A Loving Home

Allegation investigated: Staff did not prevent a resident from developing pressure injuries while in care Staff did not administer medication as prescribed Staff did not clean resident’s bedding Staff did not keep facility clear of vermin

On 04/29/26 at 4:10PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM. During investigation, LPA obtained the following documents from administrator – Personnel record (LIC500), Residents roster, Admission agreements, Physician’s reports, Needs & Services plans, Hospice care plan, Centrally stored medication logs, After visit discharge reports, incident reports. Health & safety check conducted on 01/28/26 (see LIC 809 dated 01/28/26). Continued on next page, LIC 9099-C Substantiated Allegation: Staff did not prevent a resident from developing pressure injuries while in care Investigation Finding: Substantiated During investigation, the Department conducted interviews of facility staff (ADM, S1, S2) & R1’s responsible party (POA), witness (W1) and reviewed resident (R1) documents. Review of R1’s admission agreement showed he was first admitted at the facility on 06/16/23 and resided at the facility until 01/28/26. R1 was assessed with mild cognitive impairment, non-ambulatory, needs assistance transferring in & out of bed and did not have a history of skin breakdown as shown on R1’s physician’s report dated 06/07/23. On 01/15/26, R1 was admitted into hospice care and diagnosed with a total of 5 pressure injuries on his back (three stage 2 pressure injuries), left buttock (one stage 2 pressure injury) and sacrum (one stage 3 pressure injury) and a tumor wound. On 01/27/26, responsible party (POA) removed R1 from the facility due to unsanitary conditions. W1 visited R1 at POA’s home and observed five pressure injuries on R1. Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not prevent a resident from developing pressure injuries while in care was found to be substantiated. Immediate civil penalty of $500 assessed during visit for staff failing to prevent resident from developing multiple pressure injuries while in care. Additional civil penalty related to serious bodily injury is pending review. Allegation: Staff did not administer medication as prescribed Investigation Finding: Substantiated During investigation, the Department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Staff confirmed with LPA that they were giving a topical medication orally to R1 by placing the powder inside water and giving it for him to drink until hospice nurse pointed out this error. Review of R1’s hospice care orders dated 01/20/26 showed topical powder was to be applied to R1’s right ear tumor wound 2X per week. Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not administer medications as prescribed was found to be substantiated. Continued on next page, LIC 9099-C pg 1 Allegation: Staff did not clean resident’s bedding Investigation Finding: Substantiated During investigation, the Department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. POA stated during her visits at the facility that R1’s neck pillow was caked with drainage from R1’s right ear and had a strong odor. POA also stated that the pillow was not being washed and family was not notified of need for more pillows to allow washing between uses. Staff (S1, S2) confirmed with LPA that they did not wash the neck pillow used to support R1’ infected ear while in care. Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not clean resident’s bedding was found to be substantiated. Allegation: Staff did not keep facility clear of vermin Investigation Finding: Substantiated During investigation, the Department conducted interviews of facility staff & responsible party (POA) and reviewed resident (R1) documents. On 01/28/26, LPAs D Panlilio and K Nguyen observed during visit the presence of rodent droppings in resident’s drawers, clothes, closet and personal hygiene items at the facility. POA stated they left R1’s personal items at the facility when they removed him on 01/26/26 because all his personal belongings were contaminated with vermin droppings. Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not keep facility clear of vermin was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Staff left a resident in a soiled diaper for a long period of time Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of facility staff (ADM, S1, S2), residents (R2, R3), R1’s responsible party (POA), and reviewed resident (R1) documents. Staff stated that they cleaned and changed all residents’ soiled diapers in the AM before breakfast, checked/changed their diapers as needed before lunch and changed their diapers again before bedtime. S1 stated that he changed R1’s soiled diaper in the AM on 01/20/26. However, R1 had another bowel movement before the hospice nurse arrived in the PM. LPA interviewed other non-ambulatory residents (R2, R3) who stated that staff changed their diapers 3 times a day or as needed. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff left a resident in a soiled diaper for a long period of time was found to be unsubstantiated. Allegation: Staff did not maintain a comfortable temperature for a resident in care. Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of facility staff (ADM, S1, S2), responsible parties (POAs) and reviewed resident (R1) documents. RP stated that R1’s bedroom was cold due to staff leaving the window open. During unannounced visits on 06/13/25, 08/12/25 and 01/28/26, LPA inspected the facility and observed residents’ bedrooms, bathrooms, kitchen, dining room and living room areas had a comfortable temperature with thermostat reading at 70 deg F. LPA did not observe any open windows in residents’ bedrooms during visit. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not maintain a comfortable temperature for a resident in care is unsubstantiated. Allegation: Staff left resident in the same clothing for a long period of time Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of facility staff (ADM, S1, S2), responsible party (POA) and reviewed resident (R1) documents. RP stated that during multiple visits with R1 at the facility, they observed R1 wearing the same clothes for a long period of time. Staff (S1) stated they assisted R1 with his activities of daily living such as bathing, dressing, grooming and would change his clothes after a bath or if soiled from bowel movements/urination. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff left resident in the same clothing for a long period of time is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 15-AS-20260128102015

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269 · Plan of correction due date: Apr 29, 2026

Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from neglect . . . This requirement was not met as evidenced by staff failing to provide adequate care & supervision resulting in resident developing multiple pressure injuries which posed an immediate health & safety risk to residents in carethe state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Immediate civil penalty of $500 assessed during visit for staff neglect and supervision which resulted in resident developing five pressure injuries while in care. Additional civil penalty related to serious bodily injury is pending review. NCC to be scheduled at a later date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(d) · Plan of correction due date: May 27, 2026

The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times This requirement was not met as evidenced by staff not administering medication as prescribed which posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: By POC due date, ADM agrees to complete and submit to CCLD in-service staff retraining on proper hospice care plan implementation in compliance with Section 87633 regulations.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: May 27, 2026

To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by staff did not clean resident’s bedding which posed a potential health & safety risk to resident in carethe state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: By POC due date, ADM agrees to complete and submit to CCLD in-service staff retraining on proper care and supervision of resident in compliance with Section 87468.2 regulations.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(2) · Plan of correction due date: May 27, 2026

To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by staff did not keep facility clear of vermin which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: By POC due date, ADM agrees to complete and submit to CCLD in-service staff retraining on proper care and supervision of resident in compliance with Section 87468.1 regulations.

Allegation investigated: Staff do not ensure residents’ living quarters are clean and sanitary Staff do not wash hands after handling mice feces

On 04/29/26 at 4PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the findings of above allegations. LPA explained the purpose of the visit with ADM. During investigation, LPA obtained the following documents from administrator – Personnel record (LIC500), Residents roster, Admission agreements, Physician’s reports, Needs & Services plans, Hospice care plan, Centrally stored medication logs, After visit discharge reports, incident reports. Continued on next page. LIC 9099-C Substantiated Allegation: Staff do not ensure residents’ living quarters are clean and sanitary Investigation Finding: Substantiated During investigation, the Department conducted interviews of facility staff, responsible party (POA) and reviewed resident (R1) documents. On 01/28/26, LPAs D Panlilio and K Nguyen inspected the facility and observed the presence of a dead cockroach in Rm#1 and presence of rodent droppings in Rm#2. RP shared photos of rodent droppings in resident’s (R1) drawers, clothes, closet and personal hygiene items at the facility dated 1/26/26. Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff do not ensure residents’ living quarters are clean and sanitary was found to be substantiated. Allegation: Staff do not wash hands after handling mice feces Investigation Finding: Substantiated During investigation, the Department conducted interviews of facility staff & responsible party (POA) and reviewed resident (R1) documents. POA stated that on 01/27/26, she observed staff tried to give R1 his medication and clean the open wound on his right ear without washing their hands after cleaning the closet contaminated with mice feces. Staff (S2) confirmed with LPA that they did not wash their hands when they tried to apply the medication on R1’s open wound. Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff do not wash hands after handling mice feces was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Staff handled resident in a rough manner Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of facility staff (ADM, S1), R2’s responsible party (POA) and reviewed R2’s documents. RP stated that she witnessed staff handle R2 in a rough manner when placing him in his bed or on his chair. Review of R2’s admission agreement showed he was first admitted at the facility on 09/30/23. Staff denied handling R2 in a rough manner and stated that they assisted R2 with his activities of daily living such as bathing, toileting, diaper changes, dressing, grooming, transfer to and from the bed, meals and medications. On 01/30/26, POA confirmed with LPA that staff provided R2 with proper care and supervision while residing at the facility. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff handled resident in a rough manner was found to be unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 15-AS-20260129080923

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 29, 2026

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 was not met as evidenced by staff did not ensure residents’ living quarters are clean and sanitary which posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Deficiency corrected during visit. ADM hired a professional exterminator company on 01/28/26 and resolved vermin infestation. Staff also cleaned and sanitized all bedrooms, bathrooms, kitchen, dining and common areas on 01/28/26.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(a)(1)(A) · Plan of correction due date: May 27, 2026

All staff and volunteers shall perform hand hygiene. (A) Hand hygiene shall include hand washing with soap and water or using an alcohol-based sanitizer or any other sanitizing method recommended by a medical professional, local health official, health department, or other research-based medical authority. This requirement was not met as evidenced by staff did not wash hands after handling mice feces which posed a potential health & safety risk to resident in carethe state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: By POC due date, ADM agrees to complete and submit to CCLD in-service staff retraining on infection control requirements in compliance with Section 87470 regulations.

Type of visit: Required - 1 Year

On 04/29/26 at 5:52PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. LPA observed current administrator certificate# 7029691740 which expires 01/19/2027. At 6:15PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 70 deg F. Hot water temperature was measured at 115 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguisher was observed fully charged and last inspected on 02/09/26. LPA reviewed 2 staff and 3 resident files. Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 29, 2026

Allegation investigated: Staff are not meeting residents nutritional needs

On 08/12/25 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM), gathered information and delivered investigation findings of above allegations. LPA explained the purpose of the visit with ADM. During investigation, LPA obtained the following documents from ADM - staff roster, residents’ roster, admission agreement, physicians report, ID/Emergency information, Needs & Services plan, meal plans and maintenance records. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Staff are not meeting resident’s nutritional needs Investigation Finding: Unsubstantiated On 08/12/25 at 1PM, LPA interviewed staff (ADM, S1) and residents (R1, R2, R3). ADM stated staff follows prescribed special diet requirements for residents. S1 stated he prepares low carbohydrate and gluten free meals for R1, meals rich in protein for R2 since he is on dialysis and soft minced diet for R3 since he has no upper and lower teeth. R1, R2, R3 confirmed with LPA that staff provide them 3 meals each day with snacks and drinks in between meals. LPA observed facility has sufficient 2-day perishables (fresh fruits, vegetables, eggs, milk, juices, gluten free bread, pies, various meats) and 7-day non-perishable food supply. LPA observed residents are hydrated, well nourished, odor free, and comfortable in their surroundings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff are not meeting resident’s nutritional needs is unsubstantiated. No deficiency cited during visit. Exit interview conducted and a copy of the report provided. Allegation: Facility outlets are in disrepair with exposed wires Investigation Finding: Unfounded During investigation, LPA toured the facility including but not limited to residents’ bedrooms, bathrooms, kitchen, dining and living room areas. LPA did not observe any exposed wires present at the facility on 08/12/25. LPA also reviewed prior Complaint 15- AS-20250605113309 dated 06/13/25 which showed facility replaced all ungrounded electrical outlets with three prong grounded outlets inside the home (all resident's bedrooms, bathrooms, hallways, dining and kitchen areas) on 06/14/25. On LPA’s prior unannounced visit dated 06/13/25. LPA observed resident (R1) had several devices (medical monitoring device, TV, phone charger) plugged into a surge protector strip which is connected to the wall outlet. LPA did not observe any exposed wires from the electrical outlets. The Department had investigated the complaint alleging that facility outlets are in disrepair with exposed wires. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. No deficiencies cited. Exit Interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 12, 2025 · control 15-AS-20250811112107

Allegation investigated: Staff modified the resident's medical device without authorization

On 06/13/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM), gathered information and delivered investigation findings of above allegations. LPA explained the purpose of the visit with ADM. During investigation, LPA interviewed residents (R1, R2, R3) & staff (ADM, S1), toured the facility with S1 and obtained the following documents from ADM - staff roster, residents’ roster, admission agreement, physicians report, ID/Emergency information, Needs & Services plan and incident reports. Continued on next page, LIC 9099_C Substantiated Allegation: Staff modified the resident’s medical device without authorization Investigation Finding: Substantiated During investigation, the department conducted interviews of residents (R1, R2, R3), facility staff (ADM, S1) & R1’s responsible party (POA) and reviewed resident's(R1) documents. ADM confirmed with LPA that R1's medical device was modified without her authorization to enable them to plug her medical device into the existing 2 prong ungrounded bedroom outlet. LPA observed all residents' bedroom outlets(Rms 1, 2, 3) had two prong ungrounded outlets. LPA observed only the kitchen area had grounded three prong electrical outlets. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff modified the resident's medical device without authorization was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099-D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Staff do not ensure residents receive bathing services in a timely manner Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (ADM, S1) and residents (R1, R2, R3). Residents (R1, R2, R3) confirmed with LPA that staff give them daily bed baths. R1 stated staff gives her a full shower every 7 days aside from getting bed baths. Staff confirmed with LPA that all non-ambulatory residents are given bed baths daily with R1 being given a full shower every Thursday. Staff denied not giving R1 a full bath over 13 days. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff do not ensure residents receive bathing services in a timely manner is unsubstantiated. Exit interview conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Jun 13, 2025 · control 15-AS-20250605113309

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87203 · Plan of correction due date: Jun 25, 2025

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic This requirement was not met as evidenced by staff modified resident's medical device without authorization which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 13, 2025

Plan of correction: By POC due date, ADM agreed to replace all ungrounded outlets with three prong grounded outlets and submit photo of receipt for repairs in compliance with Section 87203 regulations.

Type of visit: Required - 1 Year

On 03/12/25 at 1:50PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. LPA observed current administrator certificate# 6063977740 which expires 10/16/24. At 2PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 72 deg F. Hot water temperature was measured at 113 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 3 staff and 4 resident files. Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 12, 2025

Type of visit: Required - 1 Year

On 04/25/24 at 12PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. LPA observed current administrator certificate# 6063977740 which expires 10/16/24. At 12:15PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 70 deg F. Hot water temperature was measured at 116 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 3 staff and 5 resident files. LPA also conducted 2 staff and 2 resident interviews during visit. Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies observed during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 25, 2024