AA Best Care Homes

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marisol Cuadra arrived unannounced to conduct a Case Management visit and met with Charito Santos, Administrative Assistant to follow up on a self-incident report along with SOC341 received on 9/10/26. Per SOC341 and incident report, on September 9, 2026 around 4pm, resident (R1) lost their wallet and they were accusing residents that they took their wallet. R1 was yelling and screaming, until staff (S1) told them to relax and called the police (case #R2652055), but R1 pushed S1. Upon police arrival, they had a conversation with R1, later that day R1 left the facility and didn't come back. R1's responsible party were notified. During today's visit, LPA learned that R1 returned to the facility on 9/11/26. Based on records review, R1's physician report indicates that R1 is able to leave the facility unassisted and R1's wallet was found by them. According to administrative assistance, there were no further incidents reported. Based on records review and interviews with staff, it appears like the facility followed up their policies and procedures protocol. No deficiencies cited during today's visit. Exit interview was conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Sep 16, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management visit and met with Bailey Farrell, Administrative Assistant to follow up on a self-incident report along with SOC341 received on 8/14/26. Per SOC341 and incident report, In the evening hours of Thursday, August 13, 2026 roommates, resident (R1) and resident (R2) engaged in a disagreement about the light being on in their shared bedroom. Unable to reach an agreement, R2 reportedly struck R1 three times in the arm and stomach. R1 was emotionally distressed and frightened following the assault, but denied sustaining any physical injuries. R1 declined medical attention when offered by staff. R1 contacted Santa Rosa Police Department, filing a report with police officer, Case# 268751. Responsible parties were notified. On 8/19/26 the facility submitted a lawful 30-day eviction issued to R2 due to house rule violation by punching R1 on 8/13/26. During today’s visit, LPA made observations, conducted interviews and reviewed documents. Based on records review of facility care notes indicated that R1 was moved to another room and R2 stated in the same room to keep them separated to prevent any further incidents, after the facility learned about the incident. Based on records review and interviews with staff, it seems like the facility followed up their policies and procedures protocol. No deficiencies cited during today's visit. Exit interview was conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Aug 25, 2026

Allegation investigated: -Staff unlawfully evicted a resident in care.

Licensing Program Analyst (LPA) Cuadra conducted an unannounced visit and met with Administrative Assistant Charito Santos and administrator, Nick Aquino. LPA came to the facility to investigate and deliver findings of complaint allegation listed above. The Department received an allegation of staff unlawfully evicting a resident in care. Per complainant and co-complainant, on 7/22/26 resident (R1) was kicked out due to an incident that occurred on 7/17/26 without a lawful eviction notice issued after R1 was admitted to the hospital due to emergency medical needs, but the facility was refusing to accept R1 back following their emergency department evaluation alleging that R1 is not allowed back at the facility and they would turn R1 away if somebody attempted to drop them off at the facility. During the course of the investigation, LPA reviewed records, made observations and conducted interviews with staff. On 7/22/26, LPA Cuadra received a call from administrative assistant, inquiring about the possibility of obtaining approval for a 3-day eviction for R1 after an incident that occurred on 7/17/26 when R1 struck a staff (S1). Continued on LIC9099C... Substantiated Continued from LIC9099... According to administrative assistant, R1 called the police case # SR 260007540.0 who came and arrested them due to R1 being intoxicated. LPA explained to administrative assistant that the facility could issue a 30 day eviction instead of a 3 day eviction due to R1 was not present at the facility at this time, so they don't represent an immediate risk to the health and safety of staff and residents in care. On 7/27/26, LPA received and returned unlawful 30 day eviction notice issued to R1 due to the letter missing the unlawful detainer statement which is required per regulation. During today’s visit at the facility to conduct 10 day to open the complaint, LPA was provided with updated 30 day eviction notice including the unlawful detainer statement dated 7/27/26. Also, LPA learned through interviews with administrative assistant that the facility refused to receive R1 back to the facility after R1 was discharged from the hospital due to R1 refused to return to the facility due to R1 violated rule #4 of their house rules by exhibiting behavior which is a threat to the mental health and safety of them and others, as well as rule #11 of facility house rules about not allowing residents to return to the facility intoxicated or under the influence of alcohol and/or illegal drugs. However, the facility was unable to provide supportive evidence that R1 was intoxicated when they struck S1. Per administrative assistant, R1 was relocated to another facility, and they are unable to locate R1 to serve them with updated 30 day eviction notice. Based on records review and interviews conducted with staff, the facility failed to accept R1 to return to facility after R1 was discharged from the hospital by conducting a wrongful eviction. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 21-AS-20260723130537

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a) · Plan of correction due date: Jul 29, 2026

Type A – 87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)….Thirty (30) days written notice to the resident is required… This requirement was not met as evidenced by: Based on LPA’s record review and interviews with facility staff, the facility failed to receive R1 back from the hospital after they were discharged, without a lawful 30-day eviction letter, which poses an immediate risk to the health and safety of the resident.the state’s words, verbatim · CDSS document, Jul 28, 2026

Plan of correction: The facility agrees to send a letter to CCL agreeing to comply with eviction procedure in the future and send a copy of the facility eviction procedure. Letter and facility eviction procedure to be sent to CCL by POC due date of 7/29/2026 to clear the deficiency.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct Case Management/Collateral visit and met with Charito Santos, Administrative Assistant. LPA conducted interviews with resident (R11) regarding complaint unrelated to this facility. The purpose of this case management inspection is to follow up on self-certifications received to clear deficiencies cited during annual inspection on 7/7/2026: - 87465(c)(2) - medications were not given as prescribed by residents' physician: LPA learned that on 7/27/26 a pharmacist consultant from pharmacy vendor came to review medications with staff. According to administrative assistant, the facility is training another staff to help with medication management. - 1569.618(c)(3) - Staff did not have current CPR certificates. During today's visit, LPA observed that three staff (S2, S3 & S4) have current CPR/1st aid certificates on file. -1569.625(b)(2) - Staff did not have additional 20 hours annually of required training. LPA was provided with proof of additional 20 hours of training completed by two staff (S3 & S4). -87463 (a) - 10 out of 30 residents care plans needed to be updated. LPA reviewed records of care plans were updated for ten residents (R1, R2, R3, R4, R5, R6, R7, R8, R9 & R10). -87507(c) - All residents need to sign the addendum regarding surveillance cameras. All residents signed and dated addendum acknowledging the presence of surveillance cameras. No deficiencies cited during today's visit. Exit interview conducted with Administrative Assistant and copy of this report was given.the state’s words, verbatim · CDSS document, Jul 28, 2026

Allegation investigated: -Staff do not ensure residents lice is treated properly. -Staff do not ensure facility is free of pests.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Charito Santos Administrative Assistant. The Department received an allegation of staff does not ensure residents’ lice is treated properly. Per Reporting Party, the facility has had several outbreaks of lice over the past year, they are not treating clients but rather shaving their heads. Based on interviews conducted by LPA with facility staff (S1) and residents in care (R1 and R2), resident (R1) was transferred from another licensed facility on 3/11/26. Upon arrival, the facility staff noticed that R1 arrived itchy of their head, and lice infested hair, but facility staff relocated R1 out of their shared room until 6/17/26, after resident (R2) complained to their physician of being itchy due to lice transferred from their roommate R1. During this investigation, the facility provided LPA with daily care notes confirming above information. Also, daily care notes revealed that on 5/19/26 R1 was observed scratching their head and arms, upon staff asking about it, R1 disclosed that they were itchy, staff advised them to take a shower and put on clean clothes. Continued on LIC9099C... Substantiated Continued from LIC9099...According to R1’s physician report dated 3/11/26 indicating that R1 was able to care for themselves and perform all personal care. However, based on records review of R1’s admission agreement, it was agreed by the facility and R1 that the facility will assist with daily living activities including hygiene and grooming needs. The facility did not assist R1 with hygiene and grooming needs as agreed in their admission agreement and resulted in R1 sustained lice hair infestation. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Regarding allegation of staff do not ensure facility is free of pests. According to Reporting Party, the facility has experienced several outbreaks of bed bugs over the past year, and these untreated infestations create unsanitary living conditions for residents in care. On 5/26/26, the facility was cited in a case management due to confirmed findings of bedbug bites in a resident in care. Based on records review, R1's physician report dated 03/11/26 indicates that R1 is capable for self-care, but the facility is responsible for laundry services of residents' beddings, R1 also has a roommate resident (R2). The facility provided room treatment log reveals that the last room treated was #11, 5 and 12 located in Wing A back on 3/4/26. Based on interviews conducted with Administrative Assistant and staff (S1) who perform the treatments, after they learned about R2’s complained to their physician, they did wash their linens and clothing, but they didn't threat the room. On 4/4/25, Licensing staff held an informal meeting with facility representatives and LPA have cited the facility to address ongoing bed bugs issues and other unrelated areas of concern, where Co- Licensees agreed to contract a pest control vendor to provide their services to help to get rid of bed bugs at the facility to ensure resident’s health and safety. However, based on interviews and records reviews revealed that the facility still has bedbugs’ issues unresolved and the facility did not treat R1's room after learning of bedbugs. Based on interviews conducted with residents (R1 & R2), R1 was relocated by facility staff to a different room due to bed bugs present in their room, R1 stated that they have washed all their clothing and bed sheets. R2 confirmed that two bed bugs were observed in their shared room and facility staff relocated R1 to a different room, R2 washed all their clothing and bed sheets too. According to R2’s physician report dated 9/28/21, R2 has a history of chronic skin breakdown conditions that needs to be monitored closely to prevent it from getting worse. Based on LPA’s records review and interviews with pertinent parties, it was revealed that the facility is not ensuring to mitigate the exposure of residents in care to bed bugs, this ongoing issue has not been resolved for more than a year. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. An immediate civil penalty in the amount of $1000 will be issued for repeated violation within the last 12-month period.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 21-AS-20260617083006

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.269(a)(5) · Plan of correction due date: Jul 8, 2026

Type A - §1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement has not been met as evidence by: Based on LPA’s record review and interviews conducted the facility did not ensure R1 was accorded safe, healthful, and comfortable accommodations which resulted in R1 being infected with lice hair which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Licensee agrees to contract an outside vendor to treat all facility rooms and will submit receipt as proof of service to ensure the facility is following up on assisting resident’s needs including hygiene and grooming timely to CCL by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Jul 8, 2026

87303 Maintenance & Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services & procedures for the safety & well-being of residents, employees & visitors. This requirement has not been met as evidence by: Based on LPA’s records review and interviews conducted with the facility staff and residents (R1 & R2), the facility did not ensure R1's safety & well-being, which resulted in R1’s & R2’s shared bedroom had bedbugs, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: The facility will contract an outside vendor to treat all facility rooms and will submit receipt as proof of service to mitigate any potential re-occurring incident as well as a written plan describing how they will ensure the facility is offering a healthful and safe area to residents in care to CCL by POC due date. ***Civil penalties in the amount of $1000 issued for repeated violation.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra arrived unnanounced to conduct a Required Annual Inspection and met with Charito Santos, Administrative Assistant, Tiffany Dizon, back up Administrator) arrived later. Annual fees are current. Required postings were observed. LPA/staff toured the facility at 9:30am and made the following observations: Facility was a comfortable temperature with thermostat reading at 74 degrees F. Passageways were free from obstructions. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cleaning supplies were also observed under the kitchen sink. Knives are located in a locked drawer in the kitchen. Facility has one week of non-perishable foods, but the facility needs to have more supply of fresh fruits and vegetables. Medications were centrally stored and locked in a medication cart located in the office. Fire extinguisher was last inspected May 2026. Smoke and Carbon Monoxide detectors were tested during inspection and they were found operational. The last fire inspection conducted by Santa Rosa Fire Equipment Service was conducted on May 2026. Exit doors have auditory alert system that were functional at time of visit. Cash resources and records were reviewed. Emergency Disaster Drill has not been conducted within the last quarter. The facility has two portable generators. LPA/staff observed garbage cans needed to have a lid/cover in resident's bedrooms, facility walls need to be cleaned and shared bathroom mirror needs to be cleaned. Medications and medication records were reviewed. Water temperature in bathrooms measured at 109, 119.9 & 111.6 degrees F, which are within allowable range of 105-120 degrees F. Continued on LIC809C... Continued from LIC809... File review was initiated at 11:00 am. Ten resident and four staff files were reviewed. All residents have medical assessment on file and ten out of ten residents (R1, R2, R3, R4, R5, R6, R7, R8, R9 & R10) doesn't have current appraisal/needs and services plans on file. Three out of four staff (S2, S3 & S4) do not have 1st aid/CPR certificates on file. Two out of four staff (S3 & S4) do not have required 20 hours of annual additional training. Administrator Certificate for Nicanor Aquino 7002914740 expires October 7, 2027. During tour of the facility LPA/staff observed use of surveillance cameras located through the facility in common areas. Previously, LPA/Licensee discussed that if there were cameras located in common areas, all resident's admission agreements were needed to be updated with an addendum reflecting the use of cameras without audio in common areas. However, during file review it was revealed that admission agreements were not updated as instructed by LPA to indicate the use of surveillance cameras in the common areas. Staff agreed to elaborate an addendum to admission agreements. Facility agrees to submit updates of the following by not later than 8/7/26: corporate (LLC) documents indicating each individual's percentage (%) of ownership of the property and Liability Insurance. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 7, 2026

The state marks this report as 11 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Allegation investigated: -Residents' medications not being given per doctor's orders.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with administrative assistant, Charito Santos. The Department received an allegation of residents' medications not being given by doctor's orders. Per the reporting party, resident (R1) has not received any medications including their psychiatric and blood thinner medications in at least two to four weeks due to facility did not obtain refills for R1. Based on records review, R1’s physician report dated 4/8/26 confirmed that R1 needs assistance with medication management. According to R1’s records, R1 was admitted to the facility on 4/17/26, prescribed with the following medications: apixaban (Eliquis) 5mg tablet, one tablet by mouth in the morning and one tablet before bedtime. Quetiapine (Seroquel) 50mg tablet, take one tablet by mouth three times daily as needed for psychosis along with other medications. However, facility medication logs revealed that the above medications and six other medications were listed and signed as given until 4/20/26 by the facility staff. Continued on LIC9099C... Substantiated Continued from LIC9099... but there are gaps observed by LPA and staff (S1) in the medication logs indicating that R1 was not given their prescribed medications in a time frame between 4/20/26 until 5/28/26 at 4:30pm. Based on interviews conducted by LPA with S1, R1 arrived with a cycle of medications that lasted until 4/20/26, but there was a change of pharmacy vendors resulting in their medications were not filled by the pharmacy until 5/28/26, which was also confirmed with the pharmacy vendors. S1 was not able to provide supporting evidence of their attempts to obtain prescribed medications filled sooner for r1. Previously, on 4/4/25 the department held an office meeting with facility Co-Licensees to address ongoing areas of concern including medication management. Based on records review and interviews conducted with staff it was revealed that residents’ medications were not given by doctor’s order. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. The Department will review documentation to determine if further actions are needed. Exit interview conducted with Administrative Assistant and copy of this report was given.the state’s words, verbatim · CDSS document, Jun 8, 2026 · control 21-AS-20260605083934

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465 · Plan of correction due date: Jun 9, 2026

Type A – 87465 Incidental Medical & Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for...medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met. (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidence by: Based on LPA’s observations, records review and interviews with S1, R1 has not been assisted with their psychiatric medications between 4/20/26 through 5/28/26, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jun 8, 2026

Plan of correction: The administrative assistant agrees to review all residents’ medications to ensure that they have medications for all residents, then they will submit a written plan which addresses how facility will ensure compliance with 87465(c)(2) moving forward. The plan will be submitted to CCL by POC date in order to clear the deficiency.

Type of visit: Office

An office meeting was conducted today in the Santa Rosa Regional Office with Licensing Program Manager Victoria Bertozzi, Licensing Program Analyst Robert Frank and facility representatives, Nicanor Aquino and Tiffany Dizon. Parties previously met on 6/1/2026 to discuss the plan for this facility moving forward from the death of the Licensee. Facility has provided the following documents: Control of property Secretary of State LLC documents Facility representatives need to provide the following documents: Death certificate for Licensee Angelita Aquino Updated LLC documents No deficiencies cited during today's office meeting.the state’s words, verbatim · CDSS document, Jun 3, 2026

Type of visit: Office

An office meeting was conducted today in the Santa Rosa Regional Office with Licensing Regional Manager, Carla Nuti-Martinez, Licensing Program Managers Bethany Moellers and Victoria Bertozzi, Licensing Program Analysts Robert Frank and Marisol Cuadra, Co-Licensees of the facility, Nicanor Aquino and Tiffany Dizon regarding possible Emergency Approval to Operate (EAO) process for AA Best Care Homes # 496801684 and the Licensee's other facility, Mc Hugh Care Home 490108000. Co-licensee passed away, Nicanor Aquino and Tiffany Dizon will continue the operation of this facility. On 4/4/25, Co-licensees held an informal conference with the licensing staff to address possible options that they could choose to continue the operation of both facilities. Based on records review, LIC309 Administrative Organization form indicates that this facility is in a limited liability company (LLC) where Angelita Aquino, Nicanor Aquino and Tiffany Aquino Dizon own ten percent (10%) or more interest in LLC of this facility. During today's meeting, Co-licensees indicated their intention to continue to operate the facility and ensured that the structure change may not be 51% interest in LLC, the department will obtain clarification from centralized application unit (CAB) to review if further documentation is needed. EAO may not be required and no documentation was obtained until further guidance. Co-Licensees agree to provide the following documents with the intent of continuing operation of the facility: - Control of property – Trust Documents. No deficiencies cited during today's office meeting.the state’s words, verbatim · CDSS document, Jun 1, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management visit and met with Co-Licensee Tiffany Dizon to follow up on a self-incident report received on 5/19/26. Per incident report, on 5/13/26 resident (R1) complained of pain in their right shoulder and needed to go to the emergency room, staff called 911 immediately to transport R1 to the hospital for further evaluation. Responsible parties were notified. Based on after summary visit records, R1 was discharged back to the facility same day with a diagnosis of rash, bedbug bite, and axillary abscess. Instructions provided to R1 included an examination of R1’s bedding to take proper measurements to get rid of them and states that they didn't find any bedbug on R1's body. During today’s visit, LPA made observations, conducted interviews and reviewed documents. Based on records review, R1's physician report dated 9/11/25 indicates that R1 is capable for self-care, but the facility is responsible for laundry services of residents' beddings, R1 also has a roommate resident (R2). The facility provided room treatment log revealing that the last room treated was #11, 5 and 12 located in Wing A back on 3/4/26. Based on interviews conducted with Administrative Assistant and staff (S1) who performs the treatments, after they learned about R1's diagnosis, they went to R1's room to check and they didn't find any bedbugs, so they didn't threat the room. On 4/4/25, Licensing staff held an informal meeting with facility representatives and LPA have cited the facility to address ongoing bed bugs issues and other unrelated areas of concern, where Co- Licensees contracted a pest control vendor to provide their services to help to get rid of bed bugs at the facility to ensure resident’s health and safety. However, based on interviews and records review of after summary visits revealed that the facility still has bedbugs issues unresolved and the facility did not treated R1's room after learning of bedbugs. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. ***Civil penalties in the amount of $250 issued for repeated violation. Exit interview was conducted with Co-Licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, May 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: May 27, 2026

87303 Maintenance & Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services & procedures for the safety & well-being of residents, employees & visitors. This requirement has not been met as evidence by: Based on LPA record review and interviews conducted the facility did not ensure R1's safety & well-being, which resulted in R1 have bedbugs bite which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: The facility will submit a written plan including treatment schedule of residents' rooms to ensure facility is offering a healthful and safe area to residents in care to CCL by POC due date. ***Civil penalties in the amount of $250 issued for repeated violation.

Allegation investigated: -Fire Clearance Violation. -Facility is Not Kept Clean and Sanitary. -Resident Care Needs Not Being Met.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to delivered findings regarding the allegation listed above & met with Tiffany Dizon, Co-Licensees & Administrative Assistant, Charito Santos. The Department received an allegation of fire clearance violation. The Department learned about a report issued from an inspection conducted by another agency where there were some areas of concern identified that require immediate attention due to safety issues including missing or non-functioning smoke detectors, padlock installed on an exit door including staff’s room that can be locked from the outside, exit door does not properly close and latch, exposed electrical wiring in the shower and nonfunctional emergency lighting. Based on records review and interviews conducted with facility staff (S1) and photographs obtained by LPA as supportive evidence, it was confirmed that the violations did occur and facility staff stated that the areas of concern identified by another agency were being repaired/replaced accordingly. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. An immediate civil penalty of $500 is assessed at time of visit. Continued on LIC9099C... Substantiated Continued from LIC9099...Regarding allegation of facility is not kept clean and sanitary. The Department was provided with photographs as supportive evidence of bathroom used by residents in care has mold in the ceiling, presence of excessive clothing that prevents the door from opening fully. LPA conducted 10-day visit on 5/5/26 and based on LPA's observations mold in bathroom was present and clothing in the staff room has not been removed, then S2 arrived to remove the hanger bar that was holding the clothing, and clothing bags that were still blocking the door from opening completely. Based on records review, LPA’s interviews conducted with facility staff (S1) it was confirmed that the resident’s bathroom ceiling has mold. Also, Administrative Assistant agreed stated that they are in the process of painting the ceiling in the bathroom due to steam when residents in care take showers. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. Last allegation of resident care needs not being met. Per Reporting Party, on 5/1/26 a resident (R1) had a fall and remained on the floor overnight without assistance. Based on records review, the facility submitted an incident report on May 4, 2026, notifying the department that on April 30, 2026, around 6:00am, staff (S2) while calling residents for breakfast found R1 on the floor. However, the incident report did not address whether medical assistance was needed or not. On May 11, 2026, a second incident report was issued notifying the department that on May 7, 2026, around 12:50pm R1 complained of having pain in their left shoulder and wanted to call their case worker. Upon case worker’s arrival, they called the ambulance to take R1 to the hospital, where R1 was diagnosed with fracture of left radius initial encounter and followed up appointment with an orthopedic specialist. According to R1’s physician report dated 1/16/26, R1 is ambulatory, but has mobility limitations needing to use a cane due to immobility of left arm, and R1 has the capacity for self-care. Although R1’s admission agreement dated March 2, 2026, indicates that facility will provide continuous care and supervision. Based on LPA's observation, during visit conducted on May 5, 2026, R1 was observed walking around the facility without a cane. Based on LPA’s interviews conducted with Administrative Assistant, R1 does not have a current care plan on file. LPA conducted confidential interviews with residents (R1 & R2) where it was confirmed that during the first incident, R1 fell from their bed about 2am, remained on the floor until 6am when S2 found them on the floor, then there was a second fall incident that resulted in R1 to sustain a fracture of their left arm. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. The Department will review documentation obtained to determine if additional civil penalties are needed. Exit interview conducted with Administrator and copy of this report was given.the state’s words, verbatim · CDSS document, May 12, 2026 · control 21-AS-20260501141950

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: May 13, 2026

Type A 87202 Fire Clearance (a) All facilities shall maintain fire clearance approved by the city, county, or city & county fire department, or district providing fire protection services, or the State Fire Marshal...This requirement was not met as evidenced by: Based on LPA’s records review and interviews with facility staff, the facility failed to ensure that smoke detectors were functioning, padlocks were not installed in exit doors, exposed electrical wiring & nonfunctional emergency lighting which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Administrator agrees to repair/replace areas of concern identified by third agency report and will submit pictures as proof of corrections to clear the citation. ***An immediate civil penalty of $500 is assessed at time of visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.269(a)(6) · Plan of correction due date: May 13, 2026

Type A §1569.269 Enumerated rights; severability (a) Residents of RCFE shall have...the following rights: (6) To care, supervision, & services that meet their individual needs & are delivered by staff that are competency to meet their needs. This requirement has not been met as evidence by: Based on LPAs record review and interview with facility staff, the facility failed to meet R1's individual care needs, R1 had two incidents of falls where on the 1st incident, R1 remained on the floor since 2am until S2 found them at 6am, then a 2nd fall resulted in R1 sustained a fracture which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Administrator will have training conducted focusing on resident care plans and submit to CCL planned training date by POC due date to clear the citation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 26, 2026

Type B 87303 Maintenance & Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services & procedures for the safety and well-being of residents, employees and visitors. This requirement has not been met as evidence by: Based on LPA’s records review and interviews with facility staff, the facility failed to ensure that the facility is clean and sanitary by having mold in the bathroom’s ceiling used by residents in care and hanging excessive clothing at staff room preventing the door from opening completely which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Administrator agrees to repair/replace areas of concern identified by third agency report and will submit pictures as proof of corrections to clear the citation.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management visit and met with Administrative Assistant Charito Santos. The purpose of this case management visit is to follow up on a self reported death report submitted to Community Care Licensing (CCL) dated 4/5/26 involving resident (R1) along with incident report. LPA is following up on this death report due to R1 was not receiving hospice services when they unexpectedly passed away on 4/5/26. Per incident report, on 3/26/26 around 11:45am staff observed R1 was not at their baseline and could hardly eat, then staff called 911 immediately, paramedics transported R1 to the hospital for further evaluation. Responsible parties were notified. Per death report, “on 4/5/2026 at approximate 2:30pm, R1 passed away while in the hospital due to them not been able to breath on their own. During today's visit, LPA conducted interviews with staff, requested documentation regarding R1's health condition prior to their passing. LPA's review of R1's physician's report (LIC602) dated 12/17/24 indicates that R1's diagnosis was sepsis and urinary tract infection (UTI) and was unable to perform activities of daily living. LPA obtained R1's Needs and Services Plan (LIC625) supports physician's diagnosis. Based on interviews with staff there is no indication that they noticed anything unusual prior to R1's unexpected decease. On 4/9/26, LPA requested the facility to obtain R1's Death Certificate and provide to CCL once received. The Department will review information once is obtained to determine if further actions are needed. No deficiencies cited during today's visit. Exit interview conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 20, 2026

Allegation investigated: -Staff wrongfully evicted resident.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Administrative Assistant Charito Santos. The Department received an allegation of staff wrongfully evicted a resident. Per Reporting Party, resident (R1) was informed that they were being discharged from the crisis center to a shelter due to the facility refusing R1 to come back for unknown reasons. Based on records review, on 2/3/26 the facility submitted incident report notifying the department that on 1/30/26 around 11:00pm, R1 called 911 to complain that their life was in danger at the facility, then two police officers arrived at the facility to interview R1, the officers determined that R1 was going to be transported to the hospital for further evaluation (case #261055), and responsible parties were notified. The Police Records #261055 obtained by LPA confirmed above description of the event but did not provide any supportive evidence due to a report not being completed. Continue on LIC9099C... Unsubstantiated Continued from LIC9099... The facility provided R1’s records including their care plan and medical assessment. According to their physician report (LIC602) dated 1/9/26, R1 has a diagnosis of paranoid schizophrenia, which is addressed in R1’s care plan. Facility’s care notes dated February 6, 2026, indicate that at approximately 9:30am the facility was contacted by an outside agency individual (I1) informed them that R1’s medications should arrive prior to R1’s discharge, then another entry at approximately 9:40am revealed that I1 notified the facility that R1 will be discharged to a shelter. Last entry at 11:00am, R1 discharged from hospital to a shelter. Based on interviews conducted with outside parties (I1) confirmed that R1 was discharged to a shelter after Administrative Assistant briefly refused to take R1 back to the facility, after a couple hours due to unknown reasons Administrative Assistant contacted I1 to tell them to bring R1 back to the facility. According to Administrative Assistant, R1 has been experiencing ongoing thoughts that somebody wants to hurt or kill them (unknown names revealed). Per Administrative Assistant, the hospital wanted to discharge R1 to a shelter and they didn’t contact the facility. On 2/6/26 at approximately 9:30am, they learned that R1 had been discharged to a shelter, they subsequently at 9:40am contacted R1’s case worker to let them know that R1 could come back to the facility because they want to give them a second opportunity. LPA interviewed R1 who confirmed that they were discharged from crisis center to a place due to unknown reasons, but it was briefly, then they got picked up and were brought back to the facility. Per R1, there are no concerns about the care and supervision provided to them by facility staff. Although interviews conducted by LPA with involved parties revealed conflicting information, there was no written eviction letter issued, and it was determined that the facility refused that R1 come back to the facility for a short period of time, then they changed their mind and R1 was brought back to the facility. The finding that the allegation of staff wrongfully evicted a resident is unsubstantiated meaning 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, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Administrative Assistant and copy of report was given.the state’s words, verbatim · CDSS document, Feb 27, 2026 · control 21-AS-20260206112609

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management visit and met with Co-Licensees Tiffany Dizon and Nicanor Aquino. The purpose of this case management visit is to follow up on an informal meeting conducted on 10/29/25 in the Santa Rosa Regional Office to address concerns regarding further operation and management of the facility. On 10/29/25, LPA followed up with an email sent to Co-Licensee with instructions regarding change of ownership application. During today’s visit, LPA learned that the Co-Licensee has not submitted a change of ownership to the Centralized Application Bureau (CAB) and Co-Licensee is requesting additional guidance from LPA regarding submission of their change of ownership application to CAB. LPA explained to Co-Licensee that CAB unit handles the change of ownership applications and provided them with their contact information. No deficiencies cited during today's visit. Exit interview conducted with Co-Licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Dec 8, 2025

Type of visit: Office

An informal meeting was conducted today in the Santa Rosa Regional Office as requested by Co-Licensees Nicanor Aquino and Tiffany Dizon. Present in the meeting were Licensing Program Manager Victoria Bertozzi, Licensing Program Analysts Marisol Cuadra, Robert Frank and Co-licensees of the facility, Nicanor Aquino and Tiffany Aquino. During today’s meeting it was discussed with Co-Licensees regarding further management for this facility and the Licensee's other facility, Mc Hugh Care Home 490108000. On 4/4/25 during an informal meeting conducted options were given to Co-Licensees for them to choose to continue the operation of both facilities and they agreed to submit a change of ownership application to the Department Centralized Application Bureau (CAB). Co-Licensees provided updated email address for both facilities. No deficiencies cited during today's office meeting. Exit interview conducted with Co-Licensees and a copy of this report was given.the state’s words, verbatim · CDSS document, Oct 29, 2025

Allegation investigated: -Facility has not provided due refund as required.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Nick Aquino, Licensee and Charito Santos, Administrative Assistant. There is an allegation regarding the facility has not provided due refund as required. Per Reporting Party, resident (R1) moved out on June 9, 2025, but R1 never received due refund. On 10/24/25 LPA conducted a 10-day visit to the facility confirming through records review of a letter provided by the Licensee dated 10/14/25 from R1's representative payee services indicating that they have reconciled R1's account and discovered an overpayment made to the facility in the amount of $1420.07 as follow: check #2030925 - $1420.07 issued 6/3/25 for Jun25 Bd & care fees was cashed on 06/13/25, then check #2032473 $378.69 issued 6/3/25 for partial Jun25 Bd & Care fees was cashed on 6/30/25 along with copies of deposited checks by the facility. Continue on LIC9099C... Unsubstantiated Continue from LIC9099... The payee services have voided their original check issued for a full month of board and care fees, and re-issued a new check for R1's nine day stay prior to been relocated to a different facility. The letter was requesting if the facility could issue a refund of $1420.07 and made payable to R1 with a PO Box mailing address located in Ukiah. According to Licensee, they were not aware where R1 was residing until they received a call from R1's case worker and letter from R1's representative of their payee services inquiring for the refund, and providing an address to mail the refund, so the facility on 10/22/25 mailed R1 the requested refund check #9412 in the amount of $1420.07 to the mailing address provided with a memo stating refund and issued to R1. Although it is unclear if Licensee had knowledge or not of R1's relocation address, LPA was provided with copies of pertinent documents that indicates that the facility have mailed the refund to R1 two days prior to LPA's visit. A finding that the complaint allegation of facility has not provided due refund as required is unsubstantiated meaning 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, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Oct 24, 2025 · control 21-AS-20251021130214

Allegation investigated: -Staff yelled at resident in care.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Nick Aquino, Administrator and Charito Santos, Administrative Assistant. The Department received an allegation of staff yelling at resident in care. Per Reporting Party, on 8/13/25, they have observed Administrative Assistant (S1) with aggressive behavior towards resident (R1) and yelling at the resident (R1) for “no reason”, when R1 was brought back to the facility following an outing with their case worker, R1 asked S1 for their medication list for an upcoming neurology appointment on 8/14/25, while R1 was making the request, S1 put them off, yelled at them and told them that they were in their "own world" and R1 became visibly distressed by putting their head down and withdrawing from the conversation. During investigation LPA reviewed records, conducted interviews and made observations at the facility, LPA conducted 10-day complaint inspection on August 28, 2025. Continue on LIC9099C... Substantiated Continued from LIC9099... LPA learned based on interviews with staff (S1) and residents (R1 & R2) confirmed supporting information that S1 raises their voice to residents in care for “no reason”; S1 revealed at times raises voice due to residents and S1’s hearing challenges resulting in S1 speaks in a louder voice. LPA’s interviews revealed S1’s intent when communicating with residents in care is not to yell; But, to ensure residents in care hear communication. Although S1 wears hearing aids for both ears, S1 showed LPA their hearing aids were kept next to them, but both ear pods were still in their case. LPA inquired about the reason why they were not wearing them and S1 could not provide a reasonable response other than “I forget to wear them most of the time”. Previously, there was an unsubstantiated complaint # 21-AS-20191127093903 raised concerns regarding the same issue and the same statements were obtained from S1. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. The Department will review the information obtained to determine if any further action is needed.the state’s words, verbatim · CDSS document, Sep 18, 2025 · control 21-AS-20250819085109

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(1) · Plan of correction due date: Sep 19, 2025

Type A - §1569.269 Enumerated rights; severability (a) Residents of RCFE facilities for the elderly shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met as evidence by: Based on interviews with residents and staff, the facility staff (S1) yells at residents resulting in residents keeping their heads down and withdrawing from conversations to prevent S1 from raising their voice at them, which poses an immediate risk to the health and safety of clients in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: Licensee will conduct staff training ensuring all residents are always treated with dignity and respect. Licensee agrees to sign LIC9098 attesting understanding of Health and Safety Code 1569.269, Enumerated Rights by POC due date of 9/19/25.

Allegation investigated: -Staff did not seek timely medical for resident with scabies.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Nick Aquino, Administrator and Charito Santos, Administrative Assistant. There is an allegation regarding staff did not seek timely medical for resident with scabies. On 8/19/25 resident (R1) was admitted to the emergency room with scabies at Santa Rosa Memorial Hospital and staff did not seek timely medical assistance for R1. Based on records review, LPA obtained medical documents involving R1 dated 8/17/25 when medical assistance was needed due to R1 needed to be transported to the emergency room and scabies were noted on admission. Upon evaluation, R1 stated that their chest has been itchy for the last three weeks. R1 was discharged to Santa Rosa behavioral health due to mental challenges that need to be treated, but there was no evidence that the facility staff was made aware of R1’s diagnosis of scabies. Continue on LIC9099C... Unsubstantiated Continued from LIC9099... LPA reviewed R1’s physician report dated 12/28/22 indicates that R1 does not have a history of skin condition and they have the capacity for self-care including showering and dressing, which it was confirmed in R1’s care plan dated 3/19/25. Also, review of facility daily care notes confirms that R1 had been seen regularly by their physician. On 8/28/25, LPA conducted interviews with facility staff (S1 and S2), where it was denied by staff any signs of skin issues or rashes identified as scabies in R1’s body. During LPA’s visit on 8/28/25, LPA informed the Licensee and Administrative Assistance of R1’s diagnosis, but they stated that they were not aware of that R1 had scabies. However, facility staff did not make any efforts to check that R1’s roommate was free of scabies until LPA advised them to assess them to identify any signs of rash on their bodies as well as wash their belongings in hot water. LPA discussed the responsibility of staff to ensure resident’s health and safety instituting universal precautions and best practice when caring for the resident with scabies and/or residents in care period. LPA has concluded that there was no supporting evidence that facility staff could have been aware of R1’s diagnosis of scabies to seek medical assistance sooner because R1 did not alert staff that they were experiencing any itching. A finding that the complaint allegation of staff did not seek timely medical for resident with scabies is unsubstantiated meaning 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, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Sep 18, 2025 · control 21-AS-20250819150313

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra arrived unnanounced to conduct a Required Annual Inspection and met with Charito Santos (Administrative Assistant), Jasmine Aquino (back up Administrator) arrived later. There are outstanding annual fees in the amount of $1238. Required postings were observed. LPA/back up Administrator toured the facility at 9:00am and made the following observations: Facility was a comfortable temperature with thermostat reading at 73 degrees F. Passageways were free from obstructions. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cleaning supplies were also observed under the kitchen sink. Knives are located in a locked drawer in the kitchen. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked in a medication cart located in the office. Fire extinguisher was last inspected June 2025. Smoke and Carbon Monoxide detectors were tested during inspection and they were found operational. The last fire inspection conducted by Santa Rosa Fire Equipment Service was conducted on 5/19/25. Exit doors have auditory alert system that were functional at time of visit. Cash resources and records were reviewed. Emergency Disaster Drill has not been conducted within the last quarter (7/24/24). During last annual LPA discussed with Licensee the requirement of resident rooms needed a chair per resident per regulation, today there are some rooms needing the chair (technical violation issued). LPA/Back up administrator observed garbage cans needed to have a lid/cover in resident's bedrooms, bathrooms and living room (technical violation issued). Medications and medication records were reviewed. -At approximately 9:10am LPA/Back up administrator measured water temperature in resident's bathrooms measured at 121.8 & 121.6 degrees F, which are not within allowable range of 105-120 degrees F. Continued on LIC809C... Continued from LIC809... -At approximately 9:20am LPA/back up Administrator observed electric face plates in the dining room exposing cables, ceiling holes in resident's rooms are exposing cables, walls in room #6 needs to be painted, bathroom #6 ceiling has mold, debris of a bed in the backyard, corner walls at wing B needs to be repaired, wall in room #15 needs to be painted, shared bathroom #27 in wing B mirror needs to be replaced it has mold, hallway restroom in wing B floor needs to be repaired, there were insects: ants, spiders and spider webs inside of resident's bedrooms. Two window screens needs to be repaired or replaced. File review was initiated at 10:00 am. Nine resident and four staff files were reviewed. One out of nine residents (R1) medical assessment did not have a diagnosis (technical violation issued), nine out of nine residents (R1, R2, R3, R4, R5, R6, R7, R8 & R9) doesn't have current appraisal/needs and services plans on file. Four out of four staff (S1, S2, S3 & S4) do not have 1st aid/CPR certificates on file. According to Administrative Assistance, all staff took certification together, but they don't have the certificates as of today yet. All staff have required 20 hours of additional training. Administrator Certificate for Nicanor Aquino 7002914740 expires October 7, 2025. Today, LPA learned that back up Administrator will be submitting their documentation required to take over the administrator responsibility for this facility and the Licensee's other facility, Mc Hugh Care Home 490108000 in which Tiffany Dizon is the identified Administrator. LPA is providing required documentation to change administrator as follow by 7/31/2025: LIC 308 Designation of Facility responsibility (designation of who is the administrator), LIC 500 Personnel Report (stating the numbers of hours when Administrator will be present at the facility), LIC 501 Personnel Record, Copy of Personal ID and copy of current administrator’s certificate.Licensee also will submit updates of the following Liability Insurance and Surety bond. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. The Department will be reviewing the information obtained to determine if further actions are needed. Exit interview was conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 24, 2025

The state marks this report as 9 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: -Staff is financially abusing a client while in care.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Administrative Assistant Charito Santos. The Department received an allegation of staff is financially abusing a client while in care. Per Reporting Party, resident (R1) has mental issues including an ongoing possible delusion that they owe money to various unknown individuals that may or may not exist, but there is a staff member (S1) who R1 trusts, appears to have convinced them that they know one of the individuals that R1 believes they owe money, so R1 has been giving this individual $150 per month for the past several months to “repay” the possibly non-existent individual, where is unclear what S1 is doing with the money, but R1 believes they “should have paid everything back by now.” Based on confidential interviews conducted with staff (S1) and resident (R1) in care, S1 takes R1 out, makes purchases and R1 reimburses them when R1 receives their check. Continue on LIC9099C... Unsubstantiated Continue on LIC9099... During LPA’s visit conducted on 5/29/25, LPA was provided with copies of purchases and observed purchased items in R1’s bedroom appears to support purchases. Although, Licensee was unaware of this interaction, they have instructed S1 to stop taking R1 out to make purchases or borrowing money to them. Based on records review, police records #SR250006191 supports LPA’s findings by R1 confirmed that S1 is not doing anything wrong and do not force them to pay and they are only giving in small increments for items like cookies without any further concerns. A finding that the complaint allegation of staff is financially abusing a client while in care is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jun 13, 2025 · control 21-AS-20250528141113

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management investigation and met with Administrative Assistant Charito Santos. The purpose of this case management visit is to follow up on an informal meeting conducted on 4/4/25 in the Santa Rosa Regional Office to address concerns regarding further operation and management of the facility. Also, areas of concern regarding medication management and ongoing bed bugs’ issue. During today’s visit, LPA learned that the Co-Licensee has not submitted a change within a corporate structure application to the Centralized Application Bureau (CAB), which it was agreed to do so by not later than May 4, 2025. Also, it was agreed to contact an exterminator vendor to address ongoing bed bugs issues by not later than May 4, 2025, which Co-Licensees provided documentation of clearance of bed bug issues signed by exterminator vendor. Co-Licensee was unable to come to the facility due to illness, but updated information will be submitted to CCL. Furthermore, medication management incidents were previously addressed under complaint #21-AS-20250317092246. No deficiencies cited during today's visit. Exit interview conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, May 19, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management investigation and met with Administrative Assistant Charito Santos. The purpose of this case management visit is to follow up on a self reported death report submitted to Community Care Licensing (CCL) dated 4/17/25 involving resident (R1). LPA is following up on this death report due to R1 was not receiving hospice services when they unexpectedly passed away on 4/15/25. Per death report, “on 4/16/2024at approximate 8:45pm staff (S1) found R1 unresponsive. According to the report, most of the residents were in bed sleeping already, no one saw R1 walking or know what happened to R1 prior to their death. The facility contacted immediately 911, paramedics arrived and declared deceased. Santa Rosa Police Department were notified (SR25-4423)”. During today's visit, LPA conducted interviews with staff, requested documentation regarding R1's health condition prior to their passing. LPA's review of R1's physician's report (LIC602) indicates that R1's had auditory challenges and had the capacity to care for themselves, their diagnosis was sepsis secondary to community acquired pneumonia and acute hypoxic respiratory failure. LPA obtained R1's Needs and Services Plan (LIC625) supports physician's diagnosis. R1's care notes did not indicates any additional information that could lead to the reason of R1's decease. Based on interviews with staff there is no indication that they noticed anything unusual prior to R1's unexpected decease. According to Administrative Assistant, R1 had a heart attack and that this was probably the reason for R1's passing but they were not sure. LPA requested the facility to obtain R1's Death Certificate and provide to CCL once received. LPA clarified that R1 passed away on 4/15/25 and not 4/16/24 as stated on the death report. Administrative Assistant stated there was a typing error when preparing the death report. No deficiencies cited during today's visit. The Department will review information obtained to determine if further actions are needed. Exit interview conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 18, 2025

Allegation investigated: -Facility staff are not keeping residents free from infestation of bugs.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Charito Santos, Administrative Assistant. The Department received an anonymous complaint allegation of facility staff are not keeping residents free from infestation of bugs. Per anonymous complainant, facility staff don't care that residents are bitten up and look like they have a rash. The complainant stated that they have observed small smeared blood and what looked like bugs/ smashed bug pieces in the corner of the mattress liner/cover and unknown resident (names not provided) pulled up sleeves and there were little pinpoint bites and what looks like a rash that appeared to be caused by bed bugs or scabies, but there were smears of blood and dead small bugs in the corner of the mattress. On 4/1/25, LPA conducted 10-day visit to the facility made observations, reviewed records and conducted interviews with staff. Continued on LIC9099C... Substantiated Continue from LIC9099... Based on records review, the facility provided room treatment log revealing that the last room treated was #7 and #12 located in Wing A on 5/27/24 and 3/5/25 followed up with spray to room #12, 13, 11, 10 & 9 on 5/28/24, 5/29/24, 5/31/24, 6/2/24 & 3/4/25 respectively. Based on interviews conducted with Administrative Assistant and staff who performs the treatments, they tend to forget to document when they treat areas of the facility. However, they were unable to provide an exact date nor room of the last treatment. On 4/4/25, Licensing staff held an informal meeting with facility representatives where ongoing bed bugs issue was addressed. Licensee agreed to contact a pest control vendor to provide their services to help to get rid of bed bugs at the facility to ensure resident’s health and safety. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. An immediate civil penalty in the amount of $250 will be issued for repeated violation within the last 12-month period.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 21-AS-20250328130407

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(5) · Plan of correction due date: Apr 11, 2025

Type A §1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement has not been met as evidence by: Based on LPA record review and interviews conducted the facility did not ensure R1 was accorded safe, healthful, and comfortable accommodations which resulted in R1 have a bug infestation which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: Licensee agrees to contract a pest control vendor to come to the facility to treat all resident’s rooms to ensure facility is offering a healthful and safe area to residents in care. Licensee will submit receipts as proof of service to CCL by POC due date.

Allegation investigated: -Facility staff are not providing medication as prescribed to client.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Charito Santos, Administrative Assistant. The Department received an allegation of facility staff are not providing medication as prescribed to client. Per the reporting party, resident (R1) has not received their psychiatric medications in at least two months due to previous psychiatrist retired a while ago. Based on records review, R1 was prescribed with the following medication Risperidone F/C 4mg take one tablet by mouth every evening, Olanzapine F/C 10mg take one tablet by mouth at bedtime and Lorazepam 1mg take one tablet by mouth every four hours as needed for anxiety or insomnia. However, facility medication logs revealed that the above medications were listed, but they were not filled since December 17, 2024, as refills have run out from previous retired psychiatrist, which was also confirmed with the pharmacy vendor. Facility progress notes revealed that R1 has a history of refusal to meet with their psychiatrist on 1/16/24, 5/15/24, 10/2/24, 1/29/25. Continue on LIC9099C... Substantiated Continued from LIC9099... According to resident’s records, R1 had been hospitalized for unrelated reasons on 2/10/25 and 2/20/25. R1’s physician report dated 12/28/22 confirmed that R1 needs assistance with medication management. Based on interviews conducted with Administrative Assistant confirmed that R1 has been refusing to see their psychiatric provider for months resulting on their medications were not filled by the pharmacy. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. The Department have conducted on April 4, 2025, an informal office meeting to address areas of concerns including medication management.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 21-AS-20250317092246

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Apr 11, 2025

Type A – 87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met. (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidence by: Based on LPA’s observations, records review and interviews with Administrative Assistant, R1 has not been assisted with their psychiatric medications since 12/17/24, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: Administration to submit written plan which addresses how facility will ensure compliance with 87465(c)(2) going forward. To be submitted to CCL by POC date in order to clear the deficiency.

Allegation investigated: -Staff did not provide adequate supervision resulting in a resident wandering away from the facility. -Staff are not safeguarding residents monies.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Charito Santos, Administrative Assistant. Allegation of staff did not provide adequate supervision resulting in a resident wandering away from the facility. According to reporting party, on 3/2/25 resident (R1) was observed at Resurrection Parish church in Santa Rosa, R1 was stating that they were dropped off by somebody, but they could not state their home address, or any further details and they stated that they did not wish to return to where the unknown address where they lived. Although shelters and the police were contacted to attempt to find any leading information of R1 until the facility stated that R1 was not at the facility. Based on records review, Santa Rosa Police records SR-250610130 confirmed above information with an unfounded disposition due to the cognitive decline status that R1 was experiencing and there was no evidence of elder abuse but suggesting to R1’s responsible party the possibility to reassess and transfer R1 to a higher level of care facility. Continue on LIC9099C... Unsubstantiated Continued from LIC9099... R1’s physician report dated 1/3/2025 revealed that R1 can leave the facility unassisted without any mental challenges. However, during interviews conducted with facility staff and R1’s responsible party confirmed that R1 needs to get transferred to a memory care facility due to rapidly decline of their cognitive abilities and their actively involvement on this process to get expedited with pertinent parties. A finding that the complaint allegation occurs of staff did not provide adequate supervision resulting in a resident wandering away from the facility is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding the allegation of staff are not safeguarding residents’ monies. Per Reporting party, during the incident on 3/2/25 resident (R1) mentioned that somebody took all their money without any further details. Based on records review, the facility does not handle R1’s cash resources. During the investigation LPA conducted interviews with various parties including their case worker who confirms that R1 receives checks directly mailed to their physical address (facility address), these funds are issued by Tsunami Enterprises who is the payee services vendor, then case worker takes R1 to a financial institution to cash out the check. Although, it was revealed that there is an unclear incident regarding cleared check #2010634 dated 12/13/24 in the amount of $450. According to Tsunami representative, the incident was followed up with the bank by pertinent parties and were told that the check was cashed out by R1, if any other account details were needed, R1 will need to complete a fraudulent activity affidavit, have it notarized, then the completed form will need to be submitted to the bank to get the money refunded as well as filing a police report to have them actively investigate it, but since it’s below the felony threshold, the incident was not been able to get it resolved. Therefore, LPA was unable to determine if allegation could happen during the time of the alleged incidents. A finding that the complaint allegation occurs of staff are not safeguarding residents’ monies is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 21-AS-20250303152542

Type of visit: Office

An informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Regional Manager Carla Nuti-Martinez, Licensing Program Manager Victoria Bertozzi, Licensing Program Analysts Marisol Cuadra, Christi Coppo, Robert Frank and Co-licensees of the facility, Nicanor Aquino and Tiffany Dizon, other representatives Justice Dizon and Jasmin Dizon, via phone Nikki Aquino. The purpose of the informal conference is to address concerns regarding further operation and management for this facility and the Licensee's other facility, Mc Hugh Care Home 490108000 in which Tiffany Dizon is the identified Administrator. Also, areas of concern regarding medication management, hospice care/responsibilities related to hospice care and recurrent bed bugs’ issue. During today’s meeting it was discussed with Co-Licensees the possible options that they can choose to continue the operation of both facilities due to Co-Licensee’s Angelita Aquino health challenges. Based on records review, LIC309 Administrative Organization form indicates that this facility is in a limited liability company (LLC) where Angelita Aquino, Nicanor Aquino and Tiffany Aquino Dizon own ten percent (10%) or more interest in LLC of this facility. The current options discussed are the following: - Submit a change within a corporate structure application to the Centralized Application Bureau (CAB). Continues on LIC809C... Continued from LIC809... -Create a new corporation or LLC and submit a change of ownership application to CAB for both facilities. Co-Licensee informed that they will be submitting change in the structure application to CAB by not later than May 4, 2025. CAB contact information was provided. Also, it was agreed to contact an exterminator vendor to address ongoing bed bugs issues by not later than May 4, 2025. Co-Licensees were informed that other representatives need to be associated to the facility. Licensing staff discussed Technical Support Program (TSP) that offers advice, guidance, a review of facility operation, discusses best practice, and required regulation/hsc compliance. No deficiencies cited during today's office meeting. Exit interview conducted with Co-Licensees and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 4, 2025

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Cuadra and Contreras conducted an unannounced subsequent case management and met with Administrative Assistant Charito Santos. The purpose of this subsequent case management visit is to continue the follow up on a death certificate to Community Care Licensing (CCL) dated 2/3/25. Previously on 2/4/25 LPA have requested Death Certificate due to resident was not receiving hospice services when they unexpectedly passed away on 2/1/25. During today's visit LPA conducted interviews with additional residents in care and requested additional documentation regarding R1's health condition prior to their hospitalization on 1/31/25. According to SIR dated 2/3/25; On 1/31/25, R1 was taken by ambulance to the hospital after R1 was unable to walk or put pressure on their leg. Facility staff (S1) noticed that R1 had a wound on their ankle. R1 was transported from the facility to the hospital where they passed away on 2/1/25. Based on records review, R1's physician report dated 6/25/24 did not have a history of any skin condition or breakdown, they had the capacity to perform self-care of activities of daily living including showers, dress, grooming and toileting needs. On 2/4/25, LPA Coppo previously obtained pertinent documentation and interviewed staff. R1's progress notes for the months of August 2024 to January 2025 indicates other health condition unrelated to the wound on their ankle either. No deficiencies cited during today's visit. The Department will review information obtained to determine if further actions are needed. Exit interview conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 11, 2025

Allegation investigated: -Staff did not keep residents free from bed bugs.

Licensing Program Analysts (LPAs) Cuadra and Deniz arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Charito Santos, Administrative Assistant. The Department received an allegation of staff did not keep residents free from bed bugs. The reporting party stated that resident (R1) was observed to have a bug infestation and an infection. LPA conducted 10-day visit on 1/7/25 obtained pertinent records and conducted interviews with Administrative Assistant. The Administrative Assistant told LPA that it had been hard to get rid of bed bugs, but they are treating resident’s rooms in a regular basis. However, based on LPA’s records review of facility internal temperature logs, it revealed that the last time they have treated resident’s rooms was on May 2024. Per Administrative Assistant, the staff have been forgetting to maintain the log in a regular basis, but R1’s room have been treated after been notified of the presence and lack of treatment of bedbugs in the facility. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. An immediate civil penalty in the amount of $250 will be issued for repeated violation within the last 12-month period. Substantiatedthe state’s words, verbatim · CDSS document, Feb 13, 2025 · control 21-AS-20250102163018

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.269(a)(5) · Plan of correction due date: Feb 14, 2025

§1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement has not been met as evidence by: Based on LPA record review and interviews conducted the facility did not ensure R1 was accorded safe, healthful, and comfortable accommodations which resulted in R1 have a bug infestation which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2025

Plan of correction: Licensee agrees to submit a plan/schedule to ensure facility is following up on resident’s needs, observation of the resident and treating all resident's rooms timely to CCL by POC due date. ** Civil Penalty assessed in the amount of $250.

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Cuadra and Deniz arrived unannounced for the purpose of conducting a case management to follow up on Administrator certificate and met with Administrative Assistant Charito Santos. Licensee Nick Aquino was not able to come to the facility due to been out of the country, but LPAs held a conversation via phone with Tiffany Dizon who is Administrator at their sister facility Mc Hugh Care Home. On 6/28/23 an informal meeting was conducted in the Santa Rosa Regional Office to address concerns regarding Administrator certification at this facility and the Licensee's other facility, Mc Hugh Care Home 490108000 in which Tiffany Dizon is the identified Administrator. During annual inspection on 7/23/24, LPA have issued citations to the facility due to not having supporting evidence that submitted required documentation received by the Department's certification unit and Licensee agreed to re-submit it timely. On 7/25/24, the facility submitted certified mail tracking number dated 7/25/24 with Sacramento department's address on it to CCL to clear the citation. However, on 12/5/24, LPA have followed up with the Department's certification unit to verify that documentation mailed was received, but they stated that they had staff trying to work with them to resolve their incomplete application for almost an entire year. After multiple notices the certification unit withdrew their application due to failure to follow up and comply with Administrator Certification renewal requirements and lack of communication to remediate their application in a timely manner for both facilities. During today's visit, LPAs have a discussion with Tiffany via phone regarding this issue and was told that it has been hard to appoint a certified administrator to fill out the administrator position, which it has been the same reason given to the Department on 12/6/24 by Nick. Per Tiffany, Nick has completed and submitted Administrator certificate for further processing. However, Licensee keep failing to follow up on their submitted application to the certification unit. LPA will be issuing a citation and civil penalties on the amount of $250. Licensee have been informed that if they don't comply with regulations additional civil penalties will be warrant until this issue gets resolved.Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Exit interview was conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Feb 13, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Feb 21, 2025

87405 Administrator - Qualifications and Duties 87405 (a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: Based on LPA's/Licensee observation, interviews and record review, the licensee did not comply with the section cited above in that Licensee/Administrator keeps failing to follow up with the Department Certification Unit, which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2025

Plan of correction: Licensee will appoint a certified administrator for this facility and will submit required documentation to perform this change to the Department by POC due date 2/28/25. Licensee have been informed that if they don't comply with regulations civil penalties will be warrant until this issue gets resolved. A civil penalty in the amount of $250 issued.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management investigation and was greeted by House Manager/Administrative Assistant, Charito Santos. Administrator Nicanor Aquino is out of the country and not available. On 2/3/25 CCL received from facility an Incident Report pertaining to resident (R1). On 1/31/25, R1 was taken by ambulance to the hospital after R1 was unable to walk or put pressure on their leg. Facility staff S1 noticed that R1 had a wound on their ankle. R1 was transported from the facility to the hospital by ambulance due to R1 being unable to walk or put pressure on their leg. All required parties notified. On 2/1/25, the facility was notified that R1 had passed away. LPA conducted interviews, reviewed documents, and received copies of documents. LPA's review of R1's most recent Appraisal, Needs, and Services Plan (LIC625) indicates that R1 takes care of their own grooming, showers themselves, but needs reminding to change their incontinence brief. LPA's review of R1's most recent physician's report (LIC602) indicates that R1's capacity for self-care is affirmative with the exception of managing their own cash resources; R1 has the ability to bathe, dress, feed, groom, and care for their own toileting needs. LPA interviewed S1 and asked if they had ever noticed a wound on R1's ankle or if R1 ever had any wounds period. S1 answered that they had never seen any wound on R1 before this morning. S1 explained they saw the wound as they were helping the resident to their feet and with their incontinence brief. S1 explained that R1's medical diagnosis sometimes impairs them and it is during these times that they help R1 with stability. S1 always goes in at the beginning of their shift to change the bed chucks and see if R1 has a soiled brief. R1 does not always soil their briefs, they only wear them in case of accidents. S1 asked R1 to stand and that Continued on 809C.... Continued from 809... is when R1 told S1 that they could not stand without too much pain. S1 noticed the wound on R1's ankle and asked them how the wound got there. R1 answered that they did not know. S1 asked R1 how long has the wound been there because they never saw it before, R1 answered that they did not know. LPA interviewed HM. HM reported to LPA that R1's responsible party (RP) indicated that there was an issue with R1's lungs as they had a long history of smoking and that this was probably the reason for R1's passing but they were not sure. HM reported to LPA that they have asked R1's RP for R1's Death Certificate to provide to CCL once received. No deficiencies cited during this visit.the state’s words, verbatim · CDSS document, Feb 4, 2025

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Cuadra and Frank arrived unannounced for the purpose of conducting a case management to follow up on Administrator certificate and met with Administrative Assistant Charito Santos. Licensee Nick Aquino was not able to come to the facility, but LPA's held a conversation via phone. On 6/28/23 an informal meeting was conducted in the Santa Rosa Regional Office to address concerns regarding Administrator certification at this facility and the Licensee's other facility, Mc Hugh Care Home 490108000 in which Tiffany Dizon is the identified Administrator. During annual inspection on 7/23/24, LPA issued a citation to the facility due to not having supporting evidence that submitted required documentation received by the Department's certification unit and Licensee agreed to re-submit it timely. On 7/25/24, the facility submitted certified mail tracking number dated 7/25/24 with Sacramento department's address on it to CCL to clear the citation. However, On 12/5/24, LPA have followed up with the Department's certification unit to verify that documentation mailed was received, but they stated that they had staff trying to work with them to resolve their incomplete application for almost an entire year. After multiple notices the certification unit withdrew their application due to failure to comply with Administrator Certification renewal requirements and lack of communication to remediate their application in a timely manner for both facilities. During today's visit, LPA have a discussion with Licensee via phone regarding this issue and was told that it has been hard to appoint a certified administrator to fill out the administrator position. Per Nick, the hours needed to be completed to have their administrator certificate had been completed and they are in the process to submit required documentation for further processing. However, Licensee agreed to appoint a certified administrator who will spend at least 20 hours in each facility. LPAs will be issuing a citation and Licensee have been informed that if they don't comply with regulations civil penalties will be warrant until this issue gets resolved. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Dec 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Dec 16, 2024

87405 Administrator - Qualifications and Duties 87405 (a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: Based on LPA's/Licensee observation, interviews and record review, the licensee did not comply with the section cited above in that Licensee/Administrator Nick Aquino does not have a certified administrator from CCL, which poses a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 6, 2024

Plan of correction: Licensee will appoint a certified administrator for this facility and will submit required documentation to perform this change to the Department by POC due date 12/16/24. Licensee have been informed that if they don't comply with regulations civil penalties will be warrant until this issue gets resolved.

Allegation investigated: -staff did not meet resident's hygiene and grooming needs.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Administrative Assistant, Charito Santos. The Department received an allegation of staff did not meet resident's hygiene and grooming need. Per Reporting party, resident (R1) was transferred to another licensed facility on 7/23/24. Upon arrival, the receiving facility stated that R1 arrived with extreme matted, and lice infested hair. On 8/8/24, LPA received written statements dated 8/2/24 from the receiving facility identifying R1’s admission as of 7/23/24 and detailing their nurse (LVN) intake assessment findings of hair, nails, and body as follow: “the assessment of resident’s head is conducted at the facility for any signs of dandruff, psoriasis, lesions, open wounds and/or lice. However, they were unable to perform the assessment due to R1’s hair being severely matted on both the top and bottom halves of their head, each standing up to about 3 to 4 inches off their head. Continue on LIC9099C... Substantiated Continued from LIC9099... They assessed along their hair line due to severity. R1 had a crown on the top of their head and a clip of the back, which were difficult to remove, but once done, they applied conditioner to soften the hair. At that time, they were able to open the matted hair into two halves and noticed the infestation of lice and knits. Staff took turns to work on R1’s hair for almost four hours to complete the removal of lice.” A picture of hair was provided to the Department as well as another written statement signed by receiving facility house manager confirming the same information. During this investigation, the facility provided LPA with R1’s physician report dated 1/19/24 indicating that R1 was able to care for themselves and perform all. However, based on records review of R1’s admission agreement, it was agreed by the facility and R1 that the facility will assist with daily living activities including hygiene and grooming needs. Also, R1’s care notes revealed that on 7/2/24 staff smelled bad odor coming from R1’s clothing and body. Per daily care notes, staff requested to R1 to take a shower, but R1 refused to take a bath. The facility did not assist R1 with hygiene and grooming needs as agreed in their admission agreement. After reviewing incident reports log from the facility, LPA was unable to find any reports made to R1’s responsible parties including CCL about this incident and no further details were documented into the facility daily care notes regarding R1’s not taking showers. On 7/23/24 R1 was evicted from the facility due to unrelated reasons to this complaint. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. An immediate civil penalty in the amount of $250 will be issued for repeated violation within the last 12-month period.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 21-AS-20240725143740

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(5) · Plan of correction due date: Aug 30, 2024

§1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement has not been met as evidence by: Based on LPA record review and interviews conducted the facility did not ensure R1 was accorded safe, healthful, and comfortable accommodations which resulted in R1 sustained extreme matted, and lice infested hair which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: Licensee/Administrator agrees to submit a plan/schedule to ensure facility is following up on assisting resident’s needs including hygiene and grooming timely to CCL by POC due date. **Immediate Civil Penalty assessed in the amount of $250.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting a case management to follow up on Administrator certificate and met with Charito Santos, Administrative Assistant. On 6/28/23 an informal meeting was conducted in the Santa Rosa Regional Office to address concerns regarding Administrator certification at this facility and the Licensee's other facility, Mc Hugh Care Home 490108000 in which Tiffany Dizon is the identified Administrator. During annual inspection on 7/23/24, LPA issued a citation to the facility due to not having supporting evidence that submitted required documentation was received by the Department's certification unit and Licensee agreed to re-submit it timely. On 7/25/24, the facility submitted certified mail tracking # 9589 - 0710 - 5270 - 2020 - 4761-14 dated 7/25/24 with Sacramento's address on it to CCL to clear the citation. However, On 8/21/24, LPA have followed up with the Department's certification unit to verify that documentation mailed was received, but they stated that they did not receive any renewal/new application documentation for any of both facilities. During today's visit, LPA have a discussion with Administrative Assistant regarding this issue and was told that Licensee is waiting to fix the computer, so they will be able to submit required documentation via online, but they were not able to provide a date to do so. The Department have previously cited for this issue and will be reviewing the information obtained to determine further actions. No deficiencies cited during today's meeting. Exit interview conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Aug 29, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra arrived unnanounced to conduct a Required Annual Inspection and met with Charito Santos (Administrative Assistant), Nicanor Aquino (Licensee) arrived later. Annual fees are current. Required postings were observed. LPA/Administrative Asst. initiated the tour at 9:00am and made the following observations: Facility was a comfortable temperature with thermostat reading at 76 degrees F. Passageways were free from obstructions. Resident rooms needs a chair per resident per regulation (technical violation will be issued). During the tour of the facility LPA/Administrative Asst. bserved water temperature in resident bathroom measured at 124.3, 126.7, 106.1 and 126.3 degrees F, which are not within allowable range of 105 to 120 degrees F. Staff adjusted water heater immediately (Technical violation will be issued). Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cleaning supplies were also observed under the kitchen sink. Bathroom #2 windowsill have paint bubbles need to be cleaned; bathroom #1 sink needs to be cleaned; Resident's room (room # 10, 11, 13 and 17) window screens are missing. Face plate in room #10 needs to be replaced. Knives are located in a locked drawer in the kitchen. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked in a medication cart located in the office. Fire extinguisher was last inspected May 2024. Smoke and Carbon Monoxide detectors were tested during inspection and operational. Exit doors have auditory alert system that were functional at time of visit. Cash resources and records were reviewed. Emergency Disaster Drill has not been conducted within the last quarter. Medications and medication records were reviewed. Continued on LIC809C... Continued from LIC809... File review was initiated at 10:00 am. Five resident and four staff files were reviewed. Medical assessments, appraisals/needs and services plans are current. Staff have required First aid and CPR certificates. However, four out of four staff do not have required 20 hours additional training hours. Administrator Certificate for Nicanor Aquino 6010494740 expired October 7, 2023. Although, the licensee stated that they are taking required training hours. There is no supporting evidence that they have submitted any required documentation for the Department to review, LPA reached out to the administrator certification unit on 7/17/24 and they have not received a renewal/new application from any of the two licensees. The Department will be reviewing the information obtained to determine if further actions are needed. During today's visit, LPA is also following up on SOC341 along with an incident report submitted to the Department on 6/20/24 involving two residents (R1 & R2). Per incident report, on 6/18/24 around 7pm, staff was assisting R1 with medications when R1 complained that there were only four medications and one was missing. Staff clarified to R1 that there were five tablets, but R1 kept insisting that there were only four tablets. R1 became anger, confronted R2, who was sitting in front of R1 that they have the right to complaint to staff, then both residents started pushing and hitting each other until R1 spit on R2. Staff called 911 immediately, police arrived and talked to both of them (SR #241700309). Later, R1 found the missing tablet under their table, then R1 stated that they accidentally dropped the tablet and apologized for their behavior. Responsible parties were notified. According to staff no further incidents have happened. Licensee agreed to submit updates of the following by 8/13/2024: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Copy of Liability Insurance and Surety bond. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 23, 2024

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting a case management to follow up on three self-incident report filed by the facility to CCL and met with facility Licensee, Angelita Aquino and Administrative Assistant Charito Santos. On 5/24/24 the Department received the first incident report indicating that on 5/21/24 around 5:45 pm resident (R1) approached staff to inform them that they were depressed and had a suicidal thought. Staff called 911 immediately to transport them to the Hospital. Also, the facility notified the responsible parties. R1 was admitted to the hospital for further evaluation and discharged same day with a diagnosed of diabetes with high blood sugar and suicidal thought. R1's case worker came next day to discuss a plan to sign-up R1 into a wellness center or Interlink at least three times per week and case worker agreed to drive R1 to the places. The second incident report, notifies the department that on 5/28/24 around 5:35pm staff observed R1 was anxious and crying, so staff decided to call 911 to transport R1 to the hospital for further evaluation. Responsible parties were notified. During today's visit, LPA was told by Administrative Assistant that the facility had to issue a 30 day eviction letter to R1 dated June 1, 2024 and their responsible party due to behavior and violation of house rules by returning to the facility on 5/21/24 and 5/28/24 dates under the influence of alcohol and/or illegal drugs. R1's records were reviewed by LPA including their care plan, Physician's Report (LIC602) and discharge documents dated 5/21/24 and 5/28/24 with no follow up appointment needed with their Physician. Continues on LIC809C... Continued from LIC809... The last incident report received on 6/4/24 notified CCL regarding resident (R2) who on 5/29/24 around 7:00pm staff and two residents (R3 and R4) witnessed them lighting a glass pipe. Also, R2 was observed by R5 taking their stuff away unstoppable. Staff called the police who came and told the staff that R2 was under the influence and needed to be transported to the hospital for further evaluation, then they receive a diagnosis of methamphetamine abuse and addiction. The facility was referred to call in-response team for future assistance until resident gets relocated to a facility able to meet their needs. Responsible parties were notified. During today's visit, LPA was provided a copy of 30 day eviction letter to R2 dated June 1, 2024 and their responsible party due to violation of house rules by been under the influence of alcohol and/or illegal drugs on 5/29/24. LPA reviewed documents, facility is ensuring that residents (R1 & R2) are closely monitored and supervised by staff for their safety or other's residents health and safety. Based on records review, the facility has taken appropriate measures to address the incidents. Also, eviction notices given to both residents will be reviewed by the Department to determine if they are lawful. No deficiencies cited during today's visit. Exit interview conducted with Licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Jun 6, 2024

Allegation investigated: -Facility is not meeting resident's care needs.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Administrative Assistant Charito Santos. The Department received an allegation of facility is not meeting resident's care needs. Per Reporting party, resident (R1) was observed to be unclean, unkept with black dirty caked fingernails, dirty, dry skin with multiple open small wounds to anterior chest from bug bites, wounds to posterior back, sacrum, and bilateral heels with dried blood spots. On 4/25/24, the department received a call from an agency cross-reporting additional information regarding same allegation. Per reporting party, R1 was observed with dirt under their nails and was infested with bed bugs and mites. In addition, it was reported that another resident (R2) was observed during regular checkup on 4/19/24 with lice and it appeared that R2 had not been bathed properly. Continue on LIC9099C... Substantiated Continued from LIC9099... On 5/1/24, the department received a second call from another agency reporting additional information regarding the same allegation. However, this incident was involving three other residents (R2, R3 and R4) who were transported to a regular checkup, but as R2 pulled up their sleeve for blood test, it was noticed bugs attached to R2’s arm with possibly under the skin, along with some long black marks. Based on LPA’s records review, on 4/6/24 the Santa Rosa Police Department have conducted a welfare visit to the facility (event # SR2400040510), where findings resulted in a case closed disposition and referral to another agency due to findings of bed bugs, lack of cleaning and maintaining logs updated. The facility provided records of internal temperature log documentation that indicates that the facility had been treating resident’s rooms in a regular basis, but R1’s room revealed that the last treatment was conducted on 10/25/23. Based on observations, LPA conducted an unannounced visit to the facility on 4/9/24. During this visit, LPA toured resident’s bedroom and observe the facility appeared to be clean, safe and in sanitary condition. Although, LPA is unable to determine if an area of the facility was clean and sanitary condition at a prior date. On 5/3/24, the facility notified the department that they have treated R2’s bedroom and confirmed that R2’s room has not been treated since September 2023. After been notified of the presence and lack of treatment of bedbugs in the facility. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given.the state’s words, verbatim · CDSS document, May 21, 2024 · control 21-AS-20240405140542

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.269(a)(5) · Plan of correction due date: May 22, 2024

Type A §1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement has not been met as evidence by: Based on LPA record review and interviews conducted the facility did not ensure R1 was accorded safe, healthful and comfortable accommodations which resulted in R1 and R2 sustaining injuries which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 21, 2024

Plan of correction: Licensee/Administrator agrees to submit a plan/schedule to ensure facility is following up on resident’s needs, observation of the resident and treating all resident's rooms timely to CCL by POC due date.

Allegation investigated: -Staff member slapped resident in care. -Staff member yelled at resident in care. -Facility is in disrepair.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Administrative Assistant Charito Santos. The Department received an allegation of staff member slapped resident in care. Per reporting party, on 1/10/2024 at around 3:45 pm a staff member (S1) slapped resident (R1) on their hand after they got into a verbal altercation. According to the reporting party, at some point S1 looked like they were going to hit R1 with the mop, but they allegedly slapped R1 on their hand instead. However, the reporting party stated that R1 did not have any marks or bruising. Based on records review of Santa Rosa Police case # SR240000425, the statements obtained resulted in an unfounded case disposition and R1 denied prosecution of S1. LPA conducted confidential interviews with involved parties including staff and residents concluded that the incident could happened, but there was no information obtained or any indication of physical abuse to support that the alleged violation occurred. A finding that the complaint allegation staff member slapped resident in care is unsubstantiated meaning 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, therefore the allegation is UNSUBSTANTIATED. Continues on LIC9099C... Unsubstantiated Continued from LIC9099... Another allegation of staff member yelled at resident in care. Per reporting party, on 1/10/2024 at around 3:45 pm a staff member (S1) came into R1’s room while resident was on a private call with somebody, S1 stated that they were coming in to mop R1’s floor, R1 told S1 no do not to come in because they were on a private phone call and S1 came in anyway, both got into an argument and S1 was yelling at R1. The reporting party added that they did not report this incident to any staff/management, but a lot of other residents heard the verbal altercation. Based on records review of the facility daily care notes on 1/10/24 S1 notified facility management that R1 grab their mop, screamed, cursed at S1, throw mop away while S1 was cleaning R1’s room. Also, it was confirmed on daily progress notes about the police officers that came out to the facility on 1/11/24 and the unfounded case disposition regarding this allegation. Based on interviews conducted by LPA on 2/8/24 with staff (S1, S2 S3 & S4) and residents (R1, R2, R3, R4) in care, there was conflicting information obtained from involved parties that confirmed that there was an incident with involved parties. However, there was no supporting evidence that S1 yelled at resident in care. A finding that the complaint allegation staff member yelled resident in care is unsubstantiated meaning 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, therefore the allegation is UNSUBSTANTIATED. The last allegation received facility is in disrepair. Per reporting party, the facility has a window in bedroom located in the back of wing "A" that it has been taped due to a crack on it. Based on LPA’s records review, this allegation had been previously investigated and determined unsubstantiated under complaint# 21-AS-20231221092901. Based on records review of the facility daily care notes there is no indicative that any window in the facility is in the process or needed to be repaired. During the investigation, LPA/staff toured the facility inside and outside, the tour of the physical plant on 1/18/24, 2/8/24 and 2/27/24, where the facility windows appear to be clean, safe and in good repair. Based on LPA’s confidential interviews conducted with other residents (R2, R3 and R4) no concerns were raised regarding accommodations, buildings and grounds provided by the facility. LPA has determined and confirmed that although the facility including bedrooms and bathrooms were clean and in a sanitary condition on recent LPA inspections conducted on 1/18/24, 2/8/24 and 2/27/24, LPA is unable to determine if an area of the facility was in disrepair at a prior date. A finding that the complaint allegation facility is in disrepair is unsubstantiated meaning 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, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during today's inspection. Exit interview conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 21-AS-20240111095236

Allegation investigated: -Enumerated Rights/Staff failed to treat resident with dignity and privacy. -Facility is not clean, safe, or sanitary. -Facility staff are not ensuring residents have clean bed linens. -Personal Rights. -Medications not being given per doctor's orders.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Administrative Assistant Charito Santos. The Department received an allegation of staff failed to treat a resident with dignity and privacy. Per reporting party, on 12/20/23 around 11:10pm, three staff (S1, S2 & S3) were observed coming to resident (R1) bedroom, turned on the lights, stared at R1 for a while for no reason, they were talking in a foreign language that sounded like Filipino and then left the bedroom. Based on review of facility records of R1’s care notes do not indicate that R1 had brought to their attention the alleged incident. Based on confidential interviews conducted by LPA on 2/8/24 and 2/27/24 with residents and staff, LPA was unable to find any supporting evidence that staff could or not have treated residents with dignity and privacy violation occurred. A finding that the complaint allegation occurred of staff failed to treat a resident with dignity and privacy is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continues on LIC9099C... Unsubstantiated Continues from LIC9099... Regarding allegation facility is not clean, safe, or sanitary. Per Reporting party, the facility has lead paint in west wing of facility, paint bubbles on R1’s bedroom ceiling and bathroom windowsill contain lead where staff put new rolls of toilet paper for residents to use. During the investigation, on 2/8/2024 and 2/27/2024 LPA/staff toured, made observations at the facility including all bedrooms and bathrooms used by residents in care. During the tour of the physical plant the bedrooms and bathrooms appeared clean, free of odors and sanitary. Based on LPA’s observations, the paint bubbles on R1’s bedroom ceiling and bathroom windowsill were in acceptable condition, no issues were observed. LPA conducted interviews with staff and residents on the same dates, they did not express any concerns about the physical plant of the facility. Based on LPA’s interviews and observations, LPA has determined and confirmed that although the bathrooms were clean and in a sanitary condition on recent LPA’s inspections conducted on 2/8/2024 and 2/27/2024, LPA is unable to determine if an area of the facility was unclean or unsanitary condition at a prior date. A finding that the complaint allegation occurred of facility is not clean, safe, or sanitary is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Another allegation about the facility staff is not ensuring residents have clean bed linens. The reporting party alleges for over a week staff had been asked to have bedding changed as it now smells of urine, but staff (S4) came in on 12/20/23 and swept under other’s resident bed and changed their bedding. However, R1’s bedding was never changed by any staff. Also, R2’s had three blankets that needed to be washed as well. Based on records review of facility daily care notes, on 12/11/23 it was brought to their attention that R1 demands to do their laundry at least twice per week. During the investigation, on 2/8/2024 and 2/27/2024, LPA conducted confidential interviews with four residents (R1, R2, R3 & R4) and four staff (S1, S2, S3 & S4) who told LPA that the facility has specific staffing (S1) to change beddings once per week or as needed. Based on LPA’s observations, on 2/8/2024 and 2/27/2024 LPA/staff toured the facility including three beds that were made and five of the residents were in their beds including R1 (R1, R2, R3, R4 & R5). LPA observed that one of the nine beds inspected was unmade but had been stripped of its linens and the housekeeper was in the process of making it up. S1 stated that the rooms are cleaned thoroughly once per week and if the room is not on the housekeeping schedule that day, other staff are able to make up the bed. Three out of four residents interviewed did not report any complaints about the housekeeping staff or cleanliness of the rooms. Continues on LIC9099... Continued from LIC9099C... A finding that the complaint allegation occurred of facility staff is not ensuring residents have clean bed linens is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An allegation of personal rights was received by the Department. Per reporting party, there is another resident (unknown) who walks around the facility naked, and staff don’t do anything about it. Based on records review of facility daily care notes during the months of December 2023 and January 2024, there are no incidents reporting any resident walking around the facility naked. During the investigation, on 2/8/2024 and 2/27/2024, LPA made observations and conducted confidential interviews with four residents (R1, R2, R3 & R4) and four staff (S1, S2, S3 & S4). Based on their responses there were no concerns around this type of incident where any resident was observed walking around the facility naked, residents expressed that they feel safe in the facility. A finding that the complaint allegation personal rights is unsubstantiated meaning 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, therefore the allegation is UNSUBSTANTIATED. Regarding allegation of medications not being given per doctor's orders. It was alleged that a resident (R1) takes 10 medications, but they were only given 6. The Reporting party was unable to provide which dates this allegedly happened and what medications were missing. Based on LPA’s records review and observations made at the facility on 2/8/24, LPA performed a spot check of 5 out of 25 resident's (R1-R5) medications including R1's medications. LPA was not able to find any issues with resident’s medications. R1 was prescribed with tamsulosin HCL 0.4mg - 1 tab daily, metformin 1000mg - 1 tablet by mouth twice daily, gabapentin 100mg - 2 capsules by mouth three times daily, risperidone 2mg - 1 tablet by mouth twice daily, benztropine 0.5mg - 1 tablet by mouth twice daily, amlodipine 10mg - 1 tablet by mouth once daily, then the following medication were prescribed as needed acetaminophen 325mg – 2 tablets as needed every 8 hours for pain, ibuprofen 400mg – 1 tablet as needed for pain and calcium antacid 750mg – chew and swallow 1 to 2 tablets as needed for heartburn or diarrhea. Based on the Centrally Stored Medication and Destruction (CSMD) log, all doses of medications were listed on the facility medication records to have been dispensed as ordered by the resident's physician as prescribed in R1’s physician report dated 8/27/2023. A finding that the complaint allegation medications not being given per doctor's orders is unsubstantiated meaning 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, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Mar 7, 2024 · control 21-AS-20231221092901

Allegation investigated: -Residents are smoking in the facility

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Administrative Assistant Charito Santos. The Department received an allegation of residents smoking in the facility. Per Reporting Party residents (unknown names provided) smoke inside the facility. Sometimes they will step right outside the door and light up causing smoke to come into the facility including resident’s room, and they are not smoking in the designated area. Based on records review, there was no clear evidence that any resident had been given a warning about smoking in the facility. Based on interviews conducted with the Administrative Assistant, there was a resident (R1) who complained about other residents smoking or the smell of smoke coming in the facility. Although, contradictory information was obtained after conducting confidential interviews with residents in care on 2/8/24. The facility has conducted an internal investigation that resulted in finding that residents who smoke frequently have their clothing constantly smelling like smoke. Continues on LIC9099C... Unsubstantiated Continued from LIC9099... Per interviews conducted with staff and residents it was disclosed that staff usually does laundry once per week. Residents have been reminded to smoke only in designated areas and the facility will re assign a different area for them to smoke their cigarettes to mitigate the impact of smoke coming into the building from the outside. A finding that the complaint allegation of residents is smoking in the facility is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Feb 27, 2024 · control 21-AS-20231214125544

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting a case management to follow up on SOC341 along with a self-incident reports and met with facility Administrative Assistant, Charito Santos. On 2/5/24 at approximate 5:30pm staff (S1) called 911 due to a resident (R1) was making threats to shoot S1 and burn the facility. The incident started when S1 asked R1 if they could wash their beddings and R1 replied ok, then S1 noticed trash in a small bag, R1 took the trash bag, but R1 approached S1 requesting the trash bag back to them. They both went back to R1's bedroom to search for the bag when they couldn't find it, R1 told S1 the following: "I will get a gun and shoot you and will burn down this facility". The police officer arrived and file a case report #240360217. The facility notified responsible parties including CCL. During today's visit, LPA reviewed records and conducted interviews with staff. Per S1, R1 apologized to them after the incident. R1 also had an appointment to see their physician on 2/7/24 at 1pm, but the appointment was postponed until unknown date. Per Charito, the facility is in the process of issuing a 30-day eviction notice to R1 due to the threats to the facility including residents in care. The Department will review documents received. No deficiencies during today's visit. Exit interview was conducted with Administrative Assistant and a copy of this report was given.the state’s words, verbatim · CDSS document, Feb 8, 2024

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting a health check visit and met with facility Administrative Assistant, Charito Santos. This case management inspection is to conduct a health and safety check and ensure that facility is clean and good repair. Upon entrance to the facility, LPA/staff observed a sign stating that living room will be open until 5am. Per Administrator, on 12/6/23 there was an incident where one resident have urinated and defecated in the living room, and they have to close the living room for cleaning. During today's visit, LPA conducted confidential interviews with staff and residents in care who indicated that the living room was closed two days ago for a couple hours only. Although, staff did not take the sign off the door, there are no indications that living room was closed for more than two hours for cleaning, residents were observed in the living room engaged in activities as well as watching the television. LPA/staff toured the facility and observed one of resident's bedroom door was missing and piece of cloth was clipped to the door frame to ensure resident's privacy. Per Charito, the resident who sleeps in the bedroom experiences aggressive behaviors when closing forcefully the door, the hinges were loose, so staff removed the door to fix it since 12/2/23 afternoon and it has not been fixed yet. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. ***civil penalties are issued for repeated violation in the amount of $250. Exit interview was conducted with Administrative Assistant and copy of the report was given.the state’s words, verbatim · CDSS document, Dec 8, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Dec 9, 2023

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: Based on observation, the licensee did not comply with the section cited above because LPA/staff observed one resident's bedroom door was missing, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 8, 2023

Plan of correction: Licensee agreed to repair the door to ensure resident's privacy. Licensee will submit self-certification LIC9098 form along with picture to indicate that repairs are within CCL regulations by POC due date. *civil penalties are issued for repeated violation in the amount of $250.