Acorn Oaks Manor II

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Domingo, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Domingo was granted entry after identifying herself and stating the purpose of the inspection Community Manager Maria Williams. Later Licensee/Administrator Alex Limpin joined the visit. A tour of the facility was conducted which included a sample of resident units, the dining area, common gathering areas, and food storage areas. There are no water features on site. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with the required furnishings. Residents’ bathrooms were observed to be sanitary and operational. Showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. The facility is operating in accordance with their fire clearance. The smoke and carbon monoxide alarms were present in each building. Emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible in the kitchen area. Required licensing postings were observed in visible areas of the facility. PPE supplies are on site. Indoor passageways were free from obstructions. Food was observed to be properly labeled. All food is prepared on the property and delivered to bedside or residents can visit the common dining area for a meal. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Centrally stored medications were properly stored and locked in medication carts. Medications were labeled and kept in compliance with label instructions. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPA conducted a review of In-service training procedures. LPA interviewed Administrator Alex Limpin was assured transportation procedures as well as outside medical and dental assistance procedure are compliant. There is large common rooms used for dining and activities. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. LPA interviewed staff and clients. LPA interviews did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Files reviewed contained required documents. Confidential records were stored in locked areas. the administrator presented proof of current/active business liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were cited at the time of visit. An exit interview was conducted with Licensee/Administrator Alex Limpin to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 2, 2026

Allegation investigated: -Licensee did not meet resident(s)’ personal care needs. -Licensee did not maintain toilet paper in bathroom.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced subsequent visit to deliver findings regarding the above prior complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Supervisor Jamily “Jamila” Hallak and Licensee/Administrator Alex Limpin. The Complainant alleged that Licensee did not meet Resident(s)’ personal care needs and that Licensee did not maintain toilet paper in bathroom. CCLD’s investigation involved multiple unannounced facility tours/welfare checks and interviews of all residents in care, outside sources, and multiple facility managers and caregivers. The Department also reviewed pertinent care records. [CONTINUED ON LIC 9099-C, 1 of 2] Substantiated [CONTINUED FROM LIC 9099] Regarding the first allegation: The Complainant said Resident #1 (R1) relied on staff help for changing their clothes, but that Licensee’s staff do not regularly provide this help, as required. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] The Complainant said R1 relied on staff help with grooming (to include shaving), but Licensee’s staff did not regularly provide this help, as required. The Complainant said Resident #2 (R2) did not have the manual dexterity to peel an orange, and that Licensee’s staff would hand R2 whole oranges without peeling them, meaning R2 could not eat these fruits. According to the care assessments/plans which Licensee authored on R1 and R2, both residents were supposed to receive assistance with bathing (twice per week), dressing (twice per day), and grooming (twice per day). Grooming assistance included toenail and fingernail care. During his 01/14/2026 visit, LPA observed: R1 and R2 were in reasonably clean clothing. Neither person had foul body odor. The same was true for all other residents of the facility. However, R1 had unkempt facial hair around an inch-long. R1 had long/overgrown toenails. R2 had long/overgrown fingernails and toenails. Resident #3 (R3) also had overgrown fingernails. Interviews of staff and outside sources aligned to show: Those facility residents who could not bathe independently were typically assisted by staff with bathing twice per week, according to a facility shower schedule (which LPA obtained a copy of). Resident interviews widely corroborated that twice-per-week bathing help was provided, in practice. Almost half the time, R1 refused to be showered, despite repeated attempts/encouragement by caregivers, which was R1’s right to do. Multiple staff reported that R1 was not shaven because they had refused to be shaved. However, R1 expressed to LPA on 01/14/2026 that they preferred to be shaven, and that they would accept shaving help if it was offered to them, which LPA relayed to staff that same day. (On LPA’s return visit on 01/28/2026, LPA observed R1’s beard and moustache had been neatly trimmed/groomed.) Staff interviews showed mixed answers and a lack of general clarity among the caregivers as to who was responsible for residents’ fingernail and toenail care, and at what frequency such care should be rendered. R1 told LPA that staff indeed typically peeled and cut their oranges for them. Staff interviews widely corroborated this. [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 9099-C, 1 of 2] Regarding the second allegation: The Complaint said there have been a few occasions between August 2025 and early January 2026 when they observed no toilet paper available in a hallway bathroom shared by the facility’s residents. During his 01/14/2026 facility visit, LPA also observed that one (1) of the facility’s two (2) shared bathrooms had no toilet paper. LPA instructed staff to add more toilet paper that day. On LPA’s return visit on 01/28/2026, both bathrooms had toilet paper inside them. Based on records and interviews, a preponderance of evidence exists to show that at least during the complaint timeframe, Licensee did not meet residents’ personal care needs and that Licensee did not maintain toilet paper in bathroom. Both allegations are therefore Substantiated, and two (2) deficiencies were cited for them per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Licensee/Administrator Alex Limpin, to whom a copy of this report, the LIC 9099-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. [CONTINUED FROM LIC 9099-A] LPA met privately with all (12) residents in care, finding two (2) did not have the mental ability to answer questions. LPA also interviewed two (2) managers and four (4) direct care staff. The Complainant said most of the time when either Resident #1 (R1) or Resident #2 (R2) pushed their call button, Licensee’s caregivers did not respond to it at all. [See LIC811 Confidential Names list for a description of select person identifiers used in this report.] During his 01/14/2026 visit, LPA tested the call buttons for R1 and R2, finding both devices were working and transmitting a signal to the med tech station, as expected. Of the ten (10) residents who could answer questions about this topic, six (6) said they were ambulatory and thus generally did not use their call buttons. Of the remaining four (4) residents, only one (1) complained of slow response time. Interviews of managers and caregivers aligned to show that caregivers aimed to respond to call signals as soon as they heard them (unless they were already in middle of providing care to another resident) and that caregivers generally worked as a team to timely meet such calls for service. The Complainant said during their 01/05/2026 visit, strong urine and fecal odors pervaded the facility (rather than being specific to any room or resident). During his own 01/14/2026 and 01/28/2026 visits, LPA did not smell odors of incontinence in facility common areas or resident bedrooms; the facility smelled fine. Of the ten (10) residents who could answer questions about this topic, nine (9) said the facility smelled fine to them, and one (1) did not have an opinion on the topic. Interviews of the managers and staff did not reveal evidence of the facility being malodorous. The Complainant said on multiple days between August 2025 and early January 2026, the floor of R1 and R2’s shared bedroom had trash/debris on the floor. They also said facility staff did not clean R1’s bedside table of food debris, and that on 01/05/2026, there was a fecal stain on R1 and R2’s window curtain. During his own 01/14/2026 and 01/28/2026 visits, LPA did not see trash/debris on the bedroom floor of R1/R2, or any other resident’s bedroom or common area. R1's bedside table was also clean. The facility’s walls were clean. Of the ten (10) residents who could answer questions about this topic, all ten (10) said Licensee’s staff kept the facility in a state of general cleanliness. Manager interview showed that on an earlier date, there was indeed a stain on the window curtain of R1/R2, but this was chocolate Ensure (not feces), and the curtain was soon changed out for a clean one. LPA reviewed a photograph of the curtain in question, taken on the date in question; the splatter patterning was more consistent with the Ensure explanation (i.e., it did not look like feces). [CONTINUED ON LIC 9099-C, 2 of 3] [CONTINUED FROM LIC 9099-C, 1 of 3] Complainant said on 01/05/2026, the facility temperature fell to around 53 F, because staff left both of the facility’s two (2) front doors ajar at night. During his own 01/14/2026 visit, LPA observed the facility’s temperature was in the low 70s (well-within in the required range described in regulation). LPA also observed that Licensee kept extra portable heaters on the premises and available to deploy to resident rooms, upon demand. Of the ten (10) residents who could answer questions about this topic: Nine (9) said the facility temperature was consistently kept comfortable. Resident interviews widely aligned to show that staff typically kept the facility’s two (2) front doors closed at nighttime. Multiple residents confirmed remembering heavier rainfall during early January 2026, but said the facility was kept warm with heaters. Only one (1) resident said the facility was often too cold (to include the date of LPA’s 01/14/2026 visit). However, this last resident also stated that when they felt cold, staff provided them with blankets. (LPA witnessed this resident using three blankets during his visit). When LPA returned on 01/28/2026, the facility was again at a warm and comfortable temperature. Interviews of managers and caregivers did not produce evidence of the facility being too cold, even during the earlier week that the Complainant had referenced. The Complainant said R2 was bitten by insects while inside the facility. During his 01/14/2026 and 01/28/2026 visits, LPA did not observe any live or dead insects inside the facility. Of the ten (10) residents who could answer questions about this topic: Eight (8) denied the facility having any insect problem. One (1) resident did not have a clear opinion on the topic. One (1) resident said they had been bitten by mosquitoes on their head and cheek, but they declined to let LPA look closely at their head, and LPA did not see any bites on their face. Interviews of a facility manager plus an outside source showed that at one point during the complaint period, this last resident received a visitor who brought a dog that laid on the resident’s bed. Upon receiving an allegation of an insect bite to said resident (prior to CCLD receiving the complaint), facility staff changed that resident's bed sheets and contacted the visitor to provide them notice and instruction. The available evidence cannot reliably establish that this visitor’s dog had fleas; even if their dog did, there is no evidence of Licensee culpability here. [CONTINUED ON LIC 9099-C, 3 of 3] [CONTINUED FROM LIC 9099-C, 2 of 3] The Complainant said there was a period when R1’s hospital bed stuck out to the point that it obstructed their bedroom door from being closed. Interviews of managers, caregivers, and an outside source, along with video, showed: During late 2025, Licensee undertook a project to widen the doorframes of its residents’ bedrooms to make them more wheelchair-friendly. As part of this project, the shared bedroom door belonging to R1 and R2 was also widened. During the complaint period, R1’s/R2’s bedroom door could not be swung closed because it would contact the end of R1’s bed. After a few weeks, staff fixed the issue by rearranging/reorienting R1 and R2’s beds within the room to prevent blocking the door’s swing. Based on the specific circumstances and dimensions involved, CCLD concluded that the passageway into and out of R1’s bedroom was not blocked to the degree that people were materially slowed when coming in and out of the room. (However, the inability to close the bedroom door represented a privacy violation, which will be cited in a separate Case Management report.) Complainant said facility staff let R1 lay atop bedsheets that were dirty with food residue, rather than put clean sheets on R1’s bed. During his 01/14/2026 and 01/28/2026 visits, LPA briefly observed the beds and bedding of the twelve (12) residents in care, finding all were reasonably clean. Of the ten (10) residents who could answer questions about this topic, all ten (10) affirmed that staff consistently provided them with clean sheets and bedding. Residents widely reported that facility caregivers typically changed their sheets and pillowcases twice per week on their scheduled shower days, plus on request. Interviews of the managers and caregivers corroborated this. Based on records and interviews, a preponderance of evidence does not exist to show that that Licensee did not timely respond to resident(s)’ calls for assistance, that Licensee did not keep facility free of incontinence odors, that Licensee did not maintain facility cleanliness, that Licensee did not maintain comfortable facility temperature, that Licensee did not keep facility free of insects, that Licensee did not keep passageway free of obstruction, and that Licensee did not provide clean bedding. These seven (7) allegations are therefore Unsubstantiated, and no deficiencies were cited for them. An exit interview was conducted with Licensee/Administrator Alex Limpin, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today’s visit.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 08-AS-20260107115647

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Feb 28, 2026

87464 Basic Services: “(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident…with those activities of daily living...” This requirement is not met, as evidenced by: Based on records and interviews, Licensee did not provide 3 of 12 residents (R1, R2, and R3) assistance with activities of daily living and care as needed by the resident. This posed a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: By the date of deficiency issuance (01/28/2026), Licensee had completed trimming of R1’s facial hair and toenails; License had also completed trimming of R2’s and R3’s fingernails. Licensee agreed to make arrangements for trimming of R2’s toenails, and to retrain staff that per the residents’ care plans, residents are to receive oral hygiene care and dressing assistance at least twice per day. Licensee agreed to send LPA a photographs of R2’s trimmed toenails (after completion) and a copy of the staff training sign-in sheet, by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: Feb 28, 2026

87307 Personal Accommodations and Services: “(a)(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available…the licensee shall assure provision of: (D) Hygiene items of general use such as soap and toilet paper.” This requirement was not met, as evidenced by: Based on interview and LPA observation, Licensee did not ensure that 1 of 2 shared bathrooms was stocked with toilet paper. This posed a potential health and personal rights risk to 10 of 12 residents (R1 though Resident #10) in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: During LPA’s 01/14/2026, Licensee restocked the indicated bathroom with toilet paper. During LPA’s 02/28/2026 visit, both bathrooms remained stocked with toilet paper. Licensee agreed to train its caregivers to double-check that there is toilet paper in both the dispenser and on the counter in each shared bathroom, at the start of each work shift. Licensee agreed to E-mail the staff training sign-in sheet to LPA, by the POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite a deficiency identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Supervisor Jamily “Jamila” Hallak and Licensee/Administrator Alex Limpin. Interviews of managers, caregivers, and an outside source, along with video, showed: During late 2025, Licensee undertook a project to widen the doorframes of its residents’ bedrooms to make them more wheelchair-friendly. As part of this project, the shared bedroom door belonging to Resident #1 (R1) and Resident #2 (R2) was also widened. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] After completion, R1’s/R2’s bedroom door could not be swung closed because it would contact the end of R1’s bed. After a few weeks, staff fixed the issue by rearranging R1 and R2’s beds within the room to prevent blocking the door’s swing. Based on the specific circumstances and dimensions, CCLD concluded that the passageway into and out of R1’s bedroom was not blocked to the degree that people were materially slowed when coming in and out of the room. However, the inability to close the bedroom door represented a privacy violation. Also, during his 01/14/2026 visit, LPA observed: R1’s/R2’s bedroom door could now be closed. However, their door did not remain latched after being closed. Instead, once LPA released the door handle, the door would pop open again, repeatedly. This indicated adjustment were needed to door’s hinges and/or latch, which Licensee had completed by LPA’s return visit on 01/28/2026. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] During a review of records with management, LPA observed, and manager interviews confirmed: Licensee did not have on file proof of a negative Tuberculosis (TB) test result (or chest x-ray to rule out TB) for R2, which was required before R2 moved in, as per CCR 87458(c)(1)(A). [During LPA’s 01/14/2026 visit, R2 did not show any signs/symptoms of TB observable to a layperson.] Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). Plans of Correction were jointly developed with the Licensee. An exit interview was conducted with Licensee/Administrator Alex Limpin, to whom a copy of this report, the LIC 809-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Jan 28, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Feb 28, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications,...” This requirement was not met, as evidenced by: Based on interviews and LPA observation, Licensee did not ensure that 2 of 12 residents (R1 and R2) in this privately operated residential care facility for the elderly had a reasonable level of personal privacy in accommodations and personal care and assistance. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: As of the date of deficiency issuance (01/28/2026), Licensee had repaired/adjusted R1 and R2’s door, resolving the deficiency. The Plan of Correction is Satisfied.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(c)(1)(A) · Plan of correction due date: Feb 28, 2026

87458 Medical Assessment: “(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.” This requirement was not met, as evidenced by: Based on records review, Licensee did not ensure that the pre-admission medical assessment for 1 of 12 residents (R2) included the test results of an examination for communicable tuberculosis. This posted a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: Licensee agreed to coordinate with R2’s current physician and/or hospice agency to have a PPD skin test or chest x-ray performed on R2, along with an updated LIC602 Physician’s Report to reflect recent changes in R2’s condition. Licensee agreed to E-mail the updated LIC602 with negative TB test result to LPA, by the POC due date.

Allegation investigated: Staff do not ensure that resident is able to make and receive confidential phone calls.

Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. The LPA was greeted by Community Manager Jamila Hallak , who identified herself and disclosed the purpose of the visit. The Department’s investigation consisted of a review of records and interviews with internal and external sources. On May 1, 2025, Community Care Licensing (CCL) received a complaint alleging that licensee staff do not ensure that residents can make and receive confidential phone calls. More specifically, the licensee staff told the reporting party they could not speak with Resident #1(R1) or visit R1 without R1's power of attorney permission. (Continued on LIC9099C) Unsubstantiated (continued form LIC 9099) During the investigation, interviews were conducted with multiple residents who stated they are able to both make calls and receive calls freely and without staff interference. Staff interviews, including Staff #1(S1) and Staff #2(S2), confirmed that residents are encouraged to maintain communication with family and friends and are provided access to upon request. Interviews with the Administrator revealed ongoing communication with R1's responsible party as well as one of R1's family members, regarding communication between family/friends and residents. Interviews with Outside Sources were inconsistent; however, Outside Source #3(OS3) submitted a recorded conversation regarding an attempt to contact R1 through the facility phone. Records review indicates that S2 responded appropriately in accordance with R1's right to privacy and confidentiality of personal health information, as outlined in Title 22, California Code of Regulations. Based on records and interviews, a preponderance of evidence does not exist to show that Licensee did not ensure the facility was free of odors from incontinence. The allegation is, therefore, Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted over the phone with Administrator/Licensee Alexander “Alex” Limpin as well as in person with Community Manager Jamilla Hallack to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jul 16, 2025 · control 08-AS-20250501084930

Allegation investigated: Licensee did not maintain facility in compliance with its issued fire clearance.

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to commence a Complaint Investigation regarding the above allegation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Supervisor Jamily “Jamila” Hallak. LPA then met with Administrator/Licensee Alexander “Alex” Limpin, who arrived shortly after. The Complainant alleged that Licensee did not maintain facility in compliance with its issued fire clearance. CCLD’s investigation involved an unannounced facility tour/welfare check, interviews of relevant staff and a deputy fire marshal, and review of pertinent physical plant records and correspondence. [CONTINUED ON LIC 9099-C] Substantiated [CONTINUED FROM LIC 9099] Records and interviews showed: Licensee had not arranged for a professional reinspection of its fire alarm system within the last twelve (12) months, as required. The facility’s fire alarm system batteries were past their expiration date and needed to be replaced. The facility’s fire sprinkler system also required repair and reinspection to come back into compliance. These pending items were all necessary for the facility to maintain ongoing compliance with its prior-issued fire clearance from San Diego Fire Rescue Department. Licensee had constructive knowledge, dating back to 10/26/2023, that its fire sprinkler system required repair. Based on records and interviews, a preponderance of evidence exists to show that Licensee did not maintain facility in compliance with its issued fire clearance. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee. Since the deficiency was related to fire clearance, an immediate civil penalty of $500 was assessed/charged to Licensee (refer to the LIC421-IM page). An exit interview was conducted with Administrator/Licensee Alexander “Alex” Limpin, to whom a copy of this report, the LIC 9099-D page, the LIC421-IM page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. [CONTINUED FROM LIC 9099-A] Interviews of multiple facility staff showed they consistently checked residents’ incontinent products roughly every two hours, changing them if wet/soiled, and more often as needed. Caregivers also cleaned the shared restroom daily and performed routine housekeeping. Based on records and interviews, a preponderance of evidence does not exist to show that Licensee did not ensure facility was free of odors from incontinence. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Administrator/Licensee Alexander “Alex” Limpin, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Jul 1, 2025 · control 08-AS-20250625100036

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Jul 1, 2025

87202 Fire Clearance: “(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.” This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not maintain ongoing compliance with its prior-approved fire clearance. This posed an immediate safety risk to 12 of 12 residents (Resident #1 through Resident #12) in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: As of the date of deficiency issuance, Licensee has reviewed and approved a quote/bid with a professional vendor to both replace the batteries in the facility’s fire alarm system and to conducted needed repair to the facility’s fire sprinkler system, and to the have both systems reinspected for full safety compliance. This action resolves the immediate risk. The vendor has projected completion of work by 07/18/2025. Licensee agreed to E-mail LPA proof of both systems being fully complaint as soon as received, but not later than 08/01/2025.

Allegation investigated: Unlawful Eviction Staff neglect resulting in Injury

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings for a complaint investigation for the above-mentioned allegation. LPA identified herself, disclosed the purpose of the visit and was allowed entry by community manager Jamila Hallak. LIcensee/Administrator Alex Limpin later joined the visit. The Department’s investigation consisted of a records review, interviews and LPA observations. On 08/30/2023 it was alleged that Client #1 (C1) received an unlawful eviction and staff neglect resulted in the injury of C1. LPA Rodgers made observations, conducted interviews and reviewed facility records. [See LIC811 Confidential Name List for identification of select person identifiers used in this report]. Regarding the alligation of C1's unlawful eviction. More specifically, C1 was admitted to the hospital on 8/22/2023 and was ready to be released on 08/28/2023, but the facility refused to accept the client back due to medication non-compliance. (continued on LIC 9099-C) Unsubstantiated (CONTINUED FROM LIC 9099) A records review revealed that an admissions agreement was entered into between the facility and C1 on 8/1/2023. A records review and department interviews revealed that a thirty-day (30) eviction notice was not issued to C1 and C1’s responsible parties. Records review reveal there was not a specific time in place for C1 departure from C1 hospitalization as of August 28, 2023. Department interviews with staff confirmed they received a call from the hospital asking to take C1 back to the facility in August 2023; however, interviews with staff and the administrator did not deny or confirm that they refused C1's entry back to the facility. An email was sent by the Administrator to the department stating C1 was admitted back to the facility on 9/17/2023. it was further alleged that staff neglect resulted in injury. More specifically, Client #1 (C1) was covered in dry feces and had substantial bruising to his left hip and skin tears. A records review reveals C1 began residency on 8/1/2023 at the facility after an extended stay at the hospital. According to the physician's report dated 7/12/2023, C1 was diagnosed with Alcoholic Cirrhosis and paranormal AHIB, chronic pain syndrome, and type 2 diabetes. The physicians report further reveal C1 does can not have a bowel impairment, can be irritable at times, with no physical aggression, and does need assistance with medication. A review of hospital records reveals C1 does have a history of bowel problems, including constipation as well as loose bloody stools. The records also indicate a history of diabetic ulcers to one toe; skin tears to left forearm, wounds to the feet, elbows, and wrists, dating from 7/13/23 to 7/28/23 all noted before residence at the facility on 8/1/2023. Interviews with staff and records review reveal C1 was sent to the hospital by the facility on 8/22/2023. Nursing orders dated 8/28/23 to 9/17/2023 reveal a sitter requested due to aggressive behavior, scratching at skin tears, head CT showed no acute trauma. Hospital records did not indicate any further information about left hip bruising. Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during interviews, records review, and LPA observations, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated. An exit interview was conducted with the Administrator to whom a copy of this report and Licensee Appeal Rights (9058 01/16) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 7, 2025 · control 08-AS-20230830072340

Allegation investigated: Staff did not administer medication as prescribed

Licensing Program Analyst (LPA) Amy Rodgers made an unannounced visit to open an investigation on the above-mentioned allegation. LPA identified herself and disclosed the purpose of her visit with Licensee/Administrator Alex Limpin. On March 24th, 2025 , Community Care Licensing (CCL) received a complaint alleging that the Staff did not administer as-needed prescription medication (PRN) Oxycodone, as often as they should a couple of weeks ago. Records reveal Resident #1(R1) was a resident at the facility from 3/31/2023 to 4/28/2023. No records could be found for R1 in the timeframe the complainant states. Interviews with staff confirm they only give PRN per the physician's orders. Interview with R1's hospice care provider nurse recalls R1 and states they visited R1 at least every other day, if not every day, to ensure PRN's and prescribed medications were being given. The hospice nurse confirmed they did not have concerns and R1 was given all PRN and prescribed medication appropriately by the facility staff. Based on the information obtained during the investigation, it is determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the violation occurred, and it is therefore UNSUBSTANTIATED. An exit interview was conducted with the Licensee/Administrator Alex Limpin, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 7, 2025 · control 08-AS-20250324131918

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry after identifying herself and stating the purpose of the inspection Community Manager Jamila Hallak. Later Licensee/Administrator Alex Limpin joined the visit. A tour of the facility was conducted which included a sample of resident units, the dining area, common gathering areas, and food storage areas. There are no water features on site. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with the required furnishings. Residents’ bathrooms were observed to be sanitary and operational. Showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. The facility is operating in accordance with their fire clearance. The smoke and carbon monoxide alarms were present in each building. Emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible in the kitchen area. Required licensing postings were observed in visible areas of the facility. PPE supplies are on site. Indoor passageways were free from obstructions. Food was observed to be properly labeled. All food is prepared on the property and delivered to bedside or residents can visit the common dining area for a meal. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Centrally stored medications were properly stored and locked in medication carts. Medications were labeled and kept in compliance with label instructions. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPA conducted a review of In-service training procedures. LPA interviewed Administrator Alex Limpin was assured transportation procedures as well as outside medical and dental assistance procedure are compliant. There is large common rooms used for dining and activities. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. LPA interviewed staff and clients. LPA interviews did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Files reviewed contained required documents. Confidential records were stored in locked areas. the administrator presented proof of current/active business liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were cited at the time of visit. An exit interview was conducted with Licensee/Administrator Alex Limpin to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 7, 2025

Type of visit: POC

Licensing Program Analyst (LPA), Natasha Persaud conducted a Plan of Correction visit. LPA met with Community Manager, Jamila Hallak and discussed the purpose of the visit. On 03/05/25, the licensee was issued deficiencies regarding repairs needed to seal holes and openings inside the facility, which were allowing rodents to enter the facility, along with cleaning and disinfecting rooms according to CDC guidelines involving rat droppings. Also, a deficiency was issued for disrepair in room #8‘s bathroom as the shower was not working, shower head was broken, no toilet set, and shower floor had dark marks of debris. Today, LPA toured the facility and observed corrections have been made and deficiencies have been cleared. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Community Manager, Jamila Hallak whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Apr 11, 2025

Allegation investigated: Licensee did not provide safe and healthful living accommodations Facility in disrepair

Licensing Program Analyst (LPA), Natasha Persaud conducted a complaint investigation regarding the above mentioned allegations. LPA met with Community Manager, Jamila Hallak. Administrator, Alex Limpin arrived during the visit. During the investigation, the facility was toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged the licensee did not provide safe and healthful living accommodations for residents due to a rat/rodent infestation. Outside source photo evidence was provided for room #8 that showed rat droppings in resident’s room, in the dresser drawer, on the resident’s clothing, behind the dresser, and a resident’s shoe that had bite marks with a piece torn off. The administrator explained observing a rodent on the outside of the facility back in January 2025. Therefore, they contacted a pest control company. Continued on an LIC 9099C. Substantiated The Pest control records dated 01/23/25, which was the initial inspection, indicated heavy rodent activity found in all 5 houses; multiple trees were found touching the roofs, which allow rodents to enter through the holes/vents on roof; multiple holes (14 in total) and openings were found around the property; window screens were not properly in place providing access to rodents; and air vents were not secured also allowing access to rodents. The the pest control records dated 01/23/25 also indicated service provided included 13 rodent bait stations, rodent trapping for 30 days, and monthly service. On 02/21/25, the pest control company returned and documented 7 rats were captured in the attic spaces and pest findings in the laundry area. The facility submitted an incident report with incident dated 02/19/25 regarding rat/rodent droppings in the closet of a resident’s room, reported by a resident’s family member. Today, 03/05/25, LPA observed rat droppings in rooms #3 and #8. Also observed was a door in room #3 leading to outside that had a large gap under the door and a hole visible from the outside. There was a towel placed on the floor in front of the gap under the door. In addition, there was a hole covered by a piece wood behind a resident’s bed. The administrator explained the wood was placed there due to the bed banging against the wall creating a hole, not due to the rats. Resident interviews confirmed the rat activity in their room along with the rat droppings. A review of Centers for Disease Control (CDC) online search indicated rat droppings are harmful and can cause serious illness. The administrator explained staff vacuumed, used bleach and disinfectant to clean the rat droppings. The administrator was advised not to vacuum, per CDC guidelines and follow CDC protocols, the administrator agreed. Staff interviews revealed some residents like to keep their door open which leads to outside. LPA explained residents are allowed to leave their door open. However, mitigation is still required by patching up the holes and/or openings ensuring they are sealed, which will assist with rats/rodents entering the facility. The administrator explained the pest control are coming to the facility monthly and will continue as prevention until eradication. It was also alleged the facility was in disrepair due to the room #8 ‘s bathroom shower not working, shower head broken, no toilet set, and shower floor having dark marks of debris. The administrator explained the residents do not use that shower, only the toilet. Administrator also explained the repair order was in their que for repairs, as they were aware. Outside source photo evidence revealed the shower head was broken, no toilet seat, and the shower flooring had marks and dirt. Staff interviews confirmed the shower in room #8 was not working, as the resident uses the other shower. Resident interviews confirmed being unable to shower in that bathroom. Today, 03/05/25, LPA observed the bathroom needed an overall cleaning, shower needed to be repaired, shower floor needed cleaning, and toilet seat was missing. Based on observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Community Manager, Jamila Hallak whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Mar 5, 2025 · control 08-AS-20250226105852

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(2) · Plan of correction due date: Apr 2, 2025

Basic Services. Basic services shall at a minimum include: Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services. This requirement is not met as evidenced by: Based on observations and interviews the licensee did not provide safe and healthful living accommodations for 9 out of 9 residents (R1-R9), which poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 5, 2025

Plan of correction: Administrator stated pest control is involved and will continue. In addition, administrator agreed to repair all the holes and openings inside the facility, clean and disinfect rooms according to CDC guidelines by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(6) · Plan of correction due date: Apr 2, 2025

Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment... Ambulatory residents, based on the residents' needs. This requirement is not met as evidenced by: Based on observations and interviews the licensee did not maintain bathroom in operating condition for 2 out of 9 residents (R1-R2), which poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 5, 2025

Plan of correction: Administrator stated the bathroom will be cleaned and maintained in working order by POC due date.

Type of visit: Collateral

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Collateral Visit. LPA was greeted by, identified himself to, and discussed the purpose of the visit with Med Tech Ivana Porras. LPA then met with Administrator Alex Limpin, who arrived later during the visit. During today’s visit, LPA conducted staff and residents interviews to aid in an investigation involving a different licensed care facility. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Limpin, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, May 15, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility Med Tech Ivana Porras after identifying herself and stating the purpose of the inspection House Manager Jamily Hallak and Care Coordinator Maria Wiliams. A tour of the facility was conducted which included a sample of resident units, the dining area, common gathering areas, and food storage areas. There are no water features on site. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with the required furnishings. Overhead as well bedside lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. The facility is operating in accordance with their fire clearance. The smoke and carbon monoxide alarms were present in each building. Emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible in the medical rooms. Required licensing postings were observed in visible areas of the facility. PPE supplies are onsite. Indoor passageways were free from obstructions. Food was observed to be properly labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Centrally stored medications were properly stored and locked in medication carts. Medications were labeled and kept in compliance with label instructions. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPAs conducted a review of In-service training procedures. LPA interviewed Houses Manager Jamily Hallak was assured transportation procedures as well as outside medical and dental assistance procedure are compliant. There is large common rooms used for dining and activities. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. LPA interviewed staff and clients. LPA interviews did not raise any licensing concerns. LPA reviewed multiple staff and client records/files. Files reviewed contained required documents. Confidential records were stored in locked areas. House Manager Jamily Hallak presented proof of current/active business liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were cited at the time of visit however, a Technical Violation was issued. An exit interview was conducted with House Manager Jamily Hallak to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 26, 2024

Allegation investigated: Licensee did not provide refund as required.

Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the finding in the above mention complaint allegation. LPA Domingo identified herself and discussed the purpose of the visit with House Manager Jamila Hallak. During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents and outside sources. It was alleged that Resident 1 (R1) (See LIC811 Confidential Names list), did not receive a refund as required. LPA Domingo conducted an interview with outside source 1 (OS1) and OS1 verified that the refund was received and the facility did provide a refund as required. Staff 1 (S1) was interviewed and S1 also provided documentation that the facility did provide a refund as required. [Continue on LIC9099C] Unsubstantiated [Continued from LIC9099] Based on LPA's interview with outside sources and records reviewed there is not a preponderance of evidence to prove alleged violation did not occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with the House Manager, to whom a copy of this report, and the Licensee Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 29, 2023 · control 08-AS-20231031094440

Allegation investigated: -Personal Rights -Personal Rights -Staff did not provide timely assistance to resident in care -Licensee did not follow reporting requirements

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to commence a complaint investigation. LPA identified herself and discussed the allegations mentioned above with Staff, Jamila Hallak. During today's visit, LPA briefly toured the facility, interviewed staff, and requested records. Mulitple allegations were reported, as listed above. Evidence obtained during the investigation indicated the allegations were pertaining to a specfiic resident. Staff interviews revealed that specific resident resided at a different location. Based on interviews, we have 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 and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Staff, Jamila Hallak whose signature below confirms receipt of these rights. Unfoundedthe state’s words, verbatim · CDSS document, Sep 28, 2023 · control 08-AS-20230927093131

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.