Acacia Villas

Allegation investigated: Staff are sleeping during their shifts.

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced subsequent complaint visit to continue to investigate the allegation. LPA was greeted and granted entry by receptionist at 2:35pm. LPA met with Executive Director (ED) Tammy Joo and explained the purpose of the visit. LPA requested a copy of the call light log for the night of July 16, 2026 and early morning of July 17, 2026. The facility call light uses pull cords and auditory sounds and does not have a digital call light system. LPA requested vendor information who were doing renovation work in the lobby and requested the evening staff schedule for July 16, 2026. LPA reviewed the following documents from Resident #1 (R1)'s file: Death Report dated July 17, 2026, Identification and Emergency Information Form, Medical Assessment from 11/17/2025 and an Individualized Service Plan dated 6/4/2021. LPA obtained two of two staff documents which include: the (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) LIC 501, LIC 503, LIC 508, Training documentation. Job descriptions and Employee Corrective Action Forms. Per interview, rwo of two staff refused to sign the Employee Corrective Action Forms and stated they were inaccurate because the staff were not sleeping. On the evening of July 16, 2026 the front lobby was being renovated and an electrical company was installing wires and lights. Due to the drilling noises and loose wires hanging, staff did not remain in the front lobby and the front doors were open due to the dust. LPA interviewed three of three witnesses. Two of three witnesses stated they did not see staff sleeping during their shift. One of three witnesses confirmed staff were sleeping during their shift. LPA interviewed eight of eight staff members. Seven of eight staff members interviewed denied the allegation that the staff were sleeping during their shift. One staff member was unable to be interviewed. There were no residents that were awake during this time period, thus LPA was unable to interview residents regarding the incident. Based on LPA's record review, observations and interviews, the allegation that Staff are sleeping during their shifts is Unsubstantiated. 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 with Executive Director (ED) Tammy Joo and a copy of this report and LIC 811 were provided to the facility.the state’s words, verbatim · CDSS document, Aug 12, 2026 · control 22-AS-20260717152221

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to conduct an Annual Required Evaluation. LPA was greeted and granted entry at 8am by the Med Tech. LPA met with Tammy Joo, Administrator (AD) and explained the purpose of the visit. AD stated they recently had an Annual Required Evaluation on April 16, 2026 which was for 2025. LPA explained that the annual today would be for 2026 and AD understood. The facility is a two story building with an approved fire clearance for 99 non-ambulatory residents and an approved hospice waiver for thirty residents. LPA obtained the resident and staff roster and currently there are 98 residents in care and eleven on hospice. The facility accepts the Assisted Living Waiver. During today’s visit, LPA inspected the physical plant and reviewed fire sprinkler system and fire alarm inspection documentation. The fire sprinklers were tested on July 9, 2026 and passed. The fire alarms were inspected and passed on June 17, 2025. The facility's last fire drill was conducted on April 14, 2026. LPA observed fire extinguishers throughout the facility and they were charged and inspected on December 12, 2025. Southern California Edison had been working on a power line nearby and the facility's electricity was temporarily turned off for approximately ten minutes prior to lunch. LPA observed fire magnetic doors closing, the elevator defaulted to the first floor and residents were able to exit elevator and sit in the dining room for lunch. All hands assisted residents to the dining room until the electricity turned back on. The facility generator switched on during the temporary electrical shut-off. LPA toured the facility which consists of a large dining room and kitchen, a television room and offices on the first floor. There is one elevator and an enclosed courtyard with a shaded seating area. There were no (Continued on LIC 809-C) (Continued from LIC 809) hazards or obstructions in pathways. Emergency supplies were observed in the kitchen and office area by the front door. There are four stairwells and all stairwells had evacuation chairs. The facility was seventy eight degrees Fahrenheit. On the second floor LPA observed an activities room and theater and residents were observed in activities. LPA tested carbon monoxide detectors throughout the facility and all were in working order. The PUB 475 See Something, Say Something poster was posted in a prominent place; as well as the Long Term Care Ombudsman poster; which was in English and Korean. The facility also had cameras in common areas such as in the lobby, kitchen, med room and upstairs and downstairs hallways. Residents are informed during the admissions process and sign that they were informed. Cameras are visual only. LPA inspected the kitchen and there are modified diets and resident eating habits posted near the beverage area. The kitchen extinguisher was charged. Sharps and knives were secured and LPA observed two days of perishable food supplies and seven days of non perishable food items. Temperature logs were observed on the refrigerators and freezers and the kitchen was sanitary. LPA entered resident apartments and noted they had the required furnishings and linens. LPA tested the hot water temperatures in five of five apartments. The water temperatures ranged from 105.1 to 119.4 degrees Fahrenheit and the facility recently bought a water heater booster. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. A First Aid Kit and manual were located in the Medication Room with the required elements. LPA reviewed five of five staff training and fingerprint records and five of five resident records. Medical Assessments and Emergency Disaster Form LIC 610E was updated. The next staff Cardiopulmonary Resuscitation (CPR) training is scheduled for July 17, 2026. Staff are trained monthly by outside vendors and the community retains a nurse to review medical records. LPA interviewed alert residents regarding their quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on December 13, 2026. Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Tammy Joo, Administrator and a copy of the report and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.the state’s words, verbatim · CDSS document, Jul 10, 2026

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Tammy Joo and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 1:00PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a large commercial facility. Facility is composed of a single, two-story building with an outdoor courtyard in the center, a commercial kitchen and large dining room on the first floor, a medication room on the first floor, a laundry room on the second floor, and resident rooms on both floors, along with multiple common areas and storage rooms. There are a total of 66 resident rooms. Resident Bedrooms: the 10 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 10 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 and 128 degrees F, before corrections, in the 7 resident bathrooms tested. Call system tested in multiple resident bedrooms with prompt responses from staff. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the housekeeping closets. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees are not yet past due. At about 8:00AM, LPA reviewed 10 resident files and 10 staff files, interviewed 5 residents and 5 staff, and inspected medications for 10 residents. Facility does not handle resident money. LPA provided California Department of Public Health informational material on Legionnaires’ Disease during the inspection. During the inspection, LPA and AD observed the following: based on observation, the water temperature in Rooms 129, 122, 107, 202, and 231 tested at 122, 121, 126, 128, and 123 degrees F; based on documents, Staff #7 (S7) and Staff #10 (S10) have been working without current first aid certificates; and based on documents, the physician's reports for Resident #1 (R1) through Resident #10 (R10) are on the old form and do not include required information, including behavioral expressions. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Apr 16, 2026

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Facility staff is not ensuring safety of resident while in care.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Tammy Joo and explained the reason for today’s inspection. The investigation into the allegation that facility staff is not ensuring safety of resident while in care revealed the following: During the course of the investigation, LPA inspected the facility, interviewed Assistant Administrator (AAD) Michelle Kwak, witnesses, and residents, and obtained and reviewed copies of the resident roster, staff roster, and Resident #1’s (R1) Physician’s Report dated March 1, 2021. CONTINUED Unfounded It was alleged that R1’s responsible party is emotionally abusing R1 at the facility by encouraging them to eat when they’re not hungry, telling them in a “threatening tone” that they will not be able to go on outings if they don’t eat, and encouraging R1 to walk when they’re tired. Per a statement from R1’s hospice company, R1’s hospice nurse assessed R1 on April 14, 2021, R1 denied any concerns of emotional abuse by their responsible party, R1 stated they felt “relaxed” in the presence of their responsible party, R1 reported that their responsible party encourages them to eat to “get stronger” but does not force feed them, R1 also denied being forced to walk when too tired and reported that their responsible party encourages them to walk but takes them back to their room when they’re ready, and facility staff denied observing concerns for emotional abuse by R1’s responsible party. LPA reviewed R1’s Physician’s Report dated March 1, 2021, which indicates R1 does not have dementia. LPA interviewed AAD who stated that R1’s responsible party has been good and diligent with R1, comes to see R1 on a daily basis, is very emotionally close with R1, does not yell at R1, and treats R1 well. Per AAD, facility staff have never seen R1’s responsible party do anything bad with R1 and R1 really likes their responsible party. LPA interviewed R1 who denied the allegation, stating their responsible party treats them well and they have no concerns at the facility. LPA interviewed two additional residents who raised no safety concerns at the facility. LPA interviewed R1’s responsible party who denied the allegation and raised no concerns about the facility. No information was obtained corroborating the allegation. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. LPA reviewed R1’s hospice medical records which confirmed that R1’s rash was being assessed and treated by R1’s hospice care team. LPA interviewed AAD who stated that R1 has a history of rashes, R1 recently had a rash that got better after an anti-fungal cream was used, and facility staff regularly provide R1 showers, check on R1, and ensure R1’s incontinence needs are met. LPA reviewed R1’s Physician’s Report dated March 1, 2021, which confirms that R1 has a history of rashes. LPA interviewed R1 who denied the allegation, stating facility staff noticed and obtained treatment for their rash quickly and they have no concerns at the facility. LPA interviewed two additional residents who raised no care concerns at the facility. LPA interviewed R1’s responsible party who denied the allegation, stating the rash was properly addressed, and raised no care concerns at the facility. In addition to the rash, one witness reported that R1’s incontinence needs are not being met, there were issues with R1’s medications, and R1 had a urinary tract infection that was not addressed properly. Regarding R1’s incontinence care, R1 and R1’s responsible party did not corroborate any issues with incontinence care, with R1’s responsible party confirming that R1 was checked on and changed regularly. However, both the witness and R1’s responsible party confirmed that R1’s diapers, even if changed timely, leaked due to being the wrong size. LPA interviewed AAD who stated that R1’s diapers were provided by hospice and if they were the wrong size, then R1’s hospice bath aide, R1’s responsible party who came every day to see R1, or the facility’s staff would have noticed, raised the issue with hospice, and the diaper size would have been changed. LPA reviewed R1’s hospice medical records which confirmed R1’s diapers were provided by hospice. The information obtained did not corroborate that the facility failed to address the diaper size issue, including because the issue started with hospice and R1 and their responsible party could have addressed the issue directly with hospice. Regarding R1’s medications, the witness reported that the facility was giving R1 antacids with medications that could not be combined with antacids. LPA interviewed AAD who was unable to provide information regarding this issue. LPA reviewed R1’s hospice medical records which list R1’s medications during the relevant time period and noted R1 was prescribed milk of magnesia, but there is no special instruction that any medications on R1’s medication list cannot be taken together. Regarding R1’s urinary tract infection, LPA interviewed AAD who could not identify whether R1 had any specific urinary tract infections, but stated that residents like R1 who receive incontinence care are at higher risk for urinary tract infections, staff check for signs and symptoms during changes, and any concerns are reported to the resident’s doctor. LPA reviewed R1’s Physician’s Report dated March 1, 2021, and hospice medical records and did not note any documentation regarding urinary tract infections. When interviewed, R1 and their responsible party raised no concerns regarding urinary tract infections. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 22-AS-20210416163318

Allegation investigated: Staff did not prevent a resident from falling multiple times while in care

On November 12, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to continue the investigation into the allegation listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by Executive Director (ED) Tammy Joo after explaining the purpose for the visit. The initial complaint visit was conducted on September 22, 2023, in which resident and staff interviews were conducted, and pertinent documents to the complaint were collected. On today's visit, additional residents and staff interviews were conducted. Regarding the allegation that, staff did not prevent a resident from falling multiple times while in care, the following has been concluded: Resident #1 (R1) was admitted to the facility on December 19, 2022. Per R1's Physician Report dated November 18, 2022, R1 was diagnosed with Mild Cognitive Impairment. R1 was non-ambulatory; able to communicate his needs; able to follow instructions; but was confused/disoriented at times. CONTINUED ON LIC9099-C Unsubstantiated Per the Unusual Incident/Injury reports (UIIRs) received by the Orange County Regional Office, R1 had a total of three falls while at the facility. R1 had one fall on September 12, 2023, one fall on September 13, 2023, and had one fall on September 14, 2023. R1 was transported to the hospital after sustaining the fall on September 14, 2023, and was admitted for increasing weakness and multiple falls. Based on a review of the hospital records, R1 did not sustain any injuries as a result of the three falls. The Department conducted an interview with R1 for this complaint but R1 was unable to provide any useful information regarding the allegation. The Department also attempted to conduct an interview with R1's Responsibly Party but were unable to due to the Department being unable to reach them. The Department conducted a total of seven staff interviews. Four out of the seven staff interviewed were unable to provide any useful information regarding the allegation due to staff not recalling the incidents. Three out of the seven staff interviewed stated that increased checks were done on R1 after the first fall to try and prevent any future falls. Staff interviews conducted stated that changes to R1's apartment were recommended to R1's family to prevent future falls, however, R1's family declined the recommended changes. Staff interviews conducted also revealed that the care plan for R1 was unable to be updated to require a higher level of care for being a fall risk, due to R1 not returning to the facility after sustaining the fall on September 14, 2023. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Executive Director Tammy Joo and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 12, 2025 · control 22-AS-20230915142119

Type of visit: Case Management - Incident

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on December 24, 2024, regarding Resident #1 (R1). LPA met with Staff #1 (S1) Michelle Kwak and explained the purpose of the inspection. Administrator (AD) Tammy Joo arrived during the inspection. During the inspection, LPA and AD toured the facility. LPA conducted health and safety checks on R1 and the other residents present and confirmed they were doing well and observed no health and safety issues. LPA interviewed AD, R1, and witnesses, and requested and reviewed copies of the resident roster, staff roster, an Incident Report received December 24, 2024, R1’s Physician’s Report dated June 21, 2024, and R1’s Appraisal dated January 02, 2025. The investigation into the incident revealed the following. Per interview with AD and an Incident Report received December 24, 2024, on December 17, 2024, R1 was diagnosed with a fractured clavicle after an unwitnessed fall at the facility. Interviews with AD and a witness and review of R1’s Physician’s Report dated June 21, 2024, revealed that on June 21, 2024, R1 was readmitted to the facility after receiving treatment at a skilled nursing facility for a stroke and had fall risks related to the stroke. Per AD and a witness, the facility and R1’s family created a fall prevention plan around June 21, 2024, to address R1’s fall risks related to the stroke which included moving R1’s room to the first floor and more frequent checks, private one-on-one caregivers, and furniture and equipment in R1’s room to address possible falls. AD and the witness also stated that after R1’s fall on December 17, 2024, the facility and R1’s family updated R1’s fall prevention plan to include additional private one-on-one caregivers and additional alterations to furniture and equipment in R1’s room to address possible falls. Per R1’s Appraisal dated January 02, 2025, the facility properly reassessed R1 after R1’s change in condition relating to the fall on December 17, 2024. However, AD admitted that R1’s Appraisal was not updated in writing after R1’s readmission on June 21, 2024 to document the fall prevention plan put in place to address R1’s change in condition and fall risks related to the stroke. Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jan 2, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jan 30, 2025

87463 Reappraisals (a) The pre-admission appraisal… shall be updated in writing as frequently as necessary … to note significant changes in condition… and to keep the appraisal accurate… Based on interview and documents, the licensee did not update R1’s appraisal after R1’s stroke to include R1’s new fall prevention plan, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 2, 2025

Plan of correction: Licensee stated they will create a protocol for updating residents’ appraisals in response to changes in condition, train relevant staff on the protocol, and submit proof to LPA by POC due date.

Type of visit: Case Management - Health Checks

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check and to follow up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 12/24/24. LPA met with Staff #1 (S1) Michelle Kwak and explained the purpose of the inspection. Administrator (AD) Tammy Joo arrived during the inspection. During the inspection, LPA and AD toured the facility. LPA conducted health and safety checks on the residents present and confirmed they were doing well and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed the electricity and water were running, the medications were properly stored, and the facility had soap and paper towels. LPA requested and reviewed copies of the resident roster, staff roster, and resident files. Facility representative was advised that at this time further investigation is required. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Dec 24, 2024

Type of visit: Required - 1 Year

On 12/14/2024 at 08:30 AM, Community Care Licensing Division (CCLD) staff conducted an unannounced annual inspection visit at Acacia Villas Facility. CCLD staff was allowed entry into the facility by Administrator Tammy Joo. The facility is licensed for 99 residents 60 years or older. Currently there are 97 resident living at the facility. CCLD staff explained to Administrator Tammy Joo, the purpose of the 1-year Annual Inspection visit, and escorted CCLD staff on a tour of the entire inside and outside facility grounds. As part of the inspection, CCLD staff reviewed: ten (10) resident service records, ten (10) resident medication records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 12/12/2024. The two-story commercial building consisting of (66) resident bedrooms, (66) resident bathrooms, (4) common bathrooms, dining room, TV room, commercial kitchen, staff room, office area, commercial washer and dryer/ storage area, backyard with umbrella with table and chairs. No weapons were found or stored on the premises. Commercial Kitchen was inspected and observed to be clean and operational. CCLD staff checked commercial refrigerators and storage for 2-day supply perishable and 7-day supply of non-perishable foods are present in the facility kitchen. Emergency Water Storage was also located in the kitchen area. CCLD staff inspected resident room 101, 102, 109, 202, 206. CCLD staff observed that all resident rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. CCLD staff observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, CCLD staff observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. CCLD staff observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 109 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 107 degrees Fahrenheit. Bathroom #3 hot water temperature properly measured at 105 degrees Fahrenheit. Kitchen water temperature properly measured at 115 degrees Fahrenheit. Facility (10) Carbon Monoxide and (80) Smoke Detectors hard wired and connected were tested and are working properly. The facility (12) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the facility were free of debris and hazards. Outside patio accessible to residents. Ten (10) resident files were reviewed and found to be complete. CCLD staff reviewed ten (10) resident medications and they were all found to be administered according to doctor's orders. Five (5) staff files were checked and have the required documents. CCLD staff noted the Administrator Tammy Joo Certification # 6021814740 expiration date of 12/13/2024 was NOT valid at time of inspection. The facility does not handle resident's money/cash resources. Commercial General Liability Policy #PCI2995184802 policy period from 09/05/2024 to 09/05/2025 underwritten by Primary Care Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Administrator Tammy Joo to email CCLD staff a full copy of the commercial insurance policy including all endorsements no later than 12/30/2024. All the required documents are posted in the facility in a clearly visible area. During the visit, CCLD staff observed the facility infection control practices. CCLD staff observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). CCLD staff observed staff and residents were not wearing face coverings. CCLD staff observed the facility has a 30-day supply of Personal Protective Equipment (PPE). CCLD staff advised the Administrator Tammy Joo to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. . According to the California Code of Regulations (Title 22, Division 6, Chapter 8), CCLD staff did not observe deficiencies therefore no citations were issued at this time. Annual Licensing Fee is CURRENT. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Tammy Joo.the state’s words, verbatim · CDSS document, Dec 14, 2024

Allegation investigated: Resident is not receiving showers

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced complaint visit to investigate the allegations that were received in our office on March 16, 2023. LPA was greeted and granted entry into the facility by the concierge and met with Tammy Joo, Administrator (AD) and stated the purpose of the visit. During the investigation LPA obtained and reviewed the following documents: the resident roster, shower schedules from February and March 2023 and current shower schedules and itemized resident invoices that were provided by the accountant. LPA also reviewed seven of seven resident Admissions Agreements, Needs and Services Plans, Identification forms and Assisted Living Waiver (ALW) Medical Assessments. (Continued on LIC 9099-C) Unfounded (Continued from LIC 9099) It was alleged facility resident is not receiving showers due to Resident 1 (R1) not receiving showers. The Long Term Care Ombudsman (LTCO) assisted LPA in translating interviews of five of six residents regarding shower services received and itemized billing for services. All six residents interviewed verified they received showers on their scheduled day and get additional showers in the week beyond the two showers as agreed upon. LPA spoke with three staff members regarding shower schedules and all confirmed showers were being given. LPA reviewed current shower schedules, as well as from February and March 2023, which notated each resident is receiving two showers per week. AD Joo & Business Office Manager Michelle Kwak confirmed the shower schedules get updated every two weeks. LPA was unable to interview R1 due to R1 having passed. Based on evidence reviewed, preponderance of evidence shows residents are receiving showers. This agency has investigated the complaint alleging residents are not receiving showers. The Department found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Tammy Joo, Administrator (AD) and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 20, 2024 · control 22-AS-20230316094636

Type of visit: Case Management - Incident

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check and to follow up on a self-reported incident report received in the Orange County Regional Office (OCRO) on May 23, 2024 regarding an incident involving Resident #1 (R1). LPA met with Administrator (AD) Tammy Joo and discussed the purpose of the inspection. During today’s inspection, LPA toured the facility with AD. LPA conducted health and safety checks on the residents present and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations, the electricity and water were running, the facility had soap and paper towels, and the medications, sharps, and toxins were properly stored. LPA conducted interviews and requested and reviewed copies of the resident roster, staff roster, and resident files. The investigation into the incident revealed the following: on May 22, 2024, R1 left the facility during the overnight shift without being observed by staff, staff immediately noticed and called police, police found R1 about an hour or less later nearby the facility and took R1 to a hospital, R1 sustained no serious injuries, and R1 was moved out of the facility and relocated to a memory care unit. Per R1’s Physician’s Report, they were not able to leave the facility unassisted. AD stated that R1 had no history of wandering, facility staff had been conducting checks on R1 and other residents regularly, and when R1 left the alarm on the door went off and facility staff, who had recently just seen R1, checked for R1 again and noticed they had left, and the facility acted immediately to notify police and look for R1 within the facility, which resulted in R1 being found very close to the facility, very quickly, and with no injuries. Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, May 29, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 5, 2024

87464 Basic Services … (f) Basic services shall at a minimum include: (1) Care and supervision... This requirement was not met as evidenced by: Based on interview and documents, the licensee did not provide adequate supervision to R1 when R1 eloped, was missing for a short period of time, and was found nearby with no injuries, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2024

Plan of correction: Licensee stated they will create a list of residents who are unable to leave the facility unassisted and retrain staff on the elopement protocol and submit proof to LPA by POC due date.