Abria Del Cielo

Allegation investigated: Staff did not ensure that the resident took medications as prescribed

Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Criselda Espiritu Santo and explained the purpose of the visit regarding the allegations stated above. First Allegation: Staff did not ensure that the resident took medications as prescribed. Regarding the allegation, LPA conducted a record review pertaining to R1. During the review of R1’s medication records, LPA observed that R1 was prescribed two patches to be applied to R1’s skin every morning and to remain in place for 24 hours. LPA interviewed Staff #1 regarding the allegation. Staff #1 stated that R1 sometimes asks medication support staff if the patches can be applied at a later time. Staff #1 also stated that R1 removes the patches without staff knowledge. However, Staff #1 was unable to provide LPA with documentation, notes, or incident reports indicating that R1 had removed the patches prior to the next scheduled administration. Substantiated Based on the review of R1’s medication records, LPA observed that the physician’s medication orders require the patches to be applied to R1 every morning and remain in place for 24 hours. Therefore, the available documentation substantiates that R1 had an order requiring the patches to be applied every morning for 24 hours. However, the interview information regarding R1 removing the patches was not supported by corresponding documentation or incident reports. A finding that the complaint is Substantiated means that the findings are valid because the preponderance of the evidence standard has been met. Title 22 Regulations, from division 6, chapter, article 6, is, cited on the attached LIC 9099 D. An exit interview was conducted where this report, appeal rights, and LIC9099-D was discussed, and a copy of the report was provided to Facility Administrator Criselda Espiritu Santo at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 26, 2026 · control 56-AS-20260526154743

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Aug 27, 2026

Incidental Medical and Dental Care 87465…. (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…. (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: Based on interviews, record review the Licensee did not adhere to the regulation stated above by no following medication orders as indicated by R1 physician, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2026

Plan of correction: The Licensee has agreed to read over regulation: 87465(a)(2) and provide training to all Med staff to ensure that all medication is to be administered according to residents’ medication orders. In addition, staff will report all incidents pertaining to medication. The Licensee will provide LPA proof of training by POC date listed.

Allegation investigated: Staff handled resident in care in a rough manner Staff force-fed medication to resident in care Staff spoke inappropriately to resident in care

Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Criselda Espiritu Santo and explained the purpose of the visit regarding the allegations stated above. First allegation: Staff handled resident in care in a rough manner. Regarding the allegation stated above, LPA conducted interviews with Staff #1-3 regarding the alleged allegation and Staff #1-3 denied the allegation. In addition, Staff #2-3 denied witnessing Staff #1 hurt or handle residents in a rough manner. Furthermore, Staff #1 denied hurting or handling R#1 in a rough manner. Staff #1 also denied making derogatory comments to Resident #1. LPA conducted interviews with Resident #2-5 regarding the alleged allegation and R #2-5 denied the allegations and stated that they have not witnessed Staff #1 or any other staff who hurt, throw, or handle residents in a rough manner. In addition, R#2-5 also denied staff making derogatory comments towards residents in care. Unsubstantiated Second allegation: Staff force-fed medication to resident in care. Regarding the allegation stated above LPA conducted interviews with Staff #1-3 regarding the alleged allegation and Staff #1-3 denied the allegation. In addition, Staff #2-3 informed LPA that they have not witness Staff #1 force feed medication to any resident in care. Staff #1 denied the allegation pertaining to staff force feeding medication to Resident #1. LPA conducted interviews with Resident #2-5 regarding the alleged allegation and R#2-5 denied the allegation and stated that they have not witnessed Staff #1 or any other staff force feed medication to residents in care. Third allegation: Staff spoke inappropriately to resident in care. Regarding the allegation stated above, LPA conducted interviews with Staff #1-3 regarding the alleged allegation and Staff #1-3 denied the allegation. In addition, Staff #2-3 informed LPA that they have not witnessed Staff #1 speak to R#1 or any resident inappropriately while in care. LPA conducted an interview with Resident #2-5 regarding the alleged allegation and Resident #2-5 denied the allegation and informed LPA that they have not witness Staff #1 or any staff speak to residents inappropriately manner while in care. Based on corroborating evidence LPA has determined that the above allegation 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. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Criselda Espiritu Santothe state’s words, verbatim · CDSS document, Aug 17, 2026 · control 56-AS-20260223152636

Type of visit: Required - 1 Year

On 06/16/2026 at 9:30AM , Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced, to conduct the required annual visit to the facility. LPA met with Executive Director Criselda Espiritu Santo and introduced self and stated the purpose of the visit. The facility is operating as a Residential Care Facility for the Elderly. The total capacity is 240 residents; there are currently 140 residents in care. The facility has a dining area for all residents and adequate seating. LPAs completed a walk through of the interior and exterior facility, review of records and medication(s) audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees Fahrenheit. LPA inspected six (6) resident units; they are equipped with the required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 120 degrees Fahrenheit. The facility is equipped with carbon monoxide alarms in each of the hallways on both levels, charged fire extinguishers and first aid kit. A third party services both the fire extinguishers and the smoke alarms; last inspection was conducted on 04/14/2026 and 05/28/2026. Postings: Posters such as; the personal rights, emergency disaster plan, CCLD complaint poster and ombudsman were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed to be locked, inaccessible to residents in the medications room on the first level. There is no swimming pool, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly. Kitchen staff have ServSafe certification on file. Yards/Outside: The facility has several shaded areas and courtyards in the back of the facility. LPA observed three (3) storage units in the parking lot of the facility. Record Review: LPA reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, training(s), and health screenings. LPA also reviewed five (5) resident files for admission agreements, updated physician reports, and needs and services plans. Six (6) deficiencies were cited, seven (7) Technical Violations and a Technical Assistance was given during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and Appeal Rights were discussed and copies were provided to Executive Director, Criselda Espiritu Santo.the state’s words, verbatim · CDSS document, Jun 16, 2026

The state marks this report as 15 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Staff did not feed residents in care Staff mismanaged residents' medications Facility is unsanitary

On 11/06/2025 at 9:20AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with Executive Director, Criselda Espiritu Santo. The investigation consisted of interviews and record review. Resident 1, was discharged from the facility on 06/16/2025. In regards to the allegation of staff did not feed residents in care: LPA interviewed four (4) staff and two (2) residents. Staff stated that residents who receive dialysis services are provided snacks and either an early lunch or dinner. Both residents confirmed that they recieve snacks and meals before and after they return to the facility. Based on interviews, this allegation is UNSUBSTANTIATED. Unsubstantiated In regards to the allegation of staff mismanaged residents' medications: LPA reviewed the medication records for R1 and observed several refusals. Staff stated that medication is given as prescribed and is documented. Based upon interviews and record review, this allegation is UNSUBSTANTIATED. In regards to the allegation of facility is unsanitary: LPA conducted a tour of the facility and observed the facility to be clean and free from odors. Staff stated that the housekeeping staff sweep, mop and clean the facility regularly. Based on observation and interview, this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099 and LIC9099C were discussed and a copy was provided to Executive Director, Criselda Espiritu Santo.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 56-AS-20250725081957

Allegation investigated: Staff did not prevent a resident from being physically abused while in care Staff did not provide adequate care and supervision to a resident Staff did not prevent a resident from being financially abused while in care

Licensing Program Analyst (LPA) Becky Mann conducted an unannounced visit to the facility to initiate a complaint investigation. LPA Mann met with Criselda Espiritu Santo, Executive Director and explained the purpose of today's visit. The investigation consisted of LPAs observations, pertinent document reviews, and interviews with staff and residents. The allegation that staff did not prevent a resident from being physically abused while in care. Eleven (11) residents interviewed stated that staff does prevent residents from being physically abused. Six (6) staff interviewed stated that they do prevent residents from being physically abused. Based on the interviews with the residents, staff do intervene if there is such a situation, the staff does their job well. Unsubstantiated The allegation that staff did not provide adequate care and supervision to a resident. Eleven (11) residents interviewed stated that staff do provide adequate care and supervision to residents. Six (6) staff interviewed stated that they do provide adequate care and supervision to residents. Based on the interviews with the residents, staff do help the residents when they call for assistance. The allegation that staff did not prevent a resident from being financially abused while in care. Eleven (11) residents interviewed stated that they have not been financially abused while in care. Six (6) staff interviewed denied of financially abusing the residents in care. Based on evidence obtained during the investigation, the above allegations are 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. An exit interview was conducted where this report was discussed, and a copy was provided to Criselda Espiritu Santo, Executive Director at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 8, 2025 · control 56-AS-20230522170748

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure resident's diapering care needs were met while in care

On 08/29/2025 at 3:51PM Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced to the facility in order to deliver findings for the above allegations. LPA met with Executive Director, Criselda Espiritu Santo and informed her of the purpose of the visit. The allegation that staff did not ensure resident’s diapering needs were met in care is UNSUBSTANTIATED. An interview with Resident (1) revealed that R1 takes care of their own toileting needs and R1 stated that they do not need staff assistance, but staff will assist R1 when it is needed. Staff stated that they assist residents with their toileting needs and keep a log of the days and times they are assisted. Residents state that staff assist them with their needs. LPA did not experience any mal odors in the dining area and in the hallways during several visits. Based upon interview, observation and record review, this allegation is UNSUBSTANTIATED. Unsubstantiated The allegation that staff did not report resident incidents to appropriate parties is SUBSTANTIATED. LPA reviewed the Department’s records and did not observe any reports relating to incidents involving R1. An interview with the Executive Director revealed that staff may not report certain incidents if local law enforcement does not provide a report. Based upon interview and record review this allegation is SUBSTANTIATED. A deficiency will be cited. SUBSTANTIATED is defined as the complaint allegation(s) is valid and a violation has occurred based on the preponderance of available evidence. An exit interview was conducted where this report LIC9099, LIC9099D and Appeal Rights were discussed, and a copy was provided to Executive Director, Criselda Espiritu Santo. UNSUBSTANTIATED is defined as The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099 and LIC9099C was discussed and a copy was given to Executive Director, Criselda Espiritu Santo.the state’s words, verbatim · CDSS document, Aug 29, 2025 · control 56-AS-20250701082528

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80072(a)(1) · Plan of correction due date: Aug 30, 2025

80072 Personal Rights (a)(1 (a) ...each client shall have personal rights which include...: (1)To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by: Based upon record review, interview and observation, the facility did not ensure that all clients are comfortable and by not ensuring the safety of all the residents which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: Licensee/Administrator will conduct a staff training on personal rights, document incidents among residents who do not follow the facility's rule and submit proof to LPA by Plan of Correction (POC) due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(1)(D) · Plan of correction due date: Aug 30, 2025

Reporting Requirements 87211(1)(D) (1) A written report shall be submitted to the licensing agency...(D) Any incident which threatens the welfare, safety or health of any resident.... This requirement was not met as evidenced by: Based upon interview and record review the facility did not report any incidents to the Department relating to residents expressing physical aggression towards other residents, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: Administrator will conduct a staff training on Reporting Requirements, wlll review and submit a Statement of Understanding of the Reporting Requirements by the Plan of Correction (POC) due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to have Administrator Santo sign amended Complaint Investigation Report (LIC 9099) #18-AS-20211008105248. Report was signed by LPA Prieto and Santo and a copy was left with the facility.the state’s words, verbatim · CDSS document, Aug 14, 2025

Allegation investigated: Staff did not treat resident with dignity or respect Resident was financially abused by staff Staff did not provide resident medication as prescribed Staff did not keep the facility free from pest (flies & roaches)

On 07/02/2025 at 2:30PM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with Executive Director, Criselda Espiritu Santo. The investigation consisted of interviews and record review. In regards to the allegation of Staff did not treat resident with dignity or respect: Resident #1 (R1) has been moved as of 07/29/2024. Staff denied that residents are not treated with dignity and respect. The facility's Internal Incident Reports indicate that R1 expressed challenging behaviors toward staff. Staff stated that residents are treated with respect and patience. Staff denied making any comments regarding R1's private parts. LPA reviewed R1's file and did not observe an eviction letter or notification. Facility notes indicate that R1 and their spouse voluntarily moved from the facility. Therefore, this allegation is UNSUBSTANTIATED. Unsubstantiated In regards to the allegation of Resident was financially abused by staff: Staff denied the allegation and stated that R1 was self-responsible and managed their own cash resources. The rent statement from the facility dated 06/19/2024 indicated that R1 had an outstanding balance due on their account for the months of April, May and June of 2024. Staff denied forcing residents to give them their debit cards. Staff stated that they may assist with providing transportation to the bank. Therefore, this allegation is UNSUBSTANTIATED. In regards to the allegation of Staff did not provide resident medication as prescribed: LPA reviewed the Medication Administration Record(s) (MAR) for R1 for the months of April, May and June of 2024 and did not observe any discrepancies. Interviews with staff confirm that resident medication was given as prescribed by the physician. Therefore, this allegation is UNSUBSTANTIATED. In regards to the allegation of Staff did not keep the facility free from pest (flies & roaches): Based upon interview and record review, staff denied that that facility was not kept free from pests. The record review confirmed that the facility was being serviced on a monthly basis by an extermination company. Therefore, this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099 and LIC9099C was discussed and a copy was provided to Executive Director, Criselda Espiritu Santo.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 56-AS-20240813084641

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto arrived the facility to interview additional staff relating to complaint (18-AS-20211008105248). LPA met with Administrator Criselda Espiritu Santo and conducted interview. This report was signed by Administrator Santo and LPA Prieto and a copy was left at the facility.the state’s words, verbatim · CDSS document, Jun 30, 2025

Allegation investigated: Staff does not prevent verbal altercation between residents Staff does not provide a safe environment for residents

On 05/30/2025 at 1:00PM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with Executive DIrector, Criselda Espiritu Santo. The investigation consisted of interviews and record review. In regards to the allegation that staff does not prevent verbal altercation between residents : LPA interviewed five (5) staff and nine (9) residents. Staff stated that they are trained to redirect residents and encourage them to be patient and respectful to others. All nine (9) residents stated that staff will assist if residents are not getting along. Based on interviews, this allegation is UNSUBSTANTIATED. In regards to the allegation that staff does not provide a safe environment for residents: LPA interviewed nine (9) residents and five (5) staff. Staff denied that they do not provide a safe environment for residents. Activities are organized and supervised by staff. Residents are encouraged Continued on LIC9099C Unsubstantiated to use different areas of the facility in order to redirect certain behaviors. All nine (9) of the residents interviewed stated that they feel safe at the facility and do not have concerns about their safety. Based on interviews, this allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099 and LIC9099C were discussed and a copy was provided to Executive Director, Criselda Espiritu Santo.the state’s words, verbatim · CDSS document, May 30, 2025 · control 56-AS-20250430113318

Type of visit: Required - 1 Year

On 05/22/2025 at 9:10AM , Licensing Program Analysts (LPAs) Renese Howell-Small and Becky Mann arrived unannounced, to conduct the required annual visit to the facility. LPAs met with Executive Director Criselda Espiritu Santo and introduced self and stated the purpose of the visit. The facility is operating as a Residential Care Facility for the Elderly. The total capacity is 240 residents; there are currently 141 residents in care. The facility has a dining area for all residents and adequate seating. LPAs completed a walk through of the interior and exterior facility, review of records and medication(s) audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 72 degrees Fahrenheit. LPAs inspected six (6) resident units; they are equipped with the required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPAs inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 117 degrees Fahrenheit. The facility is equipped with carbon monoxide alarms in each of the hallways on both levels, charged fire extinguishers and first aid kit. A third party services both the fire extinguishers and the smoke alarms; last inspection was conducted on 07/12/2024. Postings: Posters such as; the personal rights, emergency disaster plan, CCLD complaint poster and ombudsman were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed to be locked, inaccessible to residents in the medications room on the first level. There is no swimming pool, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly. Kitchen staff have ServSafe certification on file. Yards/Outside: The facility has several shaded areas and courtyards in the back of the facility. LPAs observed three (3) storage units in the parking lot of the facility. Record Review: LPAs reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, training(s), and health screenings. LPAs also reviewed six (6) resident files for admission agreements, updated physician reports, and needs and services plans. One deficiency was cited, a Technical Violation and Technical Assistance was given during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102 and Appeal Rights were discussed and copies were provided to Executive Director, Criselda Espiritu Santo.the state’s words, verbatim · CDSS document, May 22, 2025

The state marks this report as 8 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Facility staff is financially abusing a resident

On 03/17/2025 at 9:11AM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA discussed the purpose of the visit with Executive DIrector, Criselda Espiritu Santo. The investigation consisted of interviews and record review. In regards to the allegation that Facility staff is financially abusing a resident: LPA interviewed six (6) staff, (5) residents and Resident 1's (R1) family member. R1 denied that staff is financially abusing R1. R1's finances are managed by family. The family member interviewed confirmed that R1's finances are managed by them and denied any concerns with the facility or its staff financially abusing R1. LPA conducted two (2) separate interviews with R1. Staff denied that the facility is financially abusing residents. Therefore, the allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099 was discussed and a copy was given to Executive Director, Criselda Espiritu Santo. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 17, 2025 · control 56-AS-20250226091408

Allegation investigated: Staff are not ensuring that resident is receiving services prescribed by their physician.

On 02/06/2025 at 2:27PM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegation. LPA discussed the purpose of the visit with Executive Director, Criselda Espiritu Santo. The investigation consisted of interviews and record review. The allegation alleges that staff are not ensuring that resident is receiving services prescribed by their physician. Based on an interview with Resident #1 (R1), R1 is escorted by a staff on each docotor's visit and other appointments. Staff remain with R1 during the entire appoinment process. R1 confirmed that psychiatric services have been provided at the facility. Staff interviews with Staff #1 (S1), Staff #2 (S2) and Staff #3 (S3) reveal that R1 is escoted to appointments and also receive services at the facility. Based upon record review, LPA observed notes of services provided to R1 for several months at the facilty. S2 is responsible for inputting resident appointments into a digital master calendar to ensure residents make it to their appointments. The allegation is UNSUBSTANTIATED. Unsubstantiated UNSUBSTANTIATED is defined as The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099 and LIC9099C was discussed and a copy was provided to Executive Director, Criselda Espiritu Santo.the state’s words, verbatim · CDSS document, Feb 6, 2025 · control 56-AS-20241115130752

Allegation investigated: Illegal eviction

On 12/23/2024 at 1:30PM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegation. LPA discussed the purpose of the visit with Executive Director, Criselda Espiritu Santo. The investigation consisted of interviews and record review. In regards to the allegation of Illegal eviction: As of 12/23/2024 Resident #1 (R1) is currently living in the facility. Based upon record review, LPA observed that R1 refused assistance with personal care. On 09/12/2024 at 1:47PM, LPA conducted a telephone interview in which R1 confirmed they had refused assistance. LPA observed Resident Shower Logs which confirmed that R1 refused assistance with personal care (19) nineteen times during the months of June-October of 2024. Unsubstantiated Staff interviews confirmed that a 30-Day Eviction letter was given to R1 on 09/10/2024 and a copy was received by Community Care Licensing Division (CCLD) which states the reason for R1’s eviction. The facility’s Admission’s Agreement clearly states the Eviction procedures. This Agreement was signed by R1 on 02/02/2023 and is in compliance with Title 22, Division 6 Chapter 8 section 87224. The allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099 and LIC9099C was discussed and a copy was given to Executive Director, Criselda Espiritu Santo.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 56-AS-20240911113843

Allegation investigated: Staff do not prevent resident from being hit by other residents

On 12/23/2024 at 1:30PM Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to deliver findings for the above allegation. LPA discussed the purpose of the visit with Executive Director, Criselda Espiritu Santo. The investigation consisted of interviews and record review. In regards to the allegation of Staff do not prevent resident from being hit by other residents: Resident #1 (R1) has been moved as of 11/12/2024 to another facility which provides a higher level of care. Based upon record review, LPA observed R1 had mild cognitive impairment. Interviews with staff confirmed that R1was forgetful and often was confused. Interviews with residents confirmed that staff lock the residents' doors at night and residents have their own keys to their assigned rooms. Residents and staff deny witnessing any residents hitting other residents. Unsubstantiated The allegation is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where this report LIC9099 and LIC9099C was discussed and a copy was given to Executive Director, Criselda Espiritu Santo.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 56-AS-20241106121830

Allegation investigated: Staff do not ensure residents are not eating expired/moldy food.

On 12/11/2024 at 10:00 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to deliver the findings of the above allegation. LPA Brown was greeted and granted entrance by a staff. Executive Director (ED) Criselda Espiritu Santo was contacted and informed of the visit and LPA Brown explained the purpose of the visit to ED Espiritu Santo. The investigation was conducted by LPA Brown. The investigation consisted of file review, observations and interviews with relevant parties. The allegation indicates Staff do not ensure residents are not eating expired/moldy food. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interview with ten (10) of ten (10) residents indicated that staffs at the facility are ensuring that the food they are serving them are fresh and no incident happened that staff gave them expired or moldy food. During the facility visit on 08/15/2024, Resident #1 (R1) reported to LPAs Melody Brown and Raquel Hernandez that the food served to R1 was not moldy but the chicken served has no meat on it and it did not taste good. During the facility visit today, 12/11/2024, R1 informed LPA Brown that staffs at the facility ***Cont. in LIC9099C*** Unsubstantiated are always serving fresh food and added that R1 never had an expired or moldy food. Interviews with seven (7) of seven staffs indicated that they are all ensuring that residents are not eating expired/moldy food. Seven (7) of seven staff interviews revealed that there's no incident that happened at the facility that they did not ensure that residents are not eating expired or moldy food because most of them eat the facility food after serving their residents. During the facility visit on 09/16/2024, LPAs Brown and Renese Howell-Small observed that the facility does not have expired foods in their perishable and non-perishable food supplies. During the facility visit today, 12/11/2024, LPA Brown checked the perishable and non-perishable food supplies and no expired or moldy food observed. Also, LPA Brown noted that no expired or moldy food served to the residents for lunch. Moreover, ED Espiritu Santo provided the facility menu to LPA Brown on 12/11/2024. Based on interviews, records review and observation, the allegation Staff do not ensure residents are not eating expired/moldy food is UNSUBSTANTIATED. A finding of unsubstantiated means 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. An exit interview was conducted, where this report (LIC9099) was discussed and provided to ED Criselda Espiritu Santo.the state’s words, verbatim · CDSS document, Dec 11, 2024 · control 56-AS-20240814082855

Type of visit: Case Management - Deficiencies

On 12/11/2024 at 10;00 AM Licensing Program Analyst (LPA) Melody Brown met with Executive Director (ED) Criselda Espiritu Santo to initiate a case management visit. The investigation consisted of observation, interviews ,and a review of pertinent documentation. During the facility visit today, 12/11/2024 LPA Brown observed that Staff#8 (S8) does not have the required Food Handlers Training certification. Deficiency will be issued. An exit interview was conducted where this report (LIC809), LIC809D) and Appeal Rights were discussed and provided to ED Criselda Espiritu Santo.the state’s words, verbatim · CDSS document, Dec 11, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(15) · Plan of correction due date: Dec 20, 2024

87555 General Food Service Requirements (b( The following food service requiremenst shall apply: (15) All persons engaged in food preparation and service shall observe personnel hygiene and food services sanitation practices...This requirement is not met by as evidence by: Based on observation, Interview, and record review ,the licensee didi not comply with the section cited above by not ensuring that Staff#8 (S8) has the required Food Handlers Training Certification which poses a potential health, safety or personal right risk to persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: Licensee stated to submit a copy of S8 Food Handlers Card Training Certification to LPA Brown by the Plan of Correction (POC) due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to interview additional residents relating to complaint 56-AS-20240805145702. LPA Prieto was accompanied Alexandra Villacis, Administrator, and assisted toured the facility. Residents were interviewed and this report was signed by LPA Prieto and Administrator Villacis.the state’s words, verbatim · CDSS document, Dec 5, 2024

Allegation investigated: Wrongful Eviction.

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings on the mentioned allegation. LPA met with Criselda Santo- Administrator and she was informed of the purpose of the visit and the allegation. The investigation included interviews with residents, staff members, and outside party, as well as a review of records. Interviews with staff and outside parties revealed that they were unaware of Resident 1 (R1) being evicted from the facility, and R1 stated that they were not given a written notice of eviction. LPA reviewed the facility files and found no record of R1 being evicted. Based on the interviews with R1 and outside parties, as well as the records reviewed, the allegation is Unsubstantiated This means that although the allegation may have occurred or is valid, there is not enough evidence to prove whether the alleged violations did or did not occur. An exit interview was conducted, and this report was discussed and provided at the conclusion of the visit with appeal rights to Criselda Santo- Administrator. Unsubstantiated An exit interview was conducted, during which this report and appeal rights were discussed and provided to xxx at the conclusion of the visit.the state’s words, verbatim · CDSS document, Nov 7, 2024 · control 56-AS-20240801123644

Allegation investigated: Staff did not keep facility free of bed bugs.

Licensing Program Analyst (LPA) Renese Howell-Small conducted an unannounced visit to the facility in order to investigate and/or deliver findings for the above allegations. LPA discussed the purpose of the visit with Executive Director, Criselda Espiritu Santo and this visit consisted of a facility tour, interviews, observation and record review. LPA Howell-Small observed the temperature to be 73 degrees Fahrenheit, toured the two-story facility and visited seven (7) resident rooms. LPA obtained documentation of monthly extermination service, waterproof and anti-bed bug mattress covers and a Sleep Tight machine specifically used to eradicate bed bugs. The allegation of staff did not keep facility free of bedbugs is UNSUBSTANTIATED. UNSUBSTANTIATED is defined as, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. Unsubstantiated Based upon a tour of the facility, observation, record review and interviews with both staff and residents, all staff and resident denies witnessing bed bugs or being bitten by bed bugs. Licensing Program Analyst (LPA) Renese Howell-Small observed mattresses and bedding in resident bedrooms to be clean, in good condition and covered with waterproof and anti-bed bug mattress covers. Therefore, the allegation that staff did not keep facility free from bed bugs is UNSUBSTANTIATED. In addition to regularly scheduled extermination, the staff follow House Rules in laundering donated clothing before the resident is allowed to place them in their rooms and are provided with containers with closed lids for opened food items to assist in maintaining a bug-free facility. UNSUBSTANTIATED is defined as, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. An exit interview was conducted and a copy of this report, LIC9099 and LIC9099C was provided to Executive Director, Criselda Espiritu Santo.the state’s words, verbatim · CDSS document, Oct 14, 2024 · control 56-AS-20241010124808

Allegation investigated: Lack of supervision resulting in physical altercation between residents

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Nurse Norma Alexandra Villacis and explained the purpose of the visit. The investigation consisted of interviews and review of records. First allegation, Lack of supervision resulting in physical altercation between residents. LPA conducted an interview with Resident#1 regarding the allegation stated above R#1 stated to LPA that such incident has not happened to resident in the past. R#1 informed LPA about feeling safe at the facility and indicated that staff assessed resident right away and provided resident with first aid. LPA conducted an interview with Resident #2 who stated to being a witness to the incident involving R#1. R#2 stated to LPA that after R#2 informed staff about the situation staff assisted R#1 right away. LPA conducted a record review and observed that staff offered R#1 additional medical care however, R#1 refused and stated being okay. In addition, during review of records LPA did not find any past incidents/or reports involving R#3 physically attack other residents in care. Unsubstantiated Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated. 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. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Nurse Norma Alexandra Villacis at the end of the visit.the state’s words, verbatim · CDSS document, Aug 27, 2024 · control 56-AS-20240820163635

Type of visit: Case Management - Deficiencies

On 08/15/2024 at 9:35 AM, Licensing Program Analysts (LPAs) Melody Brown and Raquel Hernandez conducted an unannounced visit to the facility to commence a Case Management Deficiency. LPAs Brown and Hernandez were greeted and granted entrance by a staff member and LPAs Brown and Hernandez met with Executive Director (ED) Criselda Espiritu Santo. LPAs Brown and Hernandez identified and discussed the purpose of the visit and with ED Criselda Espiritu Santo. During the quick tour of the facility, LPAs Brown and Hernandez observed that the facility does not have the required carbon monoxide alarm, LPAs Brown and Hernandez informed ED Criselda Espiritu Santo that deficiency will be issued as this poses an immediate health, safety and personal rights risk to residents in care. ED Criselda Espiritu Santo verbalized understanding. An exit interview was conducted where this report LIC809, LIC809D, and Appeal Rights were discussed and provided to ED Criselda Espiritu Santo.the state’s words, verbatim · CDSS document, Aug 15, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.311 · Plan of correction due date: Aug 16, 2024

Health and Safety Code 1569.311 Carbon monoxide detectors required; inspection. Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards...This requirement is not met as evidenced by: Based on observations and interview, the Licensee did not comply with the section cited above by not ensuring that the facility has the required carbon monoxide detectors which poses an immedaiate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 15, 2024

Plan of correction: Licensee stated to obtain/purchase carbon monoxide detectors and submit proof to LPA Brown on Plan of Corretion (POC) due date.

Allegation investigated: Staff are not allowing resident to have visitors in their room Staff are not providing comfortable accommodations for residents

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with CEO, Edna Medrano and explained the elements of the complaint. Regarding the allegation that staff are not allowing residents to have visitors in their room; LPA Prieto interviewed CEO Medrano who provided LPA with the facility's admission's agreement that addresses the visitation policy and those visitors providing proper identification upon entry. The facility also has designated visiting areas throughout the facility that are clearly labeled and indicating specific hours for the use of those specific areas. These areas are designated to assure the privacy of other resident's that may be residing in shared rooms and resident's safety. LPA interviewed resident #1 (R1), R2, R3, R4, R5, R6, R7, R8, and R9, all who stated that the facility is allowing them to have visitors and not restricting them relating to the facility's visitation policy. Unsubstantiated Regarding the allegation that staff are not providing comfortable accommodations for residents; This allegation is specifically pertaining to that area where resident's congregate during spiritual services. The facility does have designated areas, and times, for days and times of worship. The facility provides a shaded outdoor area, free of traffic and other disturbances. Indoor worship services are locate in the facility's activity room with sufficient seating and a cool comfortable temperature. Activities Director staff #1 (S1) was interviewed and stated that has not been any concerns regarding the areas where resident's congregate for spiritual services and S1 states that they abide hours designated for these activities as the area's are also used by other residents for different activities. LPA interviewed resident #1 (R1), R2, R3, R4, R5, R6, R7, R8, and R9. all who stated that the facility is providing comfortable accommodations. Based on the information obtained there is not enough evidence that staff are not allowing resident to have visitors in their room and staff are not providing comfortable accommodations for residents . Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and CEO Medrano and a copy was left with the facility.the state’s words, verbatim · CDSS document, Aug 6, 2024 · control 56-AS-20240805145702

Allegation investigated: Staff physically assaulted resident resulted in injuries Staff verbally abused resident

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility LVN Norma Villacis and explained the purpose of the visit. The investigation consisted of interviews and review of records. First allegation, Staff physically assaulted resident resulted in injuries. LPA conducted interviews with resident[s] pertaining to the allegation “staff physically assaulted resident resulted in injuries” all residents denied being physically assaulted by staff in addition, all residents denied witnessing staff physically assault residents in care. During interviews Resident (R#1), stated not remembering how bruise was obtained and denied bruise being caused by staff. LPA conducted interviews with staff pertaining to the alleged allegation and all staff denied physically assaulting resident along with witnessing staff physically assault resident in care. Unsubstantiated Second allegation, Staff verbally abused resident. LPA conducted interviews with resident[s] pertaining to the allegation “staff verbally abused resident” during interviews with residents 4 out of 5 residents denied being verbally abused by staff in addition, four out of five residents also denied witnessing staff verbally abuse resident. LPA conducted interviews with staff and all staff denied verbally abusing resident along with witnessing staff verbally abuse resident[s] in care. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated. 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. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility LVN Norma Villacis.the state’s words, verbatim · CDSS document, Jul 11, 2024 · control 56-AS-20240415102056

Allegation investigated: Staff sexually assulted resident.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Facility Director Criselda Espiritu Santo and explained the purpose of the visit. The investigation consisted of interviews and review of records. First allegation, Staff sexually assaulted resident. During the course of the investigation, interviews were conducted, a review of resident (R1) records was completed and copy of pertinent documents were obtained. Regarding the alleged allegation interviews with staff were conducted and all staff denied sexually assaulting resident (R#1) in addition, staff also denied witnessing any sexual assault. An interview with resident (R#1) was conducted and resident (#1) denied being physically or sexually assaulted by staff furthermore, resident (R#1) also denied being physically assaulted or sexually assaulted by any resident. Based on the corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated. Unsubstantiated 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. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Director Criselda Espiritu Santothe state’s words, verbatim · CDSS document, Jun 19, 2024 · control 56-AS-20240514135749

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPA met with Facility Administrator Criselda Espiritu Santo and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE). Licensed capacity is (240) current census (144). LPA was accompanied by Facility Administrator Criselda Espiritu Santo to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. 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 residents in care. There was a designated storage space for resident/staff files. Medications are kept inside Med room inaccessible to residents. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. 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. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed five (5) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Criselda Espiritu-Santo.the state’s words, verbatim · CDSS document, May 17, 2024

Type of visit: Case Management - Health Checks

licensing Program Analysts (LPA) Paola Guerrero conducted an unannounced visit to the facility on 5/17/2024 at 08:58 AM for the purpose of a Health & Safety check. LPA Guerrero identified herself toCriselda Espiritu Santo and discussed the purpose of the visit. Residents in care were present during visit. No imminent health and/or safety concerns observed at the time of visit. LPA Guerrero observed no health and/or safety hazards inside the facility. LPA Guerrero inspected the outside perimeter of the facility and observed no health and/or safety hazards. LPA Guerrero observed sufficient staff present at the facility to provide care. LPA Guerrero inspected facility food supplies and observed three (3) day supply of perishable and seven days (7) supply of non-perishable food. The needs of the residents in care appear to be met during this inspection. An exit interview was conducted where this report (LIC809) was discussed and provided to Criselda Espiritu Santo.the state’s words, verbatim · CDSS document, May 17, 2024

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Paola Guerrero conducted an unannounced visit to the facility on 4/19/2024 at 11:45 AM for the purpose of a Health & Safety check. LPA Guerrero identified herself to Executive Director Criselda Espiritu Santo and discussed the purpose of the visit. Residents in care were present during visit. No imminent health and/or safety concerns observed at the time of visit. LPA Guerrero observed no health and/or safety hazards inside the facility. LPA Guerrero inspected the outside perimeter of the facility and observed no health and/or safety hazards. LPA Guerrero observed sufficient staff present at the facility to provide care. LPA Guerrero inspected facility food supplies and observed three (3) day supply of perishable and seven days (7) supply of non-perishable food. The needs of the residents in care appear to be met during this inspection. An exit interview was conducted where this report (LIC809) was discussed and provided to Criselda Espiritu Santo- Executive Director.the state’s words, verbatim · CDSS document, Apr 19, 2024

Allegation investigated: Facility failed to notify resident authorized representative about medical treatment.

Licensing Program Analyst (LPA) Anna Fannell conducted an unannounced visit to this facility for the purpose of initiating the investigation of and delivering findings for the above allegation. LPA met with Licensee Edna Medrano who was advised of the purpose of visit. Administrator Cris Espiritu Santo arrived during today's visit. The investigation consisted of review of relevant records and interviews with relevant parties. It is alleged that the Facility failed to notify Resident (R1) authorized representative about medical treatment. LPA reviewed records showing that R1 has a medical power of attorney (POA) agent. Interviews revealed that R1 has been experiencing daily reoccurring nosebleeds that facility staff sent R1 to the local medical facility. Interviews further revealed that R1's representative has been receiving communication from the facility about R1's condition and R1's representative was aware that R1 would leave the local medical facility and return to this residential facility before R1 could receive medical treatment. Staff (S1) interview revealed they arranged for non-medical transport to take R1 to a non local medical facility in an attempt to prevent R1 from leaving the medical facility. This allegation is therefore unsubstantiated. Unsubstantiated A finding of UNSUBSTANTIATED means, 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. An exit interview was conducted with and a copy of this report was provided to Administrator Espiritu Santo.the state’s words, verbatim · CDSS document, Mar 27, 2024 · control 56-AS-20240325123035

Allegation investigated: Staff does not assist resident with transfers from bed to wheelchair. Staff does not give resident any medications for the past 2 years. Staff is attempting to become resident's payee for social security. Staff become resident's POA without resident's consent.

Licensing Program Analysts (LPA) Anna Bueno and Javier Prieto conducted an unannounced visit to the facility to initiate the complaint investigation and deliver findings on the above allegation. LPAs met with administrator Criselda Espiritu Santo was informed of the purpose of today’s visit. The investigation consisted of a review of relevant records and staff interviews. LPAs were unable to contact Resident (R1). Allegation 1: Staff does not assist R1 with transfers from bed to wheelchair. LPAs reviewed R1's assesment from 10/31/23 conducted by a third-party showing that R1 requires limited assistance in making transfers and would like to be more independent in making their own transfers. Staff interviews revealed that R1 is able to transfer independently. This allegation is unsubstantiated. Allegation 2: Staff does not give resident any medications for the past 2 years. LPAs reviewed records showing that R1 has refused services from the facility, including, medication administration, going to medical appointments, and checking their blood pressure. Records revealed that R1's refusal has been consistent since August 2023. Interviews with staff confirmed that R1 has refused to take their medication for months. This allegation is therefore unsubstantiated. Unsubstantiated Allegation 3: Staff is attempting to become resident's payee for social security; AND Allegation 4: Staff become resident's POA without resident's consent. LPAs interviewed witness who shared that during a 10/31/23 meeting with R1, they did not disclose facility staff has attempted to become R1's payee or to have authority over R1 by filing a Power of Attorney (POA). LPAs reviewed records showing that R1 is capable of making their own decisions but may need reminders. Interviews with administrator deny that the facility attempted to become R1's payee nor has the facility filed POA over R1. Administrator further added R1 is capable of going out in the community on their own using their walking assistive device. These allegations are therefore unsubstantiated. A finding of UNSUBSTANTIATED means, 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. An exit interview was conducted with and a copy of this report was provided to Administrator Espiritu Santo.the state’s words, verbatim · CDSS document, Dec 7, 2023 · control 56-AS-20231130160801