4 All Seniors Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit on 10/15/2025 and was greeted by the Administrator, Marita Samaniego. The Administrator, Marita Samaniego arrived to the facility at 9:45 am. LPA stated the purpose of the visit was to conduct an annual inspection. The caregivers confirmed there are four residents living in the facility. The facility is licensed for six (6) non-ambulatory residents and one bedridden resident. The facility has a hospice waiver for six residents. LPA Spaeth and the caregiver toured the facility at 10:30 until 11:10 am. Common Areas – The family room, dining room, and kitchen are combined. The family room was furnished with comfortable seating and a television. The dining room contained a dining room table and chairs. Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a hallway closet. Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food items. The fire extinguisher was located near the kitchen and was operable. The knives were locked in a kitchen drawer and the cleaning solutions were locked underneath the kitchen sink. Laundry Room – The laundry room was locked and contained the washer/dryer, laundry detergent and additional cleaning solutions. Continued on 809-C Garage – LPA observed an additional refrigerator which contained milk and frozen food items. Emergency water was located in the garage. Bathrooms: There are two (2) resident bathrooms and one staff bathroom. All bathrooms were well lit, clean, contained hand soap, slip resistant mats, grab bars, paper towels and trash bins with lids. Water Temperature: The water temperature was tested at 10:40 am and was 105.0 degrees F. Resident Rooms: There are five resident rooms which were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean.. Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in a shaded area in the backyard. Smoke/Carbon Monoxide Detectors: The smoke/carbon monoxide detectors were tested at 11:05 am and were operable. LPA reviewed resident files at 11:15 am until 11:45 am and reviewed staff records from 12:00 pm until 12:30 pm. LPA reviewed resident medications from 12:20 pm until 12:50 pm. LPA reviewed resident's medication at 12:50 pm until 1:10 pm. There are no deficiencies to report. Exit interview conducted, and a copy of the signed report was giventhe state’s words, verbatim · CDSS document, Oct 15, 2025

Allegation investigated: Staff neglect led to resident developing pressure injuries. Staff did not address resident's change in condition while in care.

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced subsequent complaint investigation for the allegation(s) listed above. LPA was greeted by the Administrator Marita Samaniego. LPA explained that the reason for the visit was to deliver the findings for this complaint. LPA toured the facility from 2:20 until 2:30 pm. On 02/21/2024 Licensing Program Analyst (LPA) Melissa Spaeth and Licensing Program Manager (LPM) Troy Agard initiated a complaint investigation for the allegation(s) listed above. LPA Spaeth explained the purpose of the visit was to investigate a complaint. LPM requested copies of the following documents: (1) staff roster; (2) resident roster; (3) copies of the residents' files; and (4) staff work schedule from 2/01/2023 until 2/21/2024. The Administrator provided the documentation. LPA conducted a physical plant tour from 11:00 am until 11:15 am. Continued on 9099-C Unsubstantiated On 2/16/2024, a complaint was received by the Woodland Hills Adult & Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s Investigation Branch (IB) on 4/02/2025 for a full investigation and was accepted on 4/02/2025. An investigation was conducted by IB Investigator, Jose Santana. During the course of the investigation, Investigator Santana interviewed four out of four residents (R1-R4), the Administrator, and two out of seven staff members (S1-S2). IB Investigator Santana also received copies of R1’s medical records and hospice records. LPA Spaeth conducted additional interviews with staff (S1-S3) on 6/27/2025 at 4:00 pm. Regarding the allegation: Staff neglect led to a resident developing pressure injuries - It is being alleged R1’s pressure injuries were due to facility staff not cleaning R1 and not keeping R1 dry. R1 was diagnosed with cachexia, had leg contractures, experienced pain with movement, and was not eating. R1 entered hospice on 8/21/2023. Between 8/28/2023 to 10/04/2023, R1 developed two (2) stage two (2) pressure injuries located on their sacrum and right hip, one (1) pressure injury on their buttocks and one (1) pressure injury on their left hip. Between 10/02/2023 to 1/22/2024, R1’s pressure injuries progressed to stage 4. Between 2/12/2024 to 2/26/2024, R1 developed two new wounds on their lateral right buttock. On 10/19/2023, the hospice nurse documented that R1 had a measurable decline within the preceding two weeks. The nurse also noted that R1 was difficult to reposition due to R1 sleeping up to 20 hours per day and also due to the discomfort experienced by R1 when repositioned. R1’s wounds were still present despite the two times a week wound care, repositioning, protein intake, and the use of a low air loss mattress. Three (3) out of seven (7) staff members unanimously stated they check residents every two to three hours to determine if residents require a diaper change and to ensure residents are dry. R1 confirmed they are checked every two to three hours for a diaper change Continued on 9099-C Regarding the allegation: Staff did not address resident's change in condition while in care – It is being alleged staff did not address R1’s change in condition and staff left R1 in a urine-soaked bed. S1-S3 confirmed they never leave a resident in a urine-soaked bed and have never been advised by any staff member or an outside source that this has occurred. S1-S3 confirmed they checked R1 every hour when they observed R1’s change in condition. S1-S3 also stated they never left R1 in a wet diaper for a long period of time and continued to reposition R1 every two hours. S4 was unavailable for an interview. Based upon the interview of the Administrator, staff members, and residents, the allegations are unsubstantiated. Exit interview conducted and a copy of the report was given.the state’s words, verbatim · CDSS document, Sep 24, 2025 · control 31-AS-20240216171149

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit on 10/23/2024 and was greeted by the caregivers. The Administrator, Marita Samaniego arrived to the facility at 9:45 am.. LPA stated the purpose of the visit was to conduct an annual inspection. The caregivers confirmed there are four residents living in the facility. The facility is licensed for six (6) non-ambulatory residents and one bedridden resident. The facility has a hospice waiver for six residents. LPA Spaeth and the caregiver toured the facility at 10:15 until 10:45 am. Common Areas – The family room, dining room, and kitchen are combined. The family room was furnished with comfortable seating and a television. The dining room contained a dining room table and chairs. Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a hallway closet. Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food items. The fire extinguisher was located near the kitchen and was operable. The knives were locked in a kitchen drawer and the cleaning solutions were locked underneath the kitchen sink. Laundry Room – The laundry room was locked and contained the washer/dryer, laundry detergent and additional cleaning solutions. Continued on 809-C Garage – LPA observed an additional refrigerator which contained milk and frozen food items. Emergency water was located in the garage. Bathrooms: There are two (2) resident bathrooms and one staff bathroom. All bathrooms were well lit, clean, contained hand soap, slip resistant mats, grab bars, paper towels and trash bins with lids. The water temperature was tested at 10:40 am and was 106.0 degrees F. Resident Rooms: There are five resident rooms which were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean.. Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in a shaded area in the backyard. Smoke/Carbon Monoxide Detectors: The smoke/carbon monoxide detectors were tested at 10:45 am and were operable. LPA reviewed resident files at 11:10 am until 11:30 am and reviewed staff records at 11:30 am until 12:00 pm. LPA reviewed resident medications at 12:20 pm. There are no deficiencies to report. Exit interview conducted, and a copy of the signed report was giventhe state’s words, verbatim · CDSS document, Oct 23, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the caregiver. The Administrator, Marita Samaniego arrived at 10:00 am. LPA stated the purpose of the visit was to conduct an annual inspection. The Administrator confirmed there are five residents living in the facility. The facility is licensed for six (6) non-ambulatory residents and one bedridden resident. The facility has a hospice waiver for six residents. LPA Spaeth and the Administrator toured the facility at 10:00 until 10:30 am.. Common Areas – The family room, dining room, and kitchen are combined. The family room was furnished with comfortable seating and a television. The dining room contained a dining room table and chairs. Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a hallway closet. Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food items. The fire extinguisher was located near the kitchen and was operable. The knives were locked in a kitchen drawer and the cleaning solutions were locked underneath the kitchen sink. Laundry Room – The laundry room was locked and contained the washer/dryer and the laundry detergent. Garage – LPA observed an additional refrigerator which contained milk and frozen food items. Bathrooms: There are two (2) resident bathrooms and one staff bathroom. All bathrooms were well lit, clean, contained hand soap, slip resistant mats, grab bars, paper towels and trash bins with lids. The water temperature was tested at 10:40 am and was 133.0 degrees F. Resident Rooms: There are five resident rooms which were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean.. Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in the backyard. Smoke/Carbon Monoxide Detectors: The smoke/carbon monoxide detectors were tested at 10:45 am and were operable. LPA reviewed resident files at 11:00 am until 12:00 noon and reviewed staff records at 1:00 pm until 1:20 pm. Based upon Title 22 Regulations, the following deficiencies are substantiated. (See 809-D page). Exit interview conducted, appeal rights discussed, and a copy of the signed report was given.the state’s words, verbatim · CDSS document, Feb 16, 2024