Abk Sweet Homecare

Allegation investigated: - Facility failed to seek timely medical attention resulting in hospitalization

Licensing Program Analyst (LPA) Michael Tea arrived on this day for the purpose of delivering findings into the above allegation. LPA met with Administrator (AD) Kristine Truong and Licensee (LE) Lily Nguyen. On July 21, 2025, the Orange County Adult and Senior Care Regional Office received a complaint alleging that the facility failed to seek timely medical attention resulting in hospitalization. During the investigation, the Department reviewed facility records, hospital records, incident reports, resident records, and conducted interviews with facility staff and witnesses. The investigation determined as follows: Resident 1 (R1) suffered an unwitnessed fall at the facility on July 18, 2025, between approximately 4:30 AM and 5:00 AM. Facility staff found R1 on the floor and placed R1 back into bed after determining they did not complain of pain. Per physician report dated November 15, 2024, R1 has a diagnosis of severe Dementia. (Complaint Investigation continued on LIC9099C) Substantiated Incident report record reviewed showed that staff did not immediately seek medical attention or notify R1’s family after the incident occurred. The facility’s own incident report documented that the family arrived to visit around 9:00 AM that same morning. During the investigation, R1’s family reported that they discovered bruising around R1’s forehead and left ear during their visit and questioned staff about the injuries. R1 was transported to the Hospital by their family after being advised by the facility to obtain a medical evaluation and x-ray if there was anything serious. Hospital records showed that R1 was admitted the same day with a diagnosis of fractured ribs, bruising to the forehead and ear, acute kidney injury, urinary tract infection, severe malnutrition, and delirium. During the investigation, evidence also showed that R1 had a prior fall in April 2025 and had become increasingly unsteady and at risk for falls afterward. Staff acknowledged that R1 required frequent supervision and monitoring; however, no updated assessment or additional care plan was completed to address R1’s declining condition and increased fall risk. Based on the information obtained during the investigation, the preponderance of evidence standard has been met. Therefore, the allegation mentioned above have been determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violations has occurred. The following are cited by the California Code of Regulations, Title 22, Division 6. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f) An exit interview was conducted and a copy of this report, LIC809-D, LIC421IM, appeal rights and confidential names list was provided to the facility. Records showed that staff did not notify R1’s family immediately after the incident occurred. The facility’s own incident report documented that the family was informed when they arrived to visit around 9:00 AM. R1 was transported to the hospital by their family after being advised by the facility to obtain a medical evaluation and x-ray if there was anything serious. Hospital records showed that R1 was admitted the same day with a diagnosis of fractured ribs. Although R1’s family was not immediately informed of the fall, regulatory requirements allow for seven days for the date of incident to provide a written report of incident to responsible party. Based on the information obtained during the investigation, the allegation is deemed UNSUBSTANTIATED, meaning, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report and confidential names list were provided to the facility.the state’s words, verbatim · CDSS document, May 26, 2026 · control 22-AS-20250721112732

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: May 27, 2026

Incidental Medical and Dental Care Services ... 9-1-1 shall be telephoned immediately if an injury or other circumstance has resulted in an imminent threat to a resident's health including an apparent life-threatening medical crisis. This requirement is not met as evidenced by: R1 had an unwitnessed fall in which medical attention was delayed for approximately 4 hours after which it was later discovered R1 suffered multiple rib fractures. This poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Facility will provide a statement of understanding regarding the regulation cited for and signed by staff and management. Facility will conduct an inservice training and provide proof to LPA by COB on POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced annual inspection visit to the facility. LPA Tea was greeted and granted entry by caregiver staff and explained the purpose of the visit. Administrator (AD) Kristine Truong and Licensee (LE) Lily Nguyen arrived shortly thereafter to assist with the inspection. The facility is licensed for a capacity of six residents, approved for one ambulatory and five non-ambulatory residents, with a hospice waiver for four residents. At the time of today’s visit, there were six residents residing at the facility, including one resident receiving hospice services. LPA Tea reviewed six resident files and three staff files. All required documentation was present in the files reviewed. Administrator Kristine Truong’s administrator certificate expires on January 17, 2028. LPA Tea, accompanied by AD Truong and care staff, conducted a tour of the physical plant, including resident bedrooms, bathrooms, common areas, kitchen, food supply, medication storage, and outside grounds. The facility is a two-story home consisting of five resident bedrooms, two full bathrooms, living room, kitchen, dining area, and attached garage. The second floor is designated for staff use only. LPA observed smoke detectors and carbon monoxide detectors in common areas and resident bedrooms to be operational. Resident bedrooms contained the required furniture, linens, and adequate closet and drawer space to accommodate residents comfortably. Bathrooms were clean. Toilets and faucets operated properly, grab bars were secure, and showers were free of mold and mildew. The hot water temperature measured 106.3 degrees Fahrenheit, which was within the required range. Resident hygiene supplies, toiletries, and bath towels were adequately stocked at the time of the visit. Common areas were clean, organized, and free of hazards or obstructions. The first aid kit was inspected and contained all required items, including bandages, dressings, scissors, tweezers, and a thermometer. Kitchen appliances (Annual Inspection report continued on LIC809C) were operational during today’s visit. Perishable and non-perishable food supplies were reviewed and found to be adequately stocked. LPA observed emergency food and water supplies stored in the kitchen and garage. Sharps were secured in a kitchen drawer, and toxic substances were locked and inaccessible to residents beneath the kitchen sink and inside the garage. Fire extinguishers throughout the facility were fully charged. The last documented fire drill was conducted on March 8, 2026. LPA toured the outside grounds and observed new patio furniture with an umbrella to provide outdoor seating and shade for residents. Side gates were self-latching and functioning properly. The facility provides activities based on residents’ individual preferences, health conditions, and limitations. Activities include music therapy, chair exercises, group discussions, and arts and crafts. An activity person also visits the facility periodically. During today’s visit, LPA observed residents watching television in the living room and eating lunch. LPA reviewed medication storage and administration practices. Medications were observed to be centrally stored in a locked cabinet in the kitchen and administered according to physician’s orders. LPA was unable to interview residents regarding their quality of care due to residents’ health conditions and language barriers. LPA Tea interviewed staff regarding the care and services being provided to residents. Based on observations made during today’s inspection, no deficiencies were cited in the areas inspected under Title 22, Division 6 of the California Code of Regulations. This report was reviewed with the facility. A copy of LIC 809, LIC 809-C, LIC 858, LIC 859, and LIC 9102TV was provided to the facility.the state’s words, verbatim · CDSS document, May 26, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On today's date, Licensing Program Analyst (LPA) Michael Tea conducted this case management in conjunction with Complaint visit Control #: 22-AS-20250721112732. LPA Tea met with Administrator (AD) Kristine Truong and Licensee (LE) Lily Nguyen and discussed the purpose of today's case management visit. During the review of the investigation documents, LPA observed that Resident 1 (R1)’s Physician’s Report dated November 15, 2024, documented R1 with severe dementia. R1’s Resident Appraisal, signed on November 17, 2024, stated R1 required assistance with bathing, dressing, toileting, and special observation/night supervision. However, records show R1’s condition changed after the April 10, 2025, after suffering a fall and stroke. Staff reported R1’s health declined, and R1 became unsteady making them a fall risk. Staff reported R1 was restless, removed alarms, and attempted to get out of bed. The investigation found there was no new assessment or updated Needs and Services Plan completed after the April 10, 2025, fall or after additional falls continued to occur. On July 18, 2025, R1 had another unwitnessed fall and was later hospitalized. Medical records showed R1 sustained multiple rib fractures and bruising to the forehead and ear. The investigation also found R1 arrived at the hospital in poor health and that staff did not complete an additional assessment to determine whether R1 required a higher level of care after discharge. Based on the information reviewed, the facility failed to complete a timely reappraisal when R1 had a significant change in condition, including increased fall risk, hospitalization, and a decline in care needs. A deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. (Case Management Report continued on LIC809C) An exit interview was conducted with the facility and a copy of this report LIC809, LIC809D confidential names list and appeal rights were provided at exit.the state’s words, verbatim · CDSS document, May 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(b)(1) · Plan of correction due date: May 27, 2026

Reappraisals ...The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident … Significant changes in condition, as defined in Section 87101. This requirement is not met as evidenced by: Based on record review and interviews, the facility failed to ensure R1 received a reappraisal after significant changes in condition, including falls, hospitalization, increased supervision needs, and decline in functioning resulting in multiple rib fractures. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: Facility did recently updated Needs and Service plan and appraisal. Facility will provide a statement of understanding regarding the regulation cited for and signed by staff and management. Facility will conduct an inservice training and provide proof to LPA by COB on POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 1:00 PM, LPA Tea was greeted and granted entry into the facility by a caregiver staff and explained the reason for the visit. Administrators (AD) Brenda Truong and Kristine Truong arrived shortly to assist with the visit. The facility is licensed for a capacity of six, approved for one ambulatory and five non-ambulatory, with a hospice waiver for four. Currently there are five residents, and there is no one on hospice during today's visit. At 1:25 PM, LPA Tea reviewed five resident files and two staff files. Resident files and staff files contained all required documentation. The administrator certificate expired on March 21, 2025, but AD Truong completed all course work and is pending. LPA Tea along with administrators toured the facility at 2:37 PM. LPA toured the physical plant, checked food service, and the first aid kit. The home is a two-story facility that consists of 5 resident bedrooms, 2 full bathrooms, living room, kitchen, dining area, and attached garage. The 2nd floor of the house is for staff only. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 107.7 Fahrenheit degrees and 108.8 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including dressing, bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps secured in a kitchen drawer. LPA also observed Annual Inspection continued LIC809C toxin substances to be secured and locked and inaccessible to clients underneath the kitchen sink and garage. The fire extinguishers throughout the facility are fully charged. The facility’s last fire drill was conducted on January 27, 2025. Kitchen appliances are operational during today's visit. LPA observed emergency food and water supply in the kitchen and garage. LPA toured the outside grounds. The patio furniture is currently being replaced at the time of the visit. The gates on both sides of the house are self-latching and operational. Facility provides activities based on resident’s personal preference and health condition and limitations. There is music therapy, chair exercises. There is group discussion and an activities person comes to the facility from time to time. The facility host luncheons and celebrate holidays together. There are arts and crafts activities. At the time of the visit, LPA observed residents watching TV and enjoying snacks. At 3:00 PM LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the kitchen. Medications are being administered per physician order. LPA advises facility needs to list PRNs on a separate list. LPA was unable to interview residents regarding their quality of care due to language barriers and health conditions of residents. LPA Tea spoke to staff present regarding care provided. Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Administrators Brenda Truong and Kristine Truong and a copy of this report LIC809, 809-C, LIC858, LIC859, LIC9102TVs were read and provided to the facility.the state’s words, verbatim · CDSS document, May 19, 2025

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA’s) Bernadette Allen made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Brenda Truing- Administrator who granted entry into the facility. LPA Allen created the report under the incorrect facility number 306006525 the report should have been under 306006112 on 8/21/2024 Physical Plant: LPA observed there are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms: they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. The hot water temperature tested within regulation at 102.5 degrees F. The facility is equipped with operating smoke detectors, carbon monoxide alarms and fully charge fire extinguishers. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. There was a designated place for client/staff files locked in a cabinet in family room . Overall, the facility appeared to be clean, in good repair, and operating in safe conditions. Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed two (2) client files for admission agreements, updated physician reports, and Medication Administration Records (MAR’s) which appeared to be administered as prescribed by their physicians, however LPA observed during the inspection two(2) clients medications were transferred between containers. LPA also reviewed two (2) staff files for First Aid/CPR certification, training's, and health screenings and appeared to be current. Based on the observations made during today’s visit, a citation was issued for transferring medication between containers. An exit interview was conducted, and this report LIC809, LIC809-C and LIC809-D with appeal rights was discussed and provided to Brenda Truing- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 29, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: Sep 4, 2024

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on LPA's observations the facility staff did not ensure medications were not transferred between containers which pose potential health, safety and personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: The licensee has agreed to provide training to all staff members (Med Tec) and provided a statement of understanding of the cited regulation by the POC date of 9/04/2024.