Burlingame Senior Living

Type of visit: Case Management - Incident

On September 14, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to following on two incidents that were reported by the facility. LPA met with the Resident Care Director and LPA explained the purpose of today's visit. On August 26, 2026, the facility reported two incidents that happened on August 22, 2026, in the Memory Care Unit. The first incident happened at 2PM concerning resident 1 (R1) who did not like the show that was shown on the television and became agitated. Staff #1 (S1) offered R1 to watch a different channel but R1 was not interested and walked away. Subsequently, S1 turned on the TV again for the other residents as R1 was no longer there. However, R1 returned, observed the TV was turned back on and got upset and immediately placed S1 in a headlock position while S1 was documented by the medication cart. On the same day at 3PM, the facility reported that another incident concerning resident 2 (R2) who was observed to be agitated and slapped staff #2 (S2). The incident report stated that this behavior was triggered by another who was telling R2 that he/she would be locked up in the facility resulting in R2 being agitated and asked staff to call his/her family many times. Both incident reports stated that a physical assessment was performed on both residents and no visible injuries observed that required medical treatment. The incident reports also indicated that the incident was reported to the responsible parties, the Ombudsman, the local law enforcement and the Adult Protective Services. During today’s visit, a tour of the memory care unit was provided by the resident care director and LPA observed R2 was friendly, pleasant and with a big smile while talking to LPA but he/she could not remember the incident. Regarding to R1, the resident care director informed LPA that he/she was transferred to another facility a couple of weeks ago. The resident care director also stated that the facility has updated R2’s needs and service plan with additional interventions/goals to ensure resident and staff safety. LPA interviewed S1 who stated that R2 has been doing well since the incident and the incident that happened on 8/22/2026 was an isolated incident because R1 was always pleasant, happy and friendly to everyone. In addition, the resident care director stated that R2’s medication was reviewed and adjusted by R2’s provider and R2 has been doing well since the incident. No deficiency is cited today. This report is reviewed and discussed with the resident care director and a copy is provided.the state’s words, verbatim · CDSS document, Sep 14, 2026

Type of visit: Case Management - Incident

On August 5, 2026, Licensing Program Analyst (LPA) Murial Han conducted a Case Management - Incident visit to follow-up on an incident that was reported by the facility. LPA met with the Administrator and Resident Care Director and explained the purpose of today's visit. On July 20, 2026, CCL received an incident report stating that on 7/18/2026, approximately 10:10am, resident #1 (R1) was observed by staff #1 (S1) to be agitated, physically aggressive and struck resident #2 (R2) on the upper back. Subsequently, R1 kicked another resident (R3) on the upper right thigh. The incident report stated that the facility reported the incident to the responsible parties, the ombudsman, the physician, and local law enforcement. The facility also updated the services plan, updated the assessments, made a Geri-psyche evaluation for R1, and requested medical testing for R1. During today's visit, LPA toured the memory care unit with the Resident Care Director and LPA observed R1 and R2 were participating in activities and R3 was sleeping. The Resident Care Director reported that all 3 residents did not sustain any injuries due to the altercation. The Resident Care Director stated that they are monitoring the residents more closely and frequently and no further incidents were reported. No deficient is cited today. This report is reviewed and discussed with the Resident Care Director. A copy of the report is provided.the state’s words, verbatim · CDSS document, Aug 5, 2026

Allegation investigated: Staff did not fix residents toilet in a timely manner

On July 22, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced 10-day complaint visit. LPA met with the administrator and explained the purpose of today's visit. Regarding the allegation of- staff did not fix toilet in a timely fashion, the reporting party stated that after resident #1 (R1) moved into the facility, the toilet stopped working and R1 was provided a key to an unoccupied room located next door to access the toilet and R1 was told that it would be fixed by the maintenance worker. However, the toilet was not fixed until 4 days later. During today’s visit, LPA interviewed the facility director, the administrator, and R1. According to R1, the toilet has been fixed but on the day of the move in, the toilet was not flushing properly, and he/she was giving the key to use the bathroom next door. R1 stated that he/she used that toilet during the day but not at night because there was no light in the room except for the bathroom. Substantiated According to the administrator and the facility director, the toilet was working properly prior to R1’s move-in and they were not aware that it was not working until the day of the move-in. The administrator acknowledged that it took the maintenance worker 4 days to fix it. After the investigation, this allegation is substantiated as the facility provided R1 to use the toilet in the unoccupied room next door, however, there was no sufficient lighting in that room which resulting in R1 not being able to have access to the toilet at night. Based on interviews, observation, and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in additional civil penalties. Report was discussed with the administrator; a copy is provided with Appeal Rights.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 14-AS-20260714104718

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 30, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by R1 moved into a room with a not working toilet and R1 was provided with a key to use the toilet in an unoccupied room next door, however, there was no light in that room which posed a potential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: During today's visit, LPA observed that R1's toilet has been fixed. The administrator will develop a plan of correction to ensure the facility is in good repair at all times and the plan shall indicate what actions that the facility will take to prevent this from happening again. The administrator will provide a copy of the plan of correction to CCL by 7/30/2026.

Type of visit: Case Management - Incident

On April 30, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management - Incident visit. LPA met with Administrator and the Resident Care Director, Hola Finau and LPA explained the purpose of today's visit. On April 17, 2026, the facility reported an incident that happened on April 14. 2026 in which R1 was observed by staff #1 (S1) in bed, yelling due to severe pain. S1 assessed R1 and it was noted that R1 could not stand and both legs were swollen which resulted in staff calling 911. The incident report indicated that R1 was diagnosed with hip fracture and received left hip surgery and returned to the facility. The incident report did not include the cause of the hospitalization. During today's visit, LPA interviewed the Resident Service Director and R1. According to the Resident Service Director, on 4/13/2026, R1 was pushing the wheelchair while walking with the private caregiver and R1 lost balance and fell. The private caregiver reported it to the medication technician (med tech) who assessed R1 and did not notice any injuries at the time. However, on the next day, 4/14/2026, R1 had a change in health/physical condition that resulted in hospitalization. LPA interviewed R1 who remembered the fall and the hospital stay but no other details. Based on documents provided, LPA observed R1's Needs and Service Plan was updated interventions to reduce fall. No deficient is cited today. This report is reviewed and discussed with the administrator and a copy is provided.the state’s words, verbatim · CDSS document, Apr 30, 2026

Type of visit: Case Management - Other

On March 25, 2026, Licensing Program Analyst (LPA) Murial Han conducted a case management visit to deliver the amended report dated 1/28/2026. LPA met with administrator and explained the purpose of today's visit. During the visit, LPA explained that the civil penalty that was assessed during the annual inspection on 1/28/2026 for 87411(f) will be removed and the remaining two civil penalties will stand: Personnel Records 87412(a)(13)(B) and Criminal Record Clearance in the amount of $600 instead of $850. This report is reviewed and discussed with administrator. A copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 25, 2026

Type of visit: Case Management - Other

On March 25, 2026, Licensing Program Analyst(LPA) Murial Han arrived at the facility to follow up on a Decision and Order(exclusion) of staff #1 (S1) and staff #2 (S2). LPA met with administrator and explained the purpose of the visit. According to the Administrator, S1 and S2 are no longer working at the facility and the administrator acknowledged that they have received the Decision and Order. No deficiencies cited during today. This report is reviewed and discussed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Mar 25, 2026

Type of visit: Required - 1 Year

On January 28, 2026 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with administrator, Brian Raimundo and LPA explained the purpose of today's visit. LPA toured facility and grounds of this 4-story facility with the administrator. There are two elevators and 3 stairwells, and 69 apartments--small studios, large studios, and one bedroom units, all have a private bathroom. On the ground floor, there are offices, kitchen, living and main dining rooms. The second floor is the memory care unit, and can only be accessed by a keypad for the elevator. There is a dining room, kitchen, and common rooms on the 2nd floor. There are laundry rooms on the 2nd, 3rd and 4th floors. There is an underground parking garage. LPA observed an emergency call system installed in each bathroom and all assisted living clients have pendants that transmit audible and visual signal to the centrally monitoring system and pagers carried by care staff and med techs. LPA observed fire extinguishers were last serviced on 3/4/2025 and water temperatures were measured at 105 - 116 degrees F. LPA observed medications, toxins, sharps and disinfectants were locked and inaccessible to residents in care. During the tour of the kitchen with the resident service director and the kitchen manager, LPA observed the overall of the kitchen floor to be dirty, dusty, greasy, and full of dark black partials. In addition, the ice machine was observed to be dusty, the green garage can have white, gray and brown spots on it, there was a gray tray stored on one of the carts that was filled with black dirt, and a piece of dirty black metal device in it. Furthermore, the stove/flat top was observed to have yellow and brown grease on it A review of (6) resident files was conducted and noted on the LIC 858. A review of (4) staff files was conducted and noted on the LIC 859. LPA requested for 6 staff files but the facility was able to provide 5 out of 6 files as the facility was not able to locate the file for S6. During the file review, LPA observed S1 did not have a criminal background clearance. The administrator stated that S1 has completed the process but result is still pending. S1 was asked to leave until criminal background clearance process is completed. In addition, LPA observed S2 was not associate with the facility. A civil penalty is being assessed for $850 today ( $500 for S1, $100 for S2 and $250 for repeat violation of 87411(f)). Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in additional civil penalties. This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 28, 2026

Type of visit: Case Management - Deficiencies

On 11/13/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to deliver the finding of an incident that was reported by the facility. LPA met with administrator, Brian Raimundo and explained the purpose of today's visit. On 10/9/2025, the facility reported that staff #1 (S1) witnessed staff #2 (S2) and staff #3 (S3) holding resident #1 (R1)'s arms down in bed while forcing R1 to take medicine. LPA attempted to interview R1 and R1 did not remember the incident and was not able to answer LPA's questions due to R1's diagnosis. LPA interviewed S1 who stated that on the day of the incident, she was working on the Assisting Living Unit and was called to assist the Memory Care Unit. When she got off the elevator, she heard R1 screaming in the room and when she got to the room, she witnessed S2 and S3 were holding R1's arms while forcing R1 to take the medicine. LPA interviewed S2 who stated that on the day of the incident, R1 did not want to take the medicine and R1 was attempting to hit S3 while S3 was trying to give the medicine so S2 assisted S3 by holding down R1's arms while R1 was in bed. S2 stated that R1 needed to take the medicine so R1 would not hit other people. LPA requested to interview S3 but S3 did not return call. LPA interviewed the memory care director who stated that she was not at the facility when the incident happened but when she was informed on the next day, she reported it to the Regional Director of Operations and both staff were placed on administrative leave. LPA interviewed the current administrator who stated that he was not the administrator when the incident happened but he was informed by the Regional staff that S2 and S3 were terminated. Based on training records, the facility provided an in-service on 10/8/2025 on Medication Pass and the training material indicated that resident shall not be forced to take medication, but the staff sign-in record did not indicate that S3 attended the in-service. After the investigation, this incident is substantiated as R1 has the Right to receive or reject medical care or other services. Based on interviews, observation, and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with administrator and a copy is provided with Appeal Rights.the state’s words, verbatim · CDSS document, Nov 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Nov 14, 2025

87468.1Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16)To receive or reject medical care or other services. This requirement has not been met as evidenced by based on observation, record review and interview, S1 witnessed R1 was screaming and yelling and S2 and S3 were holding R1's arms in bed while administering medicine which posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: The administrator/ licensee will develop a plan of correction to indicate what was the facility's immediate action to ensure R1's safety. The plan shall also include what is the action that the facility will take to prevent this from happen again. The plan shall include staff education. The administrator will provide a copy of the plan to CCL by 11/14/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: Nov 14, 2025

87411 Personnel Requirements - General (a)Facility personnel shall at all times be.. and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by based on observation, interview and record review, the facility director provided an in-service on 10/8/2025 on Medication Pass that included residents shall not be forced to take medicine but S2 did not attend the in-service which posed an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: The administrator/licensee will develop a plan of correction to ensure staff attends all required training. The plan shall include what is the monitoring process to ensure staff members are competent after the training. . The administrator/licensee will provide a copy of the plan of correction to CCL by 11/14/2025.

Type of visit: Case Management - Other

On 11/13/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management-Other visit. LPA met administrator, Brian Raimundo and explained the purpose of today's visit. LPA delivered an immediate exclusion letter for staff #1 (S1) and staff #2 (S2) who are currently associated in the facility. The administrator confirmed that S1 and S2 are no longer working at the facility. The exclusion letters were provided to the administrator. This report is reviewed and discussed, and a copy is provided.the state’s words, verbatim · CDSS document, Nov 13, 2025

Type of visit: Case Management - Incident

On 10/15/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow up on an incident that was reported by the facility. Upon entry, LPA was informed by the receptionist that the administrator is no longer working at the facility and LPA met with the Sales Director and LPA explained the purpose of today's visit. On 10/9/2025, the facility reported that staff #1 (S1) witnessed staff #2 (S2) and staff #3 (S3) holding resident #1 (R1)'s arm in bed and forcing R1 to take medicine. During today's visit, LPA toured the Memory Care Unit, interviewed R1, and staff members. LPA requested for documents to be submitted to CCL by 10/17/2025: R1's LIC 602, appraisal service needs and plan, and documents related to the incident. In addition, LPA requested the Licensee to submit documents for an administrator to CCL by 11/6/2025. No deficient is cited today. This report is reviewed and discussed with the Sales Director and a copy is provided.the state’s words, verbatim · CDSS document, Oct 15, 2025

Allegation investigated: Staff caused injury to resident in care.

On 8/20/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the complaint investigation finding. LPA met with the administrator and explained the purpose to today's visit. Regarding to the allegation of- staff caused injury to resident in care, the reporting party stated that resident #1 (R1) with history of dementia and Alzheimer's with significant avulsion of left hand. Skin was avulsed from wrist to knuckles on top of hand, as if pulled down, full thickness, exposing connective tissue and vasculature of hand. When R1 was asked how the injury occurred, R1 stated staff “pulled on his/her arm” with no additional details. As part of the investigation, LPA interviewed R1, facility staff, the administrator, R1's responsible party, and reviewed documents. Unsubstantiated According to the administrator, on the day of the incident, staff #1 (S1) was conducting morning routine rounds to check on the residents, and when S1 opened R1’s door, S1 witnessed R1 sitting by the end of the bed and holding the mattress pump (a device that keeps the mattress inflated). S1 proceeded to check on R1 and observed a wound on the left hand that was bleeding so S1 removed the device and called for assistance. Staff #2/med tech (S2) responded and arrived to assist. The administrator stated that after S2 saw the wound, they decided to call 911. R1 was transferred to the hospital and returned within 24 hours. The administrator stated that the mattress pump was placed by the foot board of the bed but no one knew how R1 got hold of it. The administrator stated that since the incident, they have removed the mattress pump from the foot of the bed and place it on the floor to prevent this from happening again. LPA interviewed R1 who stated that he/she can’t remember what happened to the hand, but maybe hit it on the door. LPA interviewed S1 who denied pulling R1’s hand and stated that when she saw R1 was holding the mattress pump, R1’s left hand was bleeding so she removed the mattress pump, provided a pad to cover the wound and called for assistance. LPA interviewed S2 stated that he did not pulling R1’s hand. S2 stated that when S1 called for assistance, he went to the room immediately and saw R1’s hand was bleeding, and it was covered with a pad. Therefore, they decided to call 911. Both S1 and S2 stayed with R1 until the paramedics arrived and they did not witness anyone pulled R1's hand/arm. LPA interviewed R1’s responsible party who stated that no one witnessed exactly what caused the skin tear and they are happy with the overall care that the facility is providing to R1 but the communication can improve at times. During LPA’s visit on 7/3/2025, LPA observed R1 to be calm and left hand was wrapped with gauze. LPA observed the mattress pump was placed away from the foot of the bed. Based on the police report, it indicated that R1's injury appeared to have been accidental, and there is no merit to any elder abuse or neglect. Based on interview, observation and record review during the course of the investigation, this allegation is deemed to be unsubstantiated. Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is reviewed and discussed with the administrator; a copy is provided.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 14-AS-20250630085851

Allegation investigated: Staff do not ensure carpeting is clean and sanitary Staff do not ensure that facility is maintained at a comfortable temperature Staff do not ensure facility vehicle is in good repair Director does not have the required qualifications Staff do not ensure elevators are in good repair

On July 8, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the complaint investigation findings. LPA met with the interim administrator, Rowena Cancino and explained the purpose of today's visit. Regrading to the allegations of- staff do not ensure carpeting is clean and sanitary, the reporting party stated that when resident #1 (R1) moved in on 3/21/2025, the carpet was filthy and smelled very bad resulting R1 being temporary placed in a different room. As part of the investigation, LPA interviewed the interim administrator and the sales manager and both of them acknowledged that when R1's responsible party toured the facility, they have observed the carpet being dirty and it was supposed to be cleaned and renovated before the move-in date but it was not done and R1 had to be placed in a different room while the carpet was being replaced. The interim administrator stated that the carpet was replaced by Vinyl a few days later and R1 was moved into that room. After the investigation, this allegation is deemed to be substantiated. Substantiated Regarding to the allegation of - staff do not ensure that facility is maintained a comfortable temperature, the reporting party stated, R1 was being placed in a temporary room, while the facility replaced the carpet but the heater was broken. According to the sales manager and the interim administrator, the temporary room was vacant for a long time and no one checked the heater prior to R1's move-in as R1 was not supposed to move in to that room, therefore, the facility was not aware that the heater was not working. The interim administrator stated that they called a couple of companies to fix it but they couldn't so they provided a portable heater for R1. LPA interviewed R1 who stated that the temperature of the room was comfortable after the portable heater was provided and LPA observed the room temperature was measured at 73 degrees Fahrenheit. After the investigation, this allegation is deemed to be substantiated. Regarding to the allegation of- staff do not ensure facility vehicle is in good repair, the reporting party stated the facility van has been broken for months and on 4/9/2025, R1 had a medical appointment and R1 had to be transported by the maintenance guy in a personal truck that required R1 to climb into. According to the interim administrator, the facility van was broken on the day of R1's appointment but it has been fixed. The interim administrator stated that the facility provides transportation for residents on Tuesdays and Thursdays, and R1's appointment was on a Wednesday and since the van was broken, the maintenance manager took the resident to the appointment in a private vehicle. The interim administrator stated that she/he was not aware that R1 had to climb into the private vehicle until after the appointment. The interim administrator acknowledged that the facility van breaks down from time to time and when that happens, the facility offers other means of transportation such as vouchers to transportation companies. LPA has completed and substantiated a complaint investigation in November 2024 (reference number 14- AS- 20241121125035) regarding to residents were missing their medical appointments because the facility van was broken. After the investigation, this allegation is deemed to be substantiated. Regarding to the allegation of- director does not have the required qualifications, the reporting party stated that the interim director/administrator doesn't have the qualifications to be in the position. According to the interim administrator who used to be the Health Services Director stated that when the Administrator resigned in February 2025, she was appointed by the Licensee to be the interim administrator. Based on observation and record review, the licensee did not provided any documentation to CCL to update the facility administrator. After the investigation, this allegation is deemed to be substantiated. Regarding to the allegation of- staff do not ensure elevators are in good repair, the reporting party stated that on 5/5/2025, both facility elevators were broken and residents waited downstairs for over 3 hours until one of them was fixed. As part of the investigation, LPA interviewed the sales manager and the interim administrator who acknowledged that both elevators were down on 5/5/2025 and the elevator on the right side has been down for almost 2 years. The sales manager was present on 5/5/2025 and stated that when they learned that the only working elevator was malfunctioned, they contacted management immediately, and call the elevator repair company. The sales manager acknowledged that there were a few residents who were not able to take the stairs so they waited for hours in the dining until the elevator was fixed. LPA completed and substantiated a complaint investigation on 3/11/2025 (complaint reference number 14-AS-20250110144222) regarding to Licensee did not ensure facility elevators were maintained in good repair. After the investigation, this allegation is deemed to be substantiated and a civil penalty of $250 is being assessed for repeat violation. Based on interviews, observation, and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in additional civil penalties. Report was discussed with the interim administrator; a copy is provided with Appeal Rights. Regarding to the allegation of - staff do not ensure resident's showering needs are being met and staff do not ensure resident's incontinence needs are being met, the reporting party stated that there is a resident on the first floor near the elevator that doesn't shower, and smells like urine. The reporting party stated that everyone knows who this resident is, and staff just say this resident doesn't like to shower. As part of the investigation, LPA interviewed the interim administrator who stated that resident #2 (R2) has a history of refusing shower and did not allow facility staff to assist with incontinence care and cleaning the room but R2 is no longer refusing after many conversation of encouragement. The interim administrator reported that the odor is not as strong since R2 has been showering weekly, allowing staff to assist ADLs, and weekly housekeeping and laundry service. LPA attempted to interview R2 but was not successful. LPA interviewed staff #1 (S1) and staff #2 (S2) and both of them reported that R1 is no longer refusing care, R2 has been showering weekly, managing his/her own incontinence care, and allowing staff to assist with laundry and housekeeping services. During LPA's visits on 5/14/2025, 7/3/2025 and 7/8/2025, LPA did not observed any odor by the entrance, by R2's room and the lobby area. This observation was reported to CCL in 2024 and at the time, the facility has provided documentation to proof that the facility implemented different interventions to encourage R2 to participate in care. After the investigation, this allegation is deemed to be unsubstantiated. Based on observation, interviews and records review, these allegations are deemed to be unsubstantiated. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is review with the interim administrator and a copy is providedthe state’s words, verbatim · CDSS document, Jul 8, 2025 · control 14-AS-20250509083556

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jul 9, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by based on observation, and interview R1 room's carpet was dirty, the heater was not working in, both elevators and the facility van were broken which poses an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: The Licensee will develop a plan to ensure the facility is clean, safe, sanitary and in good repair at all times; the plan shall indicate how the facility shall monitor the deficient areas, and it shall also include the time-frame for the elevator repair. and it shall be signed by the Licensee as the facility currently does not have a designated administrator.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Jul 9, 2025

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by the facility did not have a qualified administrator since March 2025 which poses an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: The licensee will develop a plan to ensure the facility has a qualified and current certified administrator and provide a copy of the plan of correction to CCL by 7/9/2025 and it shall be signed by the Licensee as the facility currently does not have a designated administrator.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b) · Plan of correction due date: Jul 16, 2025

87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. This requirement is not met as evidenced by R1 was admitted to a room that was cold because the heater was malfunctioned which poses a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 8, 2025

Plan of correction: The Licensee will develop a plan to ensure residents are residing in a environment with comfortable temperature. The Licensee will provide a copy of the plan to CCL by 7/16/2025 and it shall be signed by the Licensee as the facility currently does not have a designated administrator.

Type of visit: Case Management - Incident

On July 8, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit to follow-up on an incident that was reported by the facility. LPA met with the interim administrator, Rowena Cancino and explained the purpose of today's visit. On 7/1/2025, the facility reported resident #1 (R1) had an unwitnessed fall in the bathroom and sustained a laceration of scalp. R1 was sent to the hospital and returned a few hours later. The interim administrator stated that R1's family member was in the room during the fall and alerted staff of the fall. During today's visit, LPA observed R1 in the room, appeared to be comfortable and pleasant. R1 did not remember the fall and stated that she was not in pain. According to the interim administrator, as part of the fall management program, the facility has implemented status checks for R1 every 2 hours, R1 is receiving Physical Therapy from a home health agency and R1 has not sustained any further falls. The interim administrator stated that the facility will conduct another fall assessment for R1 in a few weeks. No deficient is cited today. This report is reviewed and discussed with the interim administrator. A copy of the report is provided.the state’s words, verbatim · CDSS document, Jul 8, 2025

Type of visit: Case Management - Incident

On April 21, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit to follow up on an incident that was reported by the facility. Upon entry, LPA met with the Business Office Manager, Batool Alsmabi and LPA explained the purpose of today's visit. The interim Executive Director, Rowena Cancino arrived shortly thereafter and assisted with the visit. On 4/17/2025, the facility reported that resident #1 (R1) left the facility and R1 was last seen at the facility on 4/10/2025 during lunch time. According to the Interim Executive Director, R1 has always been leaving and returning his/her own as R1 is fully independent and does not require any services. The Interim Executive Director stated that the facility has issued a 30-day eviction notification to R1 due to non-payment and is currently working on discharge planning. Based on documents provided by the facility, R1 is able to leave the facility unassisted and is independent with all the Activities of Daily Living. On 4/20/2025, LPA was informed by the Interim Executive Director that R1 has returned to the facility. During today's visit, LPA interviewed R1 who is aware of the 30-day eviction and stated that he/she went to a hotel for a few days and returned yesterday. R1 is aware that the facility is assisting with discharge planning. No deficiency cited today. This report is review and discuss with the Interim Executive Director and a copy is provided.the state’s words, verbatim · CDSS document, Apr 21, 2025

Type of visit: Office

**** NOTE ORIGINAL SIGNATURE IS ON FILE WITH THE PACIFICA SENIOR LIVING UNION CITY FACILITY***** **** NOTE ORIGINAL SIGNATURE IS ON FILE WITH THE PACIFICA SENIOR LIVING UNION CITY FACILITY*****the state’s words, verbatim · CDSS document, Apr 4, 2025

Allegation investigated: Licensee did not ensure facility elevators were maintained in good repair

On March 11, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the investigation findings. LPA met with the interim Administrator, Rowena Cancino and explained the purpose of today’s visit. Regarding to the allegation of- Licensee did not ensure facility elevators were maintained in good repair, the reporting party stated that the facility has 2 elevators and over the last 2 years at any given time, at least one of them has not been working. Reporting party stated that their family member has witnessed during their recent visit that both elevators were malfunctioned during an emergency situation and the Emergency Medical Team had to wait 25 minutes for the staff to “re-set” the only working elevator. As part of the investigation, LPA conducted observation, interviewed the pervious administrator, the resident coordinator director, and facility staff. Substantiated According to the previous Administrator and the Resident Service Director, one of the elevators has been broken for more than a year and it was repaired but continued to break. The former Administrator denied the allegation that the paramedics were waiting for 25 minutes while responding to an emergency call and stated that if both elevators were down, the staff would direct the paramedics to use the stairs. The Resident Service Director stated that there was one time when both elevators were down, and the paramedics had to transport a resident to the room using the stairs. The former Administrator and the Resident Service Director stated that the most recent visit from an elevator company informed them that the elevator needed to be replaced and the Senior Vice President has already approved it. LPA interviewed staff #1 (S1) and staff #2 (S2) and both stated that one of the elevators has been broken for almost a year. They stated that the only working elevator would be down from time to time due to over usage. They stated that they were informed by other staff members that during Christmas Eve, the only working elevator was also down and residents, family members, and paramedics had to wait for a long time. After the investigation, this allegation is deemed to be substantiated as the former administrator, the resident service director, and the facility staff reported that the elevator has been malfunctioned for over a year and the facility was not able to provide documents to proof that repairs were in progress. In addition, facility staff reported that when the only working elevator became malfunctioned, it created a big problem for the residents, facility staff, family members, medical visitors, etc. Based on interviews, observation, and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the interim Administrator; a copy is provided with Appeal Rights providedthe state’s words, verbatim · CDSS document, Mar 11, 2025 · control 14-AS-20250110144222

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Mar 12, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by one of the two facility elevators has been malfunctioned for more than a year and the facility was not able to provide documents to proof that the repair or replacement of the elevator is in progress which poses an immediately health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 11, 2025

Plan of correction: The Licensee and/or the administrator will provide a plan indicating details/actions that the facility will take to either repair or to replace the elevator. The plan shall have estimated time-frame of completion. The Licensee and/or the administrator will provide a copy of the plan to CCL by 3/12/2025.

Type of visit: Case Management - Other

On 1/15/2025, Licensing Program Analyst (LPA) Murial Han conduced an unannounced Case Management visit to follow - up on an Unlawful Detainer order. LPA met with the administrator and explained the purpose of today's visit. Facility was granted an unlawful detainer order for residents #1 (R1) due to non-payment and according to the order, R1 was supposed to be discharged today. Upon entrance, LPA observed the administrator, 3 sheriffs, 2 Ombudsman, representative from the placement agency and a administrator and a resident service coordinator from another facility assisting R1 with discharge planning. After a few hours of working with R1, the administrator reported that the sheriffs did not remove R1 from the facility as R1 refused to leave and go to a destination that was arranged by the facility. Therefore, R1 will be staying for 5 more days while the placement agency is seeking for a safe discharge destination. No deficiency cite today. This report is reviewed and discussed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Jan 15, 2025

Type of visit: Case Management - Annual Continuation

On January 15, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced continuation visit for an annual inspection that was conducted on 12/30/2024. LPA met with the administrator and the resident service director and LPA explained the purpose of today's visit. During today's visit: A review of (5) resident files was conducted and noted on the LIC 858. A review of (5) staff files was conducted and noted on the LIC 859. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 15, 2025

Type of visit: Required - 1 Year

On January 30, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with the administrator, Ignacio Lopez and explained the purpose of today's visit. LPA toured facility and grounds of this 4-story facility. There are two elevators and 3 stairwells, and 69 apartments--small studios, large studios, and one bedroom units, and all of the room have a private bathroom. On the ground floor, there are resident rooms, offices, kitchen, living and main dining rooms. The second floor is the memory care unit and can only be accessed by a keypad for the elevators and the unit has 30 second egress exit doors. In addition, there is a dining room, a small kitchen, and common rooms on the 2nd floor. There is a laundry rooms on the 2nd, 3rd and 4th floors. LPA observed an emergency call system installed in each bathroom and all assisted living clients have pendants that transmit audible and visual signal to the centrally monitoring system and pagers carried by care staff and med techs. LPA observed fire extinguishers were last serviced on 3/26/2024 and water temperatures were measured at 105 - 109 degrees F through-out the facility. LPA observed medications, sharps, and chemicals are locked and inaccessible to residents in care. A review of (4) staff files was conducted and noted on the LIC 859 LPA will return on another day to complete the inspection. This report is review and discussed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Dec 30, 2024

Allegation investigated: Staff did not ensure that residents are being transported to medical appointments.

On November 26, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced 10-day complaint visit. LPA met with the resident service director, Rowena Cancino and explained the purpose of today's visit. LPA also spoke to the administrator over the phone. Regarding to the allegation of- Staff did not ensure that residents are being transported to medical appointment, the reporting party stated that the facility van has been broken for eight weeks, residents are missing their appointments and the facility is not making transportation arrangements for the residents. During today's visit, LPA interviewed the Resident Service Director, the Administrator, and residents. The administrator stated that they have informed the residents verbally during the resident council meeting that the facility would be providing transportation via an Uber or a Taxi to and from their medical appointments while the facility van is being repair. Substantiated The resident service director stated that the facility van has been broken for many weeks and the facility is offering to pay for the transportation while the van is being fixed. LPA interviewed resident #1(R1) who stated that the administrator was going to make transportation arrangement for his/her recent medical appointment but the resident service director was not aware of it, and called R1's family member and the family member took R1 to the medical appointment. LPA interviewed 2 other residents and they report that the van has been broken for more than eight weeks and they were not aware that the facility was providing other means of transportation such as an Uber or a Taxi. In addition, one of them stated that he/she had to cancel the medical appointments as he/she did not have any transportation arrangements. Furthermore, he/she stated that the residents were not scheduling any appointments as there was no transportation arrangements. After the investigation, this allegation is deemed to be substantiated as the residents reported that they were missing their appointments and they were not scheduling new appointments as there was no other means of transportation that was provided by the facility. In addition, they were not aware that the facility was offering Uber/ Taxi rides. Based on interviews, and observations during the investigation, the preponderance of evidence standard has been met. Therefore, these allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the administrator; a copy is provided with Appeal Rights providedthe state’s words, verbatim · CDSS document, Nov 26, 2024 · control 14-AS-20241121125035

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jan 2, 2025

87465 Incidental Medical and Dental Care..(a) A plan for incidental medical and dental care shall be developed by each facility...(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation.. This requirement is not met as evidenced by based on interviews and observations, residents are missing their appointments and not scheduling new appointments as the facility van is broken and they were not aware of the other means of transportation which poses a potential health risks to residents in care.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: The administrator will provide a plan of correction in writing of what is the facility's plan to ensure that the residents are aware of the alternative transportation that the facility is offering while the van is being repaired. In addition, the plan shall include the estimated time for the van to be fixed. The administrator will provide a copy of the plan to CCL by 1/2/2025.

Allegation investigated: Resident wandered from the facility due to lack of staff supervision.

On November 15, 2024, Licensing Program Analyst (LPA) Murial Han conducted a visit to deliver the investigation findings. LPA met with the administrator, Ignacio Lopez and explained the purpose of today's visit. Regarding to the allegation of- resident wandered from the facility due to lack of staff supervision, the reporting party stated that resident #1 (R1)'s family received communication from the facility that R1 had been found outside of the facility and staff did not know how R1 got out of the memory care unit and they did not know how long R1 had been outside on the street. As part of the investigation, LPA interviewed the Memory Care Director, Staff #1 (S1), and reviewed documents. According to the Memory Care Director, on the day of the incident, it was during change of shift and the door alarm went off so they checked the doors and the doors were closed and no residents were around. They started searching room to room and discovered that R1 was not in the room. Subsequently, the Memory Care Director saw R1 in the courtyard in front of the facility and when staff went to escort R1 back to the facility, R1 was already on the sidewalk in front of the facility. Substantiated LPA interviewed staff #1 (S1) who stated that the door alarm went off and they responded to the alarm, however, they did not see R1 at the door. S1 also stated that they did not know R1 left the unit because the unit has 2 delayed egress doors and the elevator doors. Therefore, they did not know which exit R1 used to leave the unit. Based on the Pre-placement Appraisal Information, the facility was aware that R1 has wandering behaviors as it was indicated on the Appraisal. During the visit on 11/7/2024, LPA and the Resident Service Director tested the delayed egress doors and both doors were working properly and one of the doors lead to the courtyard in front of the facility where R1 was seen by the Memory Care Director. After the investigation, this allegation is substantiated as R1 left a secured unit unattended and the facility did not know how R1 got out. Based on interviews, observation, and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, these allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the Operation Specialists, a copy is provided with Appeal Rights provided Based on the Needs and Services Plan, R1 did not have hearing aids. Based on observation, interviews and records review, this allegations is deemed to be unsubstantiated. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is review with the administrator and a copy is providedthe state’s words, verbatim · CDSS document, Nov 15, 2024 · control 14-AS-20241025150754

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Nov 18, 2024

87705 Care of Persons with Dementia..(b) In addition to the requirements as specified in Section 87208, Plan of Operation,..(2) Safety measures to address behaviors such as wandering, aggressive behavior.. This requirement is not met as evidence by: based on interviews, observations and record reviews, R1 left the unit/facility unattended and was found by the courtyard in front of the facility and staff did not know how R1 got out which poses an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Nov 15, 2024

Plan of correction: The administrator/licensee will develop a plan to ensure residents will not leave the memory care unit unattended and the plan shall include staff training. The administrator/licensee will submit a copy of the plan to CCL by 11/18/2024.

Allegation investigated: Staff are not according resident privacy while in care.

On July 30, 2024, Licensing program Analyst (LPA), Murial Han conducted a visit to deliver the findings of the complaint investigation. LPA met with Operation Specialists, Kathleen Calobeer and Kathy Valencia and explained the purpose of today's visit. Regarding to the allegation of- staff are not according resident privacy while in care, the reporting party stated that the facility notified resident #1 (R1)'s relatives with false and damaging information without R1' consent and destroyed R1's relationship with his/her relatives. As part of the investigation, LPA interviewed the Resident Service Director and reviewed documents. Based on the documents provided by the facility, it revealed that R1 does not have a diagnosis of Mild Cognitive Impairment and/or Dementia and R1 is able to communicate his/her needs. In addition, R1 signed the admission agreement upon admission. LPA interviewed the Resident Service Director who stated that R1 is his/her own responsible party and acknowledged that the facility spoke to R1's relative about R1's Activities of Daily (ADLs) without R1's consent. The Resident Service Director stated the facility reached out to R1's relatives because they were hoping R1's relatives would convince R1 to participate in some of the ADLs that R1 was currently not. Substantiated After the investigation, this allegation is substantiated as the facility provided R1's personal information to R1's relatives without R1's permission which violated R1's Rights as the facility did not remain R1's information confidential. Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, these allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the Operation Specialists, a copy is provided with Appeal Rights provided As part of the investigation, LPA interviewed the facility director who denied the allegation and stated that R1 was inquiring about where the Ombudsman's contact information was posted and it was provided to R1. The facility director did not know that R1 was asking for assistance with the call. According to R1, staff did not prevent him/her from contacting the Ombudsman's office. R1 stated that the Resident Service Director provided the Ombudsman's contact information to R1 but R1 thought the Resident Service Director acted like he/she did not want to assist with the phone call, therefore, R1 traveled to the Ombudsman's office. After the investigation, this allegation is deemed to be unfounded. Based on records review, and interviews the department has determined that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is discussed and reviewed with the Operation Specialists and a copy is provided. After the investigation, this allegation is deemed to be unfounded as R1 stated that the medical device that was attached to his/her body part was causing the pain while he/she was being wheeled into the shower on a shower chair. Regarding to the allegation of- staff are bullying resident in care, the reporting party stated that there was much bullying at the facility and no other details was provided. As part of the investigation LPA interviewed the Administrator and the Resident Service Director who denied the allegation. LPA interviewed R1 who denied the allegation and stated that there was a lady raised her finger while talking to R1 but this lady did not work at the facility. After the investigation, this allegation is deemed to be unfounded. Regarding to the allegation of - staff are financially abusing resident in care, the reporting party reported that the facility has attempted extortion of R1's funds, pushed current invoices under R1's door. As part of investigation, LPA interviewed the Administrator who denied the allegation and stated that there were several conversations with R1 regarding to R1's outstanding balances and the facility has provided a copy of the invoices to R1 in person and placed it underneath R1's door. LPA interviewed R1 who stated that the facility was not financially abusing his/her funds but they potentially could without any further details. After the investigation, this allegation is deemed to be unfounded. Regarding to the allegation of- staff prevented resident in care from contacting the Long Term Ombudsman, the reporting party stated that R1 asked one of the facility director's to make a call on behave of him/her to the Ombudsman office but the facility director did not comply so R1 went to the Ombudsman's office.the state’s words, verbatim · CDSS document, Jul 30, 2024 · control 14-AS-20240522112110

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(2) · Plan of correction due date: Aug 7, 2024

87468.2Additional Personal Rights of Residents(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities..2) To have their records and personal information remain confidential and to approve their release,... This requirement is not met as evidenced by based on record reviews and interviews, the facility shared R1's personal information with R1's relatives without R1's permission which poses a potential health risks to residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2024

Plan of correction: The administrator/licensee will develop a plan to ensure compliance and the plan will include staff education. A copy of the plan will be submitted to CCL by 8/7/2024.

Type of visit: Case Management - Incident

On April 4, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow-up on an incident that was report to CCL by the facility. LPA met with Resident Service Director, Rowena Cancino and Administrator, Glenda Bertccui. LPA explained the purpose of today's visit. On March 28, 2024, facility reported that facility received a call from the post office reporting that one of the residents was there. Subsequently, facility director went to the post office to pick up the resident(R1). However, someone had already called 911 and resident was transferred to the hospital for further evaluation. During today's visit, LPA interviewed the Resident Service Director and the Administrator who stated that R1 usually gets transported by the facility van when R1 wanted to leave the facility; 2 days prior to the incident, R1 was informed by facility staff that the van would be out of service and if R1 could hold off on conducting outings. During the day of the incident, R1 was persistent with leaving the facility to conduct some personal business. As R1 was signing out at the front desk, the receptionist reminded R1 that R1 was not to leave the facility unassisted. However R1 left by him/herself without further actions performed by facility to ensure R1's safety. Based on R1's Physician's Order (LIC 602), R1 was not able to leave the facility unassisted. Therefore, deficient is cited under California Code of Regulations, Title 22 as the facility did not ensure care and supervisor was provided while R1 was out of the facility. Civil penalty of $250 will be assessed today for repeat violation as this deficiency was cited on 7/20/2023. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed the administrator; a copy is provided with the appeal rights.the state’s words, verbatim · CDSS document, Apr 4, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 5, 2024

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by R1 left the facility unassisted despite R1's LIC 602 indicated that R1 was not to leave the facility unassisted which posed an immediate health risks to residents in care.the state’s words, verbatim · CDSS document, Apr 4, 2024

Plan of correction: The administrator will develop a plan to ensure compliance and the plan shall include the facility's protocols to prevent this incident from happening again. The plan shall include staff training. The administrator will submit a copy of the signed and dated plan to CCL by 4/5/2024 indicating when the training will be completed.

Type of visit: Required - 1 Year

On January 30, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with resident service director, Rowena and explained the purpose of the visit. The administrator arrived shortly thereafter and assisted with the inspection. LPA toured facility and grounds of this 4-story facility. There are two elevators and 3 stairwells, and 69 apartments--small studios, large studios, and one bedroom units, all have a private bathroom. On the ground floor, there are offices, kitchen, living and main dining rooms. The second floor is the memory care unit, and can only be accessed by a keypad for the elevator. There is a dining room, kitchen, and common rooms on the 2nd floor. There are laundry rooms on the 2nd, 3rd and 4th floors. There is an underground parking garage. LPA observed an emergency call system installed in each bathroom and all assisted living clients have pendants that transmit audible and visual signal to the centrally monitoring system and pagers carried by care staff and med techs. LPA observed fire extinguishers were last serviced on 2/1/2023 and water temperatures were measured at 105 - 116 degrees F. LPA observed medications are secured in medication rooms on 1st and 2nd floors and toxins are secured in locked maintenance rooms on 2nd, 3rd and 4th floors. LPA reviewed documentation for emergency drills. During the kitchen tour, LPA observed perishable and non-perishable foods are adequate. The walk-in refrigerator and freezer floors were dirty, the mental shelves in the walk-in refrigerator was observed to have black partials hanging on the metal bars, the metal tray to hold clean cups was dirty, etc. LPA reviewed 5 resident records and all of them contained admission agreement, medical assessment- LIC 602 (Physician Order), Appraisal Needs and Service Plan, Resident Identification information, Pre-appraisal assessment, etc. LPA reviewed 3 staff files and all of them contained personnel records, health screening, COVID-19 vaccination information, Job Description, Abuse Statement, fingerprint cleared and associated to the facility and First Aid/CPR documentation was not adequate. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 30, 2024