Abounding Peace Elderly Care

Allegation investigated: The facility allowed excluded individuals to work in the facility. Staff are forging resident documents.

On July 22 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct a follow-up investigation visit regarding the allegations noted above. LPA met with staff on duty, Deaja Malcolm (S3) and stated the purpose of the visit. LPA telephoned the administrator Unaisa Waqalala but she did not answer. LPA followed up with an email. Later she telephoned back at 4:45pm and arrived approximately 5:12pm. Present upon arrival were 6 residents with 1 staff on duty (S3). Allegation - The facility allowed excluded individuals to work in the facility: The investigation into this allegation consisted of interviews, observations, and record reviews. On February 19, 2026, LPA Villanueva interviewed 6 of 6 residents. When photos of the excluded individuals (E1 and E2) shown, 5 of 6 residents did not recognize or remember seeing them at the facility. {1 of 2} Unsubstantiated One of the residents stated they saw E1 about one year ago but could not remember the exact date. This resident explained that they saw E1 outside the facility picking up a trailer. During the visit, the LPA observed a trailer in the facility driveway. LPA also interviewed staff. One staff member stated they know E1 and E2 but had not seen them at this facility. This staff reported seeing E2 at another facility around April 2025 but could not remember the exact date. Other staff members confirming knowing E1 and E2 but stated they have not seen them at this facility since employment but seen them at other facilities a long time ago but could not estimate when. A review of the facility's LIC 500 Personnel Report showed that neither E1 nor E2 was listed as facility staff. In addition, during the LPA's visits on February 19, February 27, March 20, and July 17, 2026, neither E1 nor E2 was observed at the facility, and there were no reports confirming their presence. Based on the evidence gathered, there is not enough information to support the allegation that the facility allowed excluded individuals to work at the facility. Therefore, this allegation was unsubstantiated. ********************************************************************** Allegation - Staff are forging resident documents: The investigation into this allegation consisted of interviews and record verification. On July 17, 2026, LPA contacted the physicians' offices where each resident received their Medical Assessment (LIC 602A) to verify that the residents had been seen by the listed physicians. Five of the six residents were confirmed by the medical offices. For one resident, the information could not be fully verified because the clinic had a different last name and address on file, although the birth date matched. Therefore, the verification for that resident was inconclusive. Interviews with staff could not confirm whether staff, the administrator or anyone working at this facility, had forged resident documents. Based on the evidence gathered, there is not enough information to support the allegation that staff forging resident documents. Therefore, this allegation is unsubstantiated. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit interview was conducted with Unaisi Waqalala and a copy of this report and appeal rights were provided. {2 of 2} In one staff interview, the last time this staff seen the administrator at the facility was approximately one to two weeks earlier, around June 30, 2026. They stated the administrator comes to the facility about every two weeks and usually stays for up to two hours to complete a walkthrough, review paperwork, and perform other administrative duties. Another staff member stated that they report to another staff named Yelena Bigelow rather than to the administrator. According to this staff member, they have not seen the administrator since this staff only works part-time at this facility. Interviews with residents in care, some residents stated they did not know who the administrator was nor did they recognized the name Una (Administrator). Based on the administrator's documented work schedule, the administrator's absence during multiple LPA visits, statements from staff regarding the administrator's limited presence, and residents' inability to identify or confirm the presence of the administrator at the facility, the evidence supports the allegation that the administrator was not present at the facility for a sufficient amount of time. Therefore, the allegation is substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. Failure to correct will result in civil penalties. Plan of correction and appeals were discussed during the exit interview with Unaisi; and a copy of this report and appeal rights were provided to facility.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 27-AS-20260211123649

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Jul 30, 2026

The administrator…shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. This requirement is not met as evidenced by: Based on interviews, record reviews and observations, the administrator were not present during multiple LPA visits, the conflicting staff statements about how often the administrator is at the facility, and residents being unable to identify or recall seeing the administrator. This poses a potential health, safety, or personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: Per discussion, the administrator will start documenting their presence at the facility including the date, arrival time, departure time, and duties completed during each visit; will title it Administrator Visit Log. Administrator Visit Log from 7/22/26 to 7/29/26 will be submitted to the Department by POC due date.

Type of visit: POC

On July 22, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived at this facility unannounced to conduct a case management visit. This visit is being conducted concurrently with a complaint follow-up investigation visit (Complaint #27-AS-20260211123649). LPA met with staff on duty, Deaja Malcolm (S1) and stated the purpose of the visit. LPA telephoned the administrator Unaisa Waqalala (AD) but she did not answer. LPA followed up with an email. Later AD telephoned back at 4:45pm and arrived approximately 30 minutes later. During this visit, LPA conducted a facility observation. During the inspection of the side gates, LPA observed that one of the side gates (smaller) was not changed to a single-action gate latch. This was a cited deficiency during an annual inspection visit on July 17, 2026. Per Plan of Correction (POC), the licensee agreed to replace this lock by July 18, 2026. According to their submitted POC dated 7/18/2026, licensee indicated that they were going to replace the lock with “a single-action latch that allows residents and staff to exit quickly and safely during an emergency without requiring multiple steps to unlock the gate.“ Licensee also indicated that “Photo documentation of the completed correction will be submitted to Community Care Licensing by the POC due date” This was not received by POC due date. Additionally, the other gate (bigger one), LPA observed it to be locked with a padlock. According to the facility sketch titled “Emergency Exit Plan” both of these (smaller and bigger) gates are considered emergency exits. S1 was instructed to remove the padlock during this visit. AD stated she will meet with the maintenance tomorrow and assess. AD will request additional time tommorow if needed. Based on today's visit, deficiencies were cited. A civil penalty is being assessed today in the amount of $500 due to failure to correct the above deficiencies. Failure to correct will result in additional civil penalties. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 22, 2026

Type of visit: Required - 1 Year

On July 17, 2026, Licensing Program Analyst, Arvin Villanueva (LPA) arrived at this facility unannounced to conduct the annual inspection visit. LPA initially met with staff on duty, Shanice Downer (S1), and stated the purpose of the visit. The Administrator, Unaisi Waqalala (AD) was notified. AD is unable to be present during this visit. Per LIC500 dated June 6, 2026, AD is not scheduled today. Present during this visit were six (6) residents in care with one (1) staff on duty (S1). Overview: Facility is a one-story house located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents, up to 6 may be non-ambulatory. Facility currently has a hospice waiver for one. Facility does not have clearance for bedridden, delayed egress and locked interior/exterior parameter. Physical Inspection: Areas inspected include, but not limited to, the kitchen, dining, resident units/bedrooms, resident bathrooms, common areas and outdoor areas. The following were observed during inspection: The fire door was propped open with a door stopper during this visit (photo taken). The ceiling vent located in the hallway was full of dust that had accumulated (photo taken). For the exit side gate located left of the facility, it is equipped with the slide bolt lock or barrel bolt. This lock is located at the top of the gate where someone who is wheelchair bound would not be able to reach. Additionally, when this LPA attempted to unlock, it required LPA to lift the gate a little in order to slide the lock open. This may be difficult for some of their residents to open. This lock and how difficult it is to unlock is not appropriate in residential facilities (photo taken). The other side gate (bigger gate), LPA observed that it is not level to the latch so it cannot be properly locked. Additionally, LPA attempted to swing it open, and it requires a bit of a force to swing it open. Additionally, this gate is not equipped with a handle for residents to pull. The placement of the lock is also at the top of the gate where a resident who is a wheelchair bound may not be able to reach (photo taken). {1 of 2} Record Reviews: LPA reviewed three (3) staff files, six (6) resident files, and facility records. Review of resident files, including but not limited to, review of Admission Agreement, Physician Reports, Needs and Services Plan, and Ambulatory Status. LPA reviewed 2 of 4 resident medications. Per review, 6 of 6 residents did not have PRN Authorization Letters completed. At least one resident (R6) had inaccurate Medical Assessment (LIC602A). This was observed cooking in an oven from previous visit, smoking cigarette from previous visits and during this visit, and washing dishes during this visit. Per staff interview, R6 is able to independently shower and access hygiene items. Per review of LIC602A, R6 was assessed to be at risk if they have access to these items or near heating devices. Review staff files included, but not limited, background clearance, First Aid/CPR certificate, Health Screen, Initial Training. AD's administrator certificate expired on July 8, 2026. Per review of this website on this day: https://www.cdss.ca.gov/inforesources/community-care/administrator-certification/administrator-information/active-certificates - the administrator was not listed in the “active certificates list”; but rather it was listed in the “pending renewal applications” where application was received on July 8, 2026. At this time, the administrator's certificate is not current. Review of fire drill/disaster drill records: facility conducts quarterly drills and last drill was conducted on July 1, 2026. Review of the Infection Control Plan and Emergency Procedure Plan, annual review was not conducted based on the lack of documentation or signature. Advisory was provided to update their Emergency Procedure Plan to include their exits. Documents Requested: LPA requested a copy of current LIC500, LIC308 and updated Liability Insurance Certificate and Emergency Procedure Disaster Plan to be emailed at arvin.villanueva@dss.ca.gov Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited. Immediate Civil Penalty is being assessed today in the amount of $500 based on fire safety violation. Advisories were also provided. Exit interview was conducted. A copy of the report was provided upon exit. {2 of 2}the state’s words, verbatim · CDSS document, Jul 17, 2026

The state marks this report as 12 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Staff did not safeguard resident's personal belongings. Staff do not provide resident with adequate amounts of food.

On 03-20-2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct a follow-up investigation and deliver findings regarding the allegations noted above. LPA initially met with staff on duty, Shanice Downer (S1), and stated the purpose of the visit. The administrator, Unaisi Waqalala (AD), was notified and unable to be present at this time. Allegation – Staff did not safeguard resident's personal belongings: The investigation into this allegation consisted of interviews and record reviews. This allegation centered around Resident-1 (R1) and R1’s personal belongings, specifically R1’s personal supplements and other medications that R1 keeps in their own bedroom. During an interview on 02-27-2026, staff member reported that R1 can be very particular about their needs. Staff shared that R1 has recently shown signs of confusion and had been sent to the emergency room twice in February 2026 due to health concerns. {1 of 3} Unsubstantiated Staff also explained that when R1 was admitted to this facility, staff removed medications and sharp objects from R1’s bedroom for safety reasons. Staff stated that R1 had later brought additional items into the facility, which staff tried to monitor. Regarding personal belongings, staff reported that staff label residents’ clothing with their names to prevent mix-ups and that rooms are cleaned daily. During an interview, the complainant stated that they had been drinking alcohol and wanted to withdraw the complaint submitted to the Department, as they felt the issue had already been resolved with facility staff. In an interview on 02-27-2026, R1 reported that staff had removed a bag of supplements from their room about three weeks earlier. The bag contained multivitamins, vitamin C, and Tylenol. R1 shared concerns about clothing being mixed up and stating having received another resident’s clothing and was missing a few shirts. However, R1 also stated being happy living at the facility. Additionally, during a separate visit on 02-19-2026, four residents were interviewed. None reported concerns about their personal belongings at that time, and none reported major issues with food service, although one resident mentioned that the food could be improved. A review of R1’s Physician’s Report dated December 18, 2025, showed that R1 does not have any cognitive impairment and is able to care for their own personal needs. The report also stated that R1 is allowed to have access to personal items, including supplements and other household items, without risk. Although R1 reported that staff removed their supplements and that there were some issues with clothing being mixed up, there is not enough evidence to show that staff did not safeguard R1’s belongings. Staff reported taking steps to organize and monitor resident items and other residents did not report similar concerns. Therefore, the allegation is unsubstantiated. {2 of 3} Allegation - Staff do not provide resident with adequate amounts of food. The investigation into this allegation consisted of interviews, record reviews and facility observations. This allegation centers around resident, R1. During a complaint visit on 2-27-2026, staff member reported that R1 is very particular about food. Staff stated that residents are allowed to access the refrigerator and that R1 buys their own food using their own EBT benefits. Staff reported that when R1 asks for more food, staff provides it. Staff noted that canned food is R1’s favorite snack. During an interview, the complainant stated that they had been drinking alcohol and wanted to withdraw the complaint submitted to the Department, as they felt the issue had already been resolved with facility staff. In an interview on 02-27-2026, R1 also stated that R1 sometimes feels hungry but confirmed that staff provide R1 with available food. During a separate visit on 02-19 2026, four residents were interviewed. None reported concerns about food service, although one resident stated that the food could be improved. During observations on 02-19 2026, LPA saw a resident assisting staff with preparing dinner. LPA also observed that residents had open access to the kitchen, including the refrigerator, freezer, and pantry. The facility was found to have at least a seven-day supply of non-perishable food and a two-day supply of perishable food. During a visit on 02-27-2026, LPA observed staff putting away groceries. Although R1 stated feeling hungry sometimes, R1 also confirmed that staff provide food when requested. In addition, other residents did not report concerns, and observations showed that food was available and accessible. Therefore, there is not enough evidence to support the allegation, and it is determined to be unsubstantiated. A finding of unsubstantiated means that although the allegation may have happened the preponderance of evidence does not prove it. No deficiencies were cited as a result of this visit. An exit interview was conducted with AD over the phone. AD authorized S1 to sign this report. A copy of this report and appeal rights were provided to S1. {3 of 3}the state’s words, verbatim · CDSS document, Mar 20, 2026 · control 27-AS-20260225115341

Type of visit: Case Management - Deficiencies

On 02-19-2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct a case management visit. LPA met with staff on duty, Wainikiti Ravuoco (S1), and stated the purpose of the visit. The administrator, Unaisi Waqalala (AD) was notified and unable to come to the facility today. Present during this visit were 6 residents in care with 1 staff on duty (S1). During a complaint investigation on 02-19-2026, LPA found that S1 did not have their records in the facility and were not available for review. Per review of Guardian, S1 was associated to this facility on 01-04-2026. During an inspection of the kitchen, LPA found a Tylenol medication in a packet inside the first aid kit, located in a kitchen drawer that is not locked and was accessible to residents in care. Also in one of the kitchen drawer, below where they keep the printer, LPA found a meat thermometer that is accessible to residents in care. LPA also observed a knife on a drying rack on the kitchen counter that is accessible to residents in care. Deficiencies are being cited today. Exit interview conducted a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 19, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Feb 20, 2026

the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the regulation cited above. During inspection of the kitchen, LPA found a knife on a drying rack on top of the kitchen counter and a meat thermometer in a drawer. These were accessible to residents in care. This poses an immediate safety, health, personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: Per discussion, Administrator agreed to submit a written plan on how they will comply with the regulation cited above. The written plan shall be submitted by POC due date. Per instruction of LPA, staff on duty put away the sharps in a locked cabinet.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Feb 20, 2026

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the regulation cited above. During inspection of the kitchen, LPA found a packet of Tylenol inside the first aid kit that was located in a kitchen drawer. These were not locked and were accessible to residents. This poses an immediate safety, health, personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: Per discussion, Administrator agreed to submit a written plan on how they will comply with the regulation cited above. The written plan shall be submitted by POC due date. Per instruction of LPA, staff on duty put away the Tylenol in a locked cabinet.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a) · Plan of correction due date: Feb 26, 2026

The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the regulation cited above. The only staff on duty (S1) did not have their files in the facility and were not available for review during this visit. This poses potential health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: Per discussion, Administrator agreed to submit a written plan on how they will comply with the regulation cited above. The written plan shall be submitted by POC due date.

Type of visit: Required - 1 Year

On 07/1/2025 at 8:30am, Licensing Program Analyst (LPA) Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Hughes met with caregiver Shanice Downer and explained the purpose of the visit. Shanice called the facility designated administrator to inform that CCLD was present in the facility. The current census is 5 with 1 facility staff. This facility is a single story building licensed to serve (6) non-ambulatory residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA's toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. However upon observation of 2-day perishable supply, LPA Hughes noticed contaminated vegetables located in the vegetable bin. Facility care staff immediately discarded the vegetables. Hot water temperature was measured at 105.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the entry way and was last serviced on 9/13/2024. LPA observed the facility has a public telephone in the common area and the facility has the required posters posted. Facility thermostat was observed at 77.5 degrees Fahrenheit. LPA observed toxins located in the kitchen and kept locked and inaccessible to residents. LPA observed sharp knives kept locked in the kitchen and inaccessible to residents. Continuation 809-C LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 3 out of 5 residents medications and the medication administration record (MAR) was complete. The first aid kit was checked and contained the required components. LPA's requested resident and staff files for review. LPA's reviewed 5 out of 5 resident files and they were complete. LPA's reviewed 3 staff files, and it was complete. LPA's reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. The following documents will be email to LPA by 7/8/2025 (1) LIC 308 Designation of Administrative Responsibility (3) LIC 610 Current Emergency Disaster Plan (4) Proof of Current Liability Insurance (5) LIC 500 Current Personnel Report As a result of this annual visit, the facility is not in compliance with Title 22 Regulations, and the deficiencies can be found on the LIC 809-D . An exit interview was conducted with Shanice and a copy of these LIC 809 and LIC 809-D reports, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Jul 1, 2025

Allegation investigated: Staff did not provide adequate activities to residents in care Staff did not ensure a first aid kit was maintained at the facility Staff did not ensure resident records were properly maintained

On 5/28/2025 at 1:45 PM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with facility administrator Una Waqalala and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 5. A brief interview with conducted with Una Waqalala. Allegation: Staff did not provide adequate activities to residents in care It was alleged that; staff did not provide adequate activities to residents in care. This investigation is based on observations, and interviews. On 3/19/2025 LPA Lee conducted a visit to the facility, upon observation; no residents were observed participating in activities during the visit. LPA Lee observed four residents in the facility: Resident 1 (R1) was seen outside in the courtyard smoking before returning to their room to watch TV; (R2) was sitting on their bed with an iPad; and (R3) and 4 (R4) were out for a doctor's appointment and later returned to the facility for lunch. Continuation 9099-C Substantiated Allegation: Staff did not ensure resident records were properly maintained It was alleged that staff did not ensure resident records were properly maintained. This investigation is based on observation of resident records. On 3/19/2025, LPA Lee conducted a facility visit and upon observation of 4 out of 4 resident files, and 2 of them were found to be incomplete. Both R3 and R4 had an LIC 625 Needs and Service Plan form in their files, but the document was not signed by both the administrator and the resident or their responsible party, and the form was blank. It was also observed that R3’s LIC 602 Physician’s Report was incorrectly placed in R1’s file. Resident records were observed not in compliance with Title 22 regulations Resident Records 87506(a). As resident records were observed not organized, and resident records were included in other resident files. As a result, these allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Una Waqalala and a copy of this report LIC 9099, LIC 9099-C, LIC 9099-D was provided, along with Appeal Rights and the LIC 811, the Confidential Names List. LPA Lee observed two designated areas for activities: one in the common area inside the TV stand and another in the dining area. Both areas were equipped with a variety of activities, including board games, puzzles, card games, books, painting supplies, markers, and crayons. On 5/06/2025 LPA Hughes and Lee conducted a follow-up visit to the facility, upon R5- was observed outside in the courtyard, R3- In bedroom watching television, R4- In bedroom in recliner sleeping, R2- In bedroom with a tablet watching television, R1 in bedroom sleeping. As stated in the facility program design, activities for residents include but are not limited to, resident’s assisting with meal preparation and grocery shopping, residents are also encouraged to socialize by offering opportunities to read aloud, participate in tea and office chats, ice cream socials and birthday parties. Watering plants, dancing, exercising and listening to music. On 5/28/2025 LPA Hughes, conducted interviews with 4 out of 4 residents, and concluded that no activities were being provided at the facility. Resident activites were observed as not in compliance with Title 22 regulations section 87219(a) as resident activities in the facility are not being planned or provided for residents in care. Allegation: Staff did not ensure a first aid kit was maintained at the facility It was alleged that staff did not ensure a first aid kit was maintained at the facility. This investigation is based on observation. On 3/19/2025, LPA Lee conducted a facility visit and upon observation a first aid kit was in the facility; however, the first aid manual was missing. This first aid kit was observed not in compliance with Title 22 regulations on Incidental Medical and Dental Care 87465(a)(8). As a first aid manual is a required component to be included with a first aid kit. Continuation 9099-C Allegation: Hazards were made available to residents in care It was alleged that hazards were made available to residents in care. This investigation consisted of facility observations, and interviews. On 3/19/2025 LPA Lee conducted a tour of the facility; no hazards were observed inside the building or in the courtyard. On 5/6/2025 LPA Hughes and Lee toured the facility for a follow-up visit and no hazards were made available to residents in care. Additionally, a phone interview with the reporting party (RP) revealed that no hazards were made available to residents in care, stating that this allegation was incorrect for this facility. Based on observation this allegation could not be corroborated with any supporting evidence. Allegation: Staff obstructed facility emergency exits It was alleged that staff obstructed facility emergency exits. This investigation consisted of facility observations and interviews. On 3/19/2025 LPA Lee conducted a tour of the facility; the emergency exit was not observed obstructed. However, it was observed that the emergency exit gates are not self-latching. On 5/06/2025 LPA Hughes and Lee conducted a follow-up facility visit; emergency exit located in the garage was not observed to be obstructed. Additionally, on 5/28/2025 LPA Hughes interviewed 4 out of 5 residents who did not observe any emergency exits being obstructed. 1 facility staff also denied observing facility emergency exits being obstructed. Based on observation, and interviews no corroborating evidence was identified upon examination of the allegation. Allegation: Staff did not ensure sufficient healthy food items were made available at the facility for residents in care It was alleged that staff did not ensure sufficient healthy food items were made available at the facility for residents in care. This investigation consisted of facility observation. On 3/19/2025 LPA Lee conducted a tour of the facility, upon observation the 2- day perishable food supply contained sufficient healthy food items made available to residents in care. On 5/28/2025 LPA Hughes, interviewed 4 out of 5 residents who are satisfied with the food being served in the facility. Based on observation, no corroborating evidence was identified upon examination of the allegation. Continuation 9099-C Allegation: Facility in disrepair It was alleged that; the facility is in despair, lights were inoperable. This investigation consisted of facility observations and interview. On 3/19/2025 LPA Lee conducted a tour of the facility; upon observation the facility was observed in good repair. On 5/6/2025 LPA Hughes and Lee conducted a follow-up facility visit, and observed the facilities resident bathroom, which was observed to be in good repair, lighting within the facility was observed operable and in good repair. Additionally, on 5/28/2025, LPA Hughes interviewed 4 out of 5 residents who had no concerns with the facility being in disrepair. Based on observation, and interviews conducted, no corroborating evidence was identified upon examination of the allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited. An Exit interview was conducted with XXXXX and a copy of this report LIC 9099, LIC 9099-C, LIC 9099-A was provided, along with Appeal Rights and the LIC 811, the Confidential Names List.the state’s words, verbatim · CDSS document, May 28, 2025 · control 27-AS-20250313150435

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(8) · Plan of correction due date: Jun 4, 2025

87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility...(8)If a facility has no medical unit on the ground a complete first aid kit shall be maintained and be readily available in a specific location in the facility. This requirement was not met as evidenced by: the licensee did not ensure that the first aid kit was complete, including but not limited to a first aid guide.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Licensee will ensure that the facility has a complete first aid kit with all required components including a first aid guide. Licensee will review regulations and provide CCLD with a statement of acknowledgement and a photo receipt that a first aid guide was purchased for the facility by 06/04/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jun 4, 2025

87506(a)Resident Records.(a) The licensee shall ensure that a seperate, complete, and current record is maintained for each resident in the facility or in a central location readily available.... This requirement was not met as evidenced by: The Licensee did not ensure that resident records were properly maintained, organized, and resident files were kept seperate.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: The licensee will ensure all resident records are kept organized and seperate. Additionally, licensee will review the regulations regarding Resident Records, and provide a statement of acknowledgement of the regulations by 06/04/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a) · Plan of correction due date: Jun 4, 2025

87219(a)Planned activities. Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:(1) Socialization to promote or enhance personal relationships. This requirement was not met as evidenced by: Licensee did not ensure that residents participation in planned acitvities were made available, as stated in the facility program design.the state’s words, verbatim · CDSS document, May 28, 2025

Plan of correction: Licensee will ensure that planned activities are made available to the residents in care. Licensee will review Title 22 regulations regarding Planned activites and provide a statement of acknowledgement of the regulation by 06/04/2025.

Type of visit: Case Management - Deficiencies

On 5/28/2025 at 1:50 PM Licensing Program Analyst (LPA) Shakaricka Hughes conducted a case management deficiencies on the facility, based on observed deficiencies on a complaint investigation control number: 27-AS-20250313150435. LPA is addressing concerns on this case management for the following deficiencies: Food locked in staff room: On 3/19/2025 LPA Lee visited the facility to conduct a complaint investigation. During this visit it was learned that the 7-day non-perishable food supply was not stored in the kitchen area or accessible to residents in care. LPA Lee observed 7-day supply being stored in the staff’s room. LPA Lee advised the care staff that the refrigerator and pantry cannot be locked, as doing so would violate residents' personal rights. This observation was observed not in compliance with Title 22 regulations, Personal Rights of Residents in All Facilities section 87468.1(a)(2). Residents are to be accorded safe, healthful, and comfortable accommodations, furnishings and equipment. Additionally, Residents should served food of the quality and quantity necessary to meet their nutritional needs. If food is locked away and inaccessible, healthful accommodations are not readily available to residents in care. Continuation 809-C Medication storage and discontinued medication: On 3/19/2025 LPA Lee visited the facility to conduct a complaint investigation. During this visit LPA Lee observed medications for 4 out of 4 residents. Upon review of residents' medication boxes and Medication Administration Records (MAR) log, it was noted that R1 had one medication that was not documented on the MAR log, even though R1 has the medication in R1’s medication box and the medication was being administered to R1. Furthermore, it was observed that R3 had two discontinued medications in their medication box, with discontinuation dates of 01/01/25 and 03/11/25 (per care staff). The doctor's orders for the discontinued medications were not present in the resident’s file, and care staff could not locate the necessary documentation (MAR). The facility is not in compliance with Title 22 Incidental Medical and Dental Care Services 87465(6) in that R1’s medications were not recorded. Additionally, Title 22 Incidental Medical and Dental Care Services 87465(e) R3’s medications were not administered; the medications were discontinued and should’ve been properly destructed and documented as required. An exit interview was conducted with the facility administrator Una Waqalala, and the following documents were provided to the facility LIC 809, LIC 809-C, were provided to the facility.the state’s words, verbatim · CDSS document, May 28, 2025

Type of visit: Case Management - Other

On 11/20/2024, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a case management visit. LPA were met by caregiver Andora Montaque and explained the purpose of this visit. The census is 8. Care staff Andora attempted to reached administrator Unaisi Waqalala via telephone.; however, administrator didn't answer the call. During today's visit administrator was not present. The purposed of today's visit is deliver the Order to Licensee/Facility of Immediate Exclusion and explained that staff (S1) is excluded from any involvement in the facility effective immediately. No citations were issued on today's date. A copy of this report and exclusion letter was provided to the facility care staff Andora Montaque at the end of this visit.the state’s words, verbatim · CDSS document, Nov 21, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 Year Inspection Visit. LPA met with administrator and explained the purpose of the visit. Administrator Certificate expires 7/8/2024. LPA and administrator toured the physical plant including resident bedrooms, resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 110.7 degrees Fahrenheit in kitchen sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 5/3/2024. LPA checked medication storage and found medication to be locked away and inaccessible to clients. First aid kit was checked and is complete. Emergency Disaster/Fire Drill conducted on 5/4/2024. LPA reviewed three resident files and three staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. LPA requested the following updated documents for community care licensing to be submitted via email by June 11, 2024: LIC 308 Designation of Administrator, LIC 500 - Personnel Report, Copy of Administrator's Certificate, and Copy of Liability Insurance with expiration date. ruth.wallace@dss.ca.gov Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies observed or cited today. Exit interview conducted with administrator. A copy of report and LIC 811 (Confidential Names) left at facility.the state’s words, verbatim · CDSS document, Jun 7, 2024

Allegation investigated: Staff locked resident out of the facility Resident does not receive proper medication assistance

On 4/2/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to complete and delivery findings for a complaint investigation received on 2/7/24. LPA met with Administrator Unaisi Waqalala and explained the purpose of the visit. Throughout the course of the investigation, LPA conducted interviews and reviewed records. Regarding allegation, Staff locked resident out of the facility, Resident does not receive proper medication assistance, the investigation revealed that no preponderance of evidence was observed or obtained to substantiate the facility failed to uphold resident rights and provide appropriate care and supervision. Based on resident interviews, 4 out of 6 residents stated that they were not aware of any resident being locked out of the facility and that they all received their medications timely. Staff S1 denied locking any clients out of the care home. Continued on 9099-C Unsubstantiated As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint 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. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted, copy of report provided.the state’s words, verbatim · CDSS document, Apr 2, 2024 · control 27-AS-20240207141252