Loma Linda Assisted Living

Allegation investigated: Staff did not ensure that resident had ointment administered as prescribed

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with Resident Care Coordinator Keisha Martin, and explained the purpose of the visit. Resident #1 (R1) could not be interviewed due to no longer residing at the facility, R1 discharged from the facility on 1/06/26. LPA conducted an interview with staff and R1’s ointments were administered as prescribed. LPA reviewed relevant documentation and audited R1’s eMAR, it appears staff administered R1’s ointments Triamcinolone Acetonide Cream 0.1% and Calmoseptine External Ointment as prescribed. LPA did not find documentation indicating Hydrocortisone Ointment 1% was prescribed. Based on the evidence gathered the allegation is deemed unsubstantiated. An Unsubstantiated complaint means, that 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. An exit interview was conducted with Executive Director Eileen Sanchez and a copy of this report was provided at the conclusion of the visit. Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 1, 2026 · control 56-AS-20260113203811

Allegation investigated: Staff handle residents in a rough manner Staff do not ensure the residents bedding is clean and sanitary Staff do not ensure the residents toileting needs are met

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with Resident Care Coordinator Keisha Martin, and explained the purpose of the visit. Regarding allegation #1, LPA conducted interviews with three (3) staff and five (5) residents. All three (3) of the staff informed LPA, residents are not handled in a rough manner nor have they seen or heard staff handling residents in a rough manner. Four (4) of the Five (5) residents informed LPA they are not treated in a rough manner. One (1) of the Five (5) residents could not answer LPA’s question. Unsubstantiated Regarding allegation #2, LPA observed and conducted interviews with staff and residents. LPA observed Four (4) resident bedrooms to have their bedding made, clean, and sanitary. Interviews with three (3) staff informed LPA, the beds are made daily, sheets are washed weekly unless an accident occurred then the sheets are washed immediately and house keeping shampoos the mattress. One (1) of the Four (4) residents interviewed voiced they do not like when their sheets are placed on the floor while the bed is being made, aside from that comment all four (4) residents have informed LPA, staff maintain their bedding clean and sanitary. Regarding allegation #3, LPA conducted interviews with three (3) staff and five (5) residents. Interviews with all three (3) staff members informed LPA residents toileting needs are being met. Staff stated every resident’s incontinent needs are different, the residents who need constant changes are checked between every 1-2 hours based on the resident. Two (2) out of the Five (5) residents informed LPA they did not need assistance with toileting. Two (2) of the Five (5) residents informed LPA although they don’t need much assistance with toileting when staff is called, they assist in a timely manner. One (1) of the five (5) residents could not answer LPA’s question. Based on LPAs observations, record review, and interviews, the above allegations are Unsubstantiated; meaning that although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. An exit interview was conducted where this report was discussed and a copy was provided to Executive Director Eileen Sanchez at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 1, 2026 · control 56-AS-20260114121520

Allegation investigated: Staff are not following infectious disease protocols Resident fell sustaining injury due to staff neglect Staff are not ensuring resident's room is cleaned Staff are not ensuring resident's bedding is washed

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with Resident Care Coordinator Keisha Martin, and explained the purpose of the visit. Regarding allegation #1, LPA reviewed relevant documentation and the facility has their infectious disease plans on file. The facility did not experience any type of infectious outbreak. LPA reviewed resident #1 (R1) discharge paperwork and there was no indication R1 sustain an infectious disease. Regarding allegation #2, LPA reviewed relevant documentation and conducted interviews with staff and residents. There was no documentation indicating Resident #1 (R1) fell and/or sustained injuries from a fall. LPA conducted an interview with Resident #1 (R1) and they informed LPA they have not fallen while at the facility nor have they sustained an injury from a fall. Unsubstantiated Regarding allegation #3, LPA observed Four (4) resident bedrooms to be clean and sanitary. Interviews with three (3) staff informed LPA, the bedrooms are cleaned daily. LPA conducted interviews with four (4) residents and all (4) have informed LPA, staff maintain their room clean and sanitary. Regarding allegation #4, LPA observed Four (4) resident bedrooms to have their bedding made, clean, and sanitary. Interviews with three (3) staff informed LPA, the beds are made daily, sheets are washed weekly unless an accident occurred then the sheets are washed immediately and house keeping shampoos the mattress. One (1) of the Four (4) residents interviewed voiced they do not like when their sheets are placed on the floor while the bed is being made, aside from that comment all four (4) residents have informed LPA, staff maintain their bedding clean and sanitary. Based on LPAs observations, record review, and interviews, the above allegations are Unsubstantiated; meaning that although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. An exit interview was conducted where this report was discussed and a copy was provided to Executive Director Eileen Sanchez at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 1, 2026 · control 56-AS-20251124160335

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Sarina Ramirez and Eldin Serrano made an unannounced visit to the facility to conduct a required annual inspection. LPAs met with Wellness Director Mayra Alfaro, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (60), a current census of (51). LPAs conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility does not have a swimming pool or similar bodies of water. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities The facility is equipped with operating smoke detectors/carbon monoxide alarms, working laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in two (2) resident bathrooms measured between 106 and 108 degrees F. Six (6) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, administrator certificate, facility sketch, personal rights, resident counsel, theft and loss, emergency disaster plan and telephone numbers, CCLD complaint poster, and Ombudsman poster. Food Service: Facility kitchen and dining area are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps and chemicals were kept locked and inaccessible to residents in care, however technical violation issued. Continuation on LIC – 809C: Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff have current CPR/first aid training. Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet. Record Review: Six (6) Staff files reviewed were observed to be incomplete, five (5) staff were not associated to the facility through Guardian; two (2) staff had missing TB results; citation issued. Six (6) Resident files reviewed were observed to be complete. Based on observations and record review deficiencies and technical violations were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report along with LIC 902, LIC 809D, Appeal Rights were discussed and provided to Wellness Director Mayra Alfaro.the state’s words, verbatim · CDSS document, Nov 26, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Sarina Ramirez conducted an announced visit to the facility for the purpose of a Change of Ownership evaluation. LPA met with Administrator Eileen Sanchez. An initial application for change of ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Centralized Applications Bureau (CAB) on 02/09/2024 for a total capacity of sixty-four (64) residents. Fire clearance was granted on 04/04/2024. LPA observed the following: Eight (8) bedrooms and seven (7) bathrooms were inspected. There are no bodies of water. The physical plant, in general, was in good repair. Buildings and grounds are free from hazards. Indoor and outdoor passageways were free of obstruction. There is a charged fire extinguisher, operating smoke alarms, and carbon monoxide detectors. There is a locked area for medications, cleaning supplies, and sharps. LPA observed a working telephone and basic laundry equipment. Resident bedrooms had the required bedding and furniture. Bedrooms had sufficient lighting. LPA measured the hot water temperature in the resident bathrooms, and it ranged from 105 to 111 degrees F. The facility had a sufficient amount of linen and hygiene items for the residents. The facility had a sufficient amount of nonperishable and perishable food items. The food was kept in a safe and healthful manner. The facility menu was available for review. Dishes, glasses, and utensils were in good condition. The facility had a designated area for staff and resident records. Emergency disaster plan, emergency telephone numbers, personal rights, monthly activities, and complaint posters were posted in a common area. The facility was equipped with a complete first aid kit. There is adequate seating in the common areas. Facility had a supply of activities for the residents. Night lights were maintained in the hallways. Pre-licensing inspection is complete, and no corrections are needed to be made. Facility appears to be ready for licensure. An exit interview was conducted where this report was discussed and provided to the Applicant Eileen Sanchez.the state’s words, verbatim · CDSS document, Nov 15, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 64 Census (if any clients in care): 56 Interview Method: Telephone interview On 10/24/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting Pre-licensing readinessthe state’s words, verbatim · CDSS document, Oct 24, 2024