Island Grove Guest Home II

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Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Roman conducted an announced case management visit for the purpose of a capacity increase request. LPA met with Administrator, Shand Hillel. Licensee was initially licensed for twelve (12) ambulatory adults, and has requested a capacity increase to fourteen (14) all of whom maybe non ambulatory adults and eight (8) maybe bedridden. LPA is in receipt of the fire clearance for fourteen (14) adults which maybe non-ambulatory and eight (8) bedridden, rooms 4-6 can be used for bedridden and room 1 maybe used for bedridden if direct egress is accessible. During the case management inspection LPA toured the interior and exterior of the facility along with facility staff. The facility tour consisted of inspecting each room for dual occupancy accommodations, assessment of resident rooms furniture, supplies, lighting and linens are sufficient. Clients have access to three (3) bathrooms which should be adequate to meet their needs. Medication is locked and secured. LPA observed the facility to be clean, physical plant free of hazards, toxic substance storage, and overall compliance with Title 22 regulations. Based on LPA observations, Licensee's request for increase in capacity is granted pending final Management approval. An exit interview was conducted with Licensee, Shand Hillel, to which a copy of this report and Licensee/Appeal Rights were provided. Their signature on this report acknowledges the receipt of this report and their rights.the state’s words, verbatim · CDSS document, Apr 15, 2026

Allegation investigated: Facility staff did not properly address change in resident’s condition Facility staff did not assist resident with hygiene as needed Facility staff did not ensure resident's dietary needs were met Facility staff did not properly report incident

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced visit to the facility to deliver investigative findings regarding the above mentioned allegation. LPA identified herself, explained the purpose of the visit and nature of the complaint to Lucero Ochoa, caregiver. LPA also spoke with Administrator Hillel Shand over the phone. On January 28, 2026 the Department received this complaint which alleged facility staff did not properly address change in Resident #1’s (R1) condition, facility staff did not assist R1 with hygiene as needed, facility staff did not ensure R1’s dietary needs were met, and facility staff did not properly report an incident. [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] The Department’s investigation included a facility tour, record reviews, as well as interviews with residents, staff and outside sources. (Continued on LIC9099-C) Unsubstantiated (Continued from LIC9099) Regarding the allegation that facility staff did not properly address change in R1’s condition, based on observation notes the facility kept on R1, there was nothing indicative of a change of condition throughout the month of January. Interviews with staff also reported not observing any change in condition of R1 until R1 was observed to have seizure like activity which prompted staff to contact emergency medical assistance, which was documented on R1's care notes and in an Incident Report. Regarding the allegation that facility staff did not assist R1 with hygiene as needed, records reviewed revealed that R1 was assessed to need minimal standby assistance with dressing and personal hygiene care. Interviews with outside sources reported residents always appear to be clean and well groomed. Interviews with residents reported staff ensure their hygiene needs are being met. Further, during LPA unannounced facility visits, LPA observed residents in care to appear clean and well groomed. Regarding the allegation that facility staff did not ensure resident’s dietary needs were met, according to records reviewed, R1 did not require a special diet and was able to feed himself. Further, R1’s nutrition and hydration plan noted that the administrator and family would be notified if R1’s intake declined for 2 consecutive days, which did not occur per observation notes. Regarding the allegation that facility staff did not properly report an incident, records reviewed revealed that the facility submitted an Incident Report to the Department regarding the incident involving R1. This report indicated contacting R1’s responsible party. Additional facility records noted contacting R1’s responsible party in regards to the incident. The Department has investigated the above mentioned allegations. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and therefore deemed unsubstantiated. An exit interview was conducted with Lucero Ochoa, caregiver, to whom a copy of this report and the Licensee’s Rights (LIC9058 01/16) were provided.the state’s words, verbatim · CDSS document, Apr 14, 2026 · control 08-AS-20260128085925

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Angelica Boyles conducted an announced Pre-Licensing for a change of ownership visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of California Code of Regulations and Health & Safety Code. LPA was greeted by, identified herself to, and explained the purpose of the visit to applicant Hillel Shand. The facility's license shows a maximum capacity of twelve (12) non-ambulatory residents, two (2) of whom may be bedridden. There is an approved hospice care waiver for three (3) residents. During today’s visit, LPA, accompanied by the applicant, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets and showers were in working order. The facility’s ambient internal temperature was comfortable and compliant and water temperatures at taps accessible to residents were compliant. (Continued on LIC 809C) (Continued from LIC809) The facility has enough linens, hygiene supplies, dining supplies, and perishable and non-perishable food for resident use. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of medication and confidential resident and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant, no firearms or ammunition are or will be stored at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. Fire extinguishers were present. Required licensing postings were observed in visible areas of the facility. The items reviewed were complaint with Title 22, Division 6 of California Code of Regulations and Health & Safety Code. The applicant passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit. The applicant was advised that the facility’s application is pending management's final review and approval. An exit interview was conducted with the applicant, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 20, 2025

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call at CAB Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Oct 7, 2025