Aaa Residential Elderly Retreat

Allegation investigated: Facility staff speaks inappropriately to residents in care.

On 08/14/2026, Licensing Program Analyst (LPA) J. Duarte arrived unannounced to conduct interviews and deliver findings. LPA introduced self, stated the purpose of the visit and met with Lead Caregiver Gwendolyn Bonner. The Department investigated the above allegation. LPA interviewed residents in care and staff. Based on interviews conducted, staff communicate with residents appropriately. 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. An exit interview was conducted with Lead Caregiver Gwendolyn Bonner and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 14, 2026 · control 24-AS-20260504163930

Type of visit: Case Management - Deficiencies

On 08/14/2026, Licensing Program Analyst (LPA) J. Duarte, arrived unannounced to conduct a case management. LPA met with Lead Caregiver Gwendolyn Bonner. During the investigation of complaint #24-AS-20260504163930, LPA observed that there was a latch at the top of the front door of the facility. LPA conducted a file review for the facility and the facility has a waiver for locked perimeter gates; however, LPA observed the interior front door of the facility had a latch to secure the door closed. On today's vist, LPA observed the latch was removed from the front door. Staff stated that on 05/11/2026, the same day LPA went to the facility, the front door and back door latches were removed. During today's visit, LPA observed a resident with a restricted health condition. LPA requested to review the restricted health care plan for the resident. Licensee stated that the resident has a restricted health care plan, home health goes comes to the facility, and staff have been trained. However, licensee stated that documentation is locked and licensee is not available to come to the facility. LPA was not provided with a health care plan for review. Deficiencies are being issued in accordance to California Code of Regulations, Title 22, Division 6, chapter 8 on the attached 809D reports. A plan of correction was implemented and an immediate civil penalty in the amount of $500 was assessed for fire clearance, see LIC421IM. Exit interview conducted. A copy of this report and appeal rights were discussed and provided to Lead Caregiver Gwendolyn Bonner, whose signature on this form confirms receipt of this document.the state’s words, verbatim · CDSS document, Aug 14, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Aug 15, 2026

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by: During the investigation of complaint #24-AS-20260504163930, LPA observed that there was a latch at the top of the front door of the facility. LPA conducted a file review for the facility and the facility has a waiver for locked perimeter gates; however, LPA observed the interior front door of the facility had a latch to secure the door closed, which poses an Immediate Health and Safety Risk to persons in care.the state’s words, verbatim · CDSS document, Aug 14, 2026

Plan of correction: On today's vist, LPA observed the latch was removed from the front door. Staff stated that on 05/11/2026, the same day LPA went to the facility, the front door and back door latches were removed. POC CLEARED

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a) · Plan of correction due date: Aug 17, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: This requirement was not met as evidenced by: LPA observed a resident with a restricted health condition. LPA requested to review the restricted health care plan. Licensee stated that the resident has a restricted health care plan, home health goes to facility, and staff have been trained. However, licensee stated that documentation is locked and licensee is not available to come to the facility. LPA was not provided with a health care plan for review, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 14, 2026

Plan of correction: Licensee will provide restricted health care plan and documentation of staff that have been trained on the resident's restricted health condition by POC due date of 08/17/2026.

Allegation investigated: Facility does not provide necessary supplies for staff to do their job Facility does not properly clean laundry Administrator License is expired Facility does not offer a variety of activities for residents in care Facility is not kept at a comfortable temperature for residents in care Facility serves food that is not of good quality to meet residents needs Facility does not serve food in a quantity to meet residents needs Facility does not address residents medical needs in a timely manner

On May 26, 2026, Licensing Program Analyst (LPA) M Vega conducted an unannounced inspection at the facility and met with Administrator - Alexis Bell. The purpose of the visit was to resume complaint investigation and deliver findings regarding the above allegation. Based on interviews, record review, Health and satety walthough visual inspection, it has been determined that the facility Facility does not provide necessary supplies for staff to do their job, Facility does not properly clean laundry, Administrator License is expired, Facility does not offer a variety of activities for residents in care, Facility is not kept at a comfortable temperature for residents in care, facility serves food that is not of good quality to meet residents needs Facility does not serve food in a quantity to meet residents needs, Facility does not address residents medical needs in a timely mannerand determined the allegation is UNFOUNDED. Continuation on LIC 9099C Unfounded This agency has investigated the complaint alleging “Facility does not provide necessary supplies for staff to do their job, Facility does not properly clean laundry, Administrator License is expired, Facility does not offer a variety of activities for residents in care, Facility is not kept at a comfortable temperature for residents in care, Facility serves food that is not of good quality to meet residents needs, Facility does not serve food in a quantity to meet residents needs, Facility does not address residents medical needs in a timely manner” We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened or is without a reasonable basis. We have found that the complaint was UNFOUNDED, therefore we have dismissed the complaint.the state’s words, verbatim · CDSS document, Mar 26, 2026 · control 24-AS-20250411104340

Allegation investigated: Staff did not provide activities or outings for residents in care Staff did not provide adequate care to residents Staff are serving contaminated tea to residents in care Staff spoke inappropriately to residents in care Staff do not ensure that residents are cleaned properly

On May 26, 2026, Licensing Program Analyst (LPA) M Vega conducted an unannounced inspection at the facility and met with Administrator - Alexis Bell. The purpose of the visit was to close an open complaint investigation and deliver findings regarding the above allegation. It was alleged that, “Staff did not provide activities or outings for residents in care, Staff did not provide adequate care to residents, Staff are serving contaminated tea to residents in care, Staff spoke inappropriately to residents in care, Staff do not ensure that residents are cleaned properly.” Based on interviews, record review, Health and safety walkthrough visual inspection. it has been determined that the facility does ensure Staff did not provide activities or outings for residents in care, Staff did not provide adequate care to residents, Staff are serving contaminated tea to residents in care Staff spoke inappropriately to residents in care Staff do not ensure that residents are cleaned properly determined the allegation is UNFOUNDED. Continuation on LIC 9099 Unfounded This agency has investigated the complaint alleging “Staff did not provide activities or outings for residents in care, Staff did not provide adequate care to residents, Staff are serving contaminated tea to residents in care, Staff spoke inappropriately to residents in care, Staff do not ensure that residents are cleaned properly” We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened or is without a reasonable basis. We have found that the complaint was unfounded, therefore we have dismissed the complaint.the state’s words, verbatim · CDSS document, Mar 26, 2026 · control 24-AS-20250319161325

Type of visit: Required - 1 Year

On 12/4/2025 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct an unannounced annual inspection. LPA was greeted by staff and was informed Administrator would not be available until after 1:30. Staff also informed LPA a resident had active Covid. As a precaution LPA did not conduct annual inspection and will return to conduct at a later time. Staff was informed.the state’s words, verbatim · CDSS document, Dec 4, 2025

Allegation investigated: Facility neglected to seek medical treatment for resident.

On May 28, 2025, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced inspection at the facility and met with Caregiver (CG) Latecha Thompson. The purpose of the visit was to open a complaint investigation and deliver findings regarding the above allegation. It was alleged that the facility was not seeking medical care for a resident. (R1- see attached confidential names list). Based on interviews and record review it has been determined that the facility does ensure R1 receives medical care and determined the allegation is unfounded. This agency has investigated the complaint alleging “Facility neglected to seek medical treatment for resident.” We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened or is without a reasonable basis. We have found that the complaint was unfounded, therefore we have dismissed the complaint. Unfoundedthe state’s words, verbatim · CDSS document, May 28, 2025 · control 24-AS-20250521114432

Allegation investigated: Licensee did not ensure facility plumbing was in good repair.

On 5/21/2025, Licensing Program Analyst (LPA) conducted unannounced inspection and met with Latecha Thompson, Caregiver. The purpose of the visit is to deliver findings on the above allegations. During the course of this complaint investigation LPA conducted an inspecation, spoke with staff and residents, and obtained and/or reviewed facility records. Based on the investigation it was found that the facility did encounter a plumbing issue that was impactful to both staff and residents as the water was backed up and only one restroom was functional. Based on LPAs observations and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Title 22 regulations are being cited on the attached LIC 9099D. An exit interview was conducted and a copy will be provided to the Administrator by email. Substantiatedthe state’s words, verbatim · CDSS document, May 21, 2025 · control 24-AS-20250221090844

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 21, 2025

87303 Maintenance and Operation a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by plumbing issue which caused one toilet and kitchen sink to backup. This poses a potential risk to the health and safety of the residents in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: Facility has already remedied the issue and had the plumbing fixed. Plan of correction to be cleared as of today's visit.

Allegation investigated: Staff violate client's personal rights Medication mishandled by staff Neglect / lack of supervision resulting in an injury

On 3/4/2025, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced complaint investigation visit to the facility. During this visit LPA delivered the investigative findings regarding the allegations listed above and described below. Allegation 1- Personal Rights violation - not enough clothing or proper toiletries- LPA conducted tour and found that at the time of the visit, clients had sufficient clothing and there were appropriate toiletry items for staff and clients. Interviews conducted provided conflicting information regarding supplies. Allegation 2- Medical violation- not enough medication- clients share and medication is physically mishandled. LPA conducted tour and conducted interviews. At the time of the visit, medication appeared to be in order. Interviews conducted provided conflicting information regarding how medication is handled in the facility and the way that is stored and distributed. Allegation 3- Neglect / lack of supervision resulting in an injury- This was concerning a resident who had a broken finger due to mistreatment. No records of that being reported to staff were found. The other issue referenced that the same client was mistreated verbally and was left in their room in the wheelchair. LPA conducted tour and interviews which revealed conflicting information and no record of the above found in documentation. Unsubstantiated The Department has concluded the investigation regarding the complaint and the allegations noted above. LPA conducted tours and interviews and received conflicting information. Based on the information received the above allegations are UNSUBSTANTIATED. Although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are found to be unsubstantiated. No citations were issued regarding the allegations at today's visit. An exit interview was conducted and a copy of the report and appeal rights was provided to the Licensee whose signature acknowledges receipt.the state’s words, verbatim · CDSS document, Mar 4, 2025 · control 24-AS-20241205100619

Allegation investigated: Staff interacted with resident in an inappropriate manner.

On 3/4/2025, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced complaint investigation visit to the facility. During this visit LPA delivered the investigation finding regarding the above allegation. The Department has investigated the complaint alleging that a staff member interacted with a resident inappropriately by the way the resident was physically handled; specifically the manner which client was moved in his wheelchair. Staff involved indicated it was not rough just a matter of directing traffic. LPA conducted interviews and received conflicting information. Based on the interviews conducted and/or records review the above allegation is UNSUBSTANTIATED. Although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is found to be unsubstantiated. No citation issued regarding the allegation. An exit interview was conducted and a copy of the report and appeal rights was provided to the Licensee whose signature acknowledges receipt. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 3, 2025 · control 24-AS-20241219100153

Type of visit: Case Management - Other

On December 26, 2024, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced visit for the purpose of discussing incident reporting. On December 21, 2024, Community Care Licensing received an incident report from AAA Residential Elderly Retreat. The report was regarding an incident with a resident (R1) who had an episode at the day program and was sent to the ER on 12/10/2024. The report indicates that it was called into the CCL phone line on 12/11/2024 providing an initial notification to be followed up with a submitted physical report. LPA discussed with Administrator, Alexis Bell (AB) , the need to submit reports within seven day per regulation. AB indicated that she faxed the report in as usual and on time however she did not notice until four days later that she did not get a confirmation notice and the report was now late. AB indicated that she will pay closer attention to the confirmation notice and ensure that reports are sent in timely. No citation issued at today's visit. Below is the regulation regarding reporting requirements: 80061 Reporting Requirements (a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section. (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following (D) Any injury to any client which requires medical treatment.the state’s words, verbatim · CDSS document, Dec 26, 2024

Allegation investigated: Staff handled resident in a rough manner Facility is not meeting food service requirements resulting in weight loss Staff violate resident's personal rights

Licensing Program Analysts (LPA)'s Shawna Doucette conducted an unannounced complaint visit and was granted entry by Administrator Alexis Bell. LPA's explained the purpose of the visit. LPA conducted interviews and reviewed records. Based on record review and interviews Staff documentation indicates R1 refused meals regularly. Based on interviews, staff did not violate resident's personal rights or handle resident in a rough manner Based on record reviews and interviews, 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. An exit interview was conducted and a copy of this report was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 8, 2024 · control 24-AS-20240722153956

Type of visit: Required - 1 Year

On 10/15/24, Licensing Program Analyst (LPA) R. Bruce arrived unannounced to conduct an Annual Required Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry by Direct Care Staff Gwen Bonner. Staff contacted Administrator, Alexis Bell who arrived shortly thereafter. Facility has one entrance/exit point. Facility appeared clean with no obvious obstruction or fire clearance issues. Tour of facility was provided by Gwen Bonner. Bedrooms were clean and furnished per regulation. Sharp items were locked in kitchen cabinet. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. There is a locked shed in the backyard which holds a large supply of non-perishable food. Two additional locked sheds are located in the backyard which store office supplies and various equipment. There are three freezers located on the back patio. Two are not completely functioning and will be repaired or removed. Currently the facility dryer is located in the den and clothes are being dried by hanging outside. Dryer has been serviced and when part comes in will be moved back to wash room. Medications observed locked in hallway closet. LPA reviewed all 4 resident's Centrally Stored Medication list, MARS and medication. No regulation violations were noted. Fire extinguisher purchased today and is located in the kitchen. LPA toured bathrooms. Water registered at 105 degrees. Personal hygiene items are locked in hall closet. Bathroom trash bins were observed lids. Securely fastened grab bars observed in bathroom along with no slip bath mats. Resident rooms toured and observed to be adequately furnished and lit. A tour of the exterior was conducted. No issues noted. Four staff records were reviewed as well as three resident files and all were found to contain required documentation. LPA is requesting the following documents be submitted to the Fresno CCL office by 11/01/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020. An exit interview was conducted with Administrator. Report signed on-site and copy will be provided by email as printer is not working.the state’s words, verbatim · CDSS document, Oct 15, 2024