stated that R1 reported the fall to staff and S2 asked R1 if they would like to be sent out to the hospital. It was reported that R1 refused, but was later evaluated and there were no injuries. Information obtained from interviews with staff and residents stated residents that use a walker or wheelchair, store their devices in their rooms. Regarding the allegation that the facility staff did not appropriately assist resident with meals, it was reported during COVID, the facility served meals to the residents’ rooms. It was reported that R1 was not provided meals unless they asked. Information obtained from interviews with residents denied that facility staff did not feed them or assist with meals. Interviews with staff also denied the allegation. It was stated that residents were always provided meals. It was further advised that with the process of passing out meal trays, the facility incorporated the use of walk talkies to be able to communicate with kitchen staff to bring additional or different food trays. Facility Administration completed in-service training dated on February 23, 2021 regarding food service. Due to the allegation, the facility did complete their own investigation, in which three staff were interviewed. It was stated that during one feeding, one of the staff had to move with the cart out of the way to let another resident pass. When R1 opened their door, R1 seen the staff moving, R1 got upset. R1 was still provided their meal. Administration met with R1 to discuss R1’s concerns and explain the incident, however R1 became upset with Administrator during the discussion. Administrator apologize for the confusion. Regarding the allegation that staff are using inappropriate language with residents, it was reported that Staff (S1), Administrator stated to R1, “We are going to make sure you get your damn juice.” LPA conducted interviews with staff and it was revealed that S1 was not on shift on the day R1 stated the allegation occurred. LPA also conducted interviews with residents and the interviews did not reveal that any residents had been inappropriately spoken to by S1 or any other staff. (Continued on Page 3) (Continued from Page 2) Based on LPAs observations and interviews, the preponderance of evidence standard has not been met. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations is unsubstantiated. An exit interview was conducted, and a copy of this report was provided along with LIC811 – Confidential Names List.the state’s words, verbatim · CDSS document, Aug 6, 2024 · control 18-AS-20210223101326

Allegation investigated: Staff spoke to residents in an inappropriate manner.

Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility for the purpose of initiating an investigation and delivering findings for the above complaint allegation. LPA met Administrator Assistant Maria "Mary" Gonzalez and explained the reason for the visit. During today’s visit, LPA interviewed residents and interviewed staff. For allegation, Staff spoke to residents in an inappropriate manner: During interviews with the residents, it was revealed that the residents are not spoken to in an inappropriate manner. The residents denied that the staff yelled at them. The residents denied witnessing other residents being yelled at by the staff. The residents stated that the staff at the facility are nice and are professional when they speak to the residents. The residents stated that the only time a staff would raise their voice to a resident is when a resident is having a hard time hearing. Unsubstantiated During interviews with the staff, the staff denied yelling at the residents. The staff denied witnessing other staff yelling at the residents. The staff stated that the only time a staff would raise their voice to the residents is if they were having a hard time hearing. When the voice is raised, there is not an aggressive tone, and it is done in way to help the resident hear the staff. Based on the evidence discovered during the investigation, the allegation listed above is deemed UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Administrator Assistant Maria "Mary" Gonzalez, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Apr 15, 2024 · control 56-AS-20240411144800

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct follow up case management visit on a self-reported incident regarding Resident R1 that occurred at the facility on 12/29/2023. LPA met with Administrator Assistant Maria “Mary” Gonzalez and was granted entry to the facility. LPA conducted an initial visit to the facility on 1/10/2024 to investigate the incident that occurred on 12/29/2023. During the investigation, LPA found through interviews with the staff and document review of R1’s MARs record that R1 was not given their medication from 12/28/2023 around 1PM to 12/29/2023 around 2 PM. The staff made thirteen (13) attempts to contact R1 to provide medication. These contacts included knocking on R1’s door, waiting outside R1’s door, and yelling R1’s name through the door. During these attempts, there was no attempt to open R1’s bedroom door until around thirteen (13) hours after the first contact attempt with R1 on 12/28/2023. The facility failed to ensure that R1 was assisted and provided with their medication during this time frame. Based on the investigation, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), LIC811, and LIC809D were discussed and provided to Administrator Assistant Maria “Mary” Gonzalez, along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Apr 15, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 16, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced based on interview and document review, the licensee did not comply with the section cited above evidenced by the staff not providing medication assistance to R1 which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 15, 2024

Plan of correction: The licensee has agreed to read regulation 87465 entirely and send LPA a statement of understanding that the regulation was read and understood. The licensee has agreed to conduct a medication training with the staff and send LPA proof of attendance by the POC due date. POC is due by 4/16/2024.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced case management visit to the facility and was met by Administrator Assistant Maria “Mary” Gonzales. Today’s visit was conducted to follow up on a self-reported incident regarding Resident R1 that occurred at the facility on 12/29/2023. During today’s visit, LPA interviewed staff and obtained documents relating to the incident. No deficiencies or citations were issued on this visit. An exit interview was conducted where this report (LIC809) and LIC811 were discussed and provided to Administrator Assistant Maria “Mary” Gonzales.the state’s words, verbatim · CDSS document, Jan 10, 2024