Adult Care Oc Saturna

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by staff. LPA met with John Bardon, Supervisor and explained the nature of the visit. There are six (6) residents at the facility and there only one (1) resident currently receiving hospice services. LPA accompanied by supervisor began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in a spare refrigerator and a pantry in the garage. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the bedroom hallway. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA inspected the facility bathrooms and LPA measured the hot water temperature which measured 119.3 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and storage cabinet in the garage. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors/carbon monoxide detectors were tested and found to be Continued on LIC809-C operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there are shaded seating areas for residents’ enjoyment. LPA observed a fire extinguisher with service date of January 15, 2026, charged and mounted in the kitchen. Fire drills are conducted every three months, LPA verified fire drill logs are kept and last drill was conducted May 23, 2026. LPA began review of records. LPA reviewed three resident records. All the required documentation was present and reviewed in the residents’ files. LPA reviewed two employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. LPA as a reminder provided annual fee dues information. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the facility representative and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 4, 2026

Allegation investigated: Facility is not administering medications as prescribed.

Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of delivering the investigation findings into the above allegation. LPA met with Supervisor John Bardon and explained the reason for the visit. On August 1, 2025, the Department received a complaint, and the investigation was initiated by LPA on August 11, 2025. During the course of the investigation, LPA observed the medication closet, inspected residents’ medications, interviewed four residents/staff, and obtained the following documentation: Resident/Staff Rosters, Face Sheets, Physician’s Reports, Medication Administration Records (MARs) for all residents in addition to the Admission Agreement and medical records for Resident #1 (R1). Regarding the allegation, Facility is not administering medications as prescribed, the investigation is as follows: It is alleged that the facility staff laced R1’s food and water with Coumadin also referred to as warfarin. Unsubstantiated Per the incident report dated August 4, 2025, R1 was admitted to the hospital per the nurse’s advice on July 28, 2025. The American Heart Association indicates that warfarin is a prescription medication used to prevent blood clots. Warfarin is adjusted based on the results of the blood test, International Normalized Ratio (INR). A normal INR range is between 2 and 3.5 when taking blood thinners. However, R1’s INR levels was an 8 and increased to 12 upon hospital admission which is considered high. Based on the interviews, four out of four staff denied the allegation indicating that R1’s medications were administered appropriately. For R1’s warfarin, the Veterans Affair (VA) Inquiry Sheet dated November 5, 2024, indicates that one tablet is given every evening. In review of the Medication Administration Records (MARs) for June and July 2025, R1 did not receive warfarin on June 16, 19, 21, and 23. One out of the four staff indicated that medication was not given due to R1’s refusal. R1 did not recall why the warfarin was refused at the time of the interview. Three out of the four staff denied tampering R1’s food and water with warfarin and had only administered the medication at the request of R1 which was instructed and relayed by R1’s nurse. The remaining one staff was not assigned to administer medication at this facility and could not provide further information. During the initial visit conducted on August 4, 2025, LPA observed all medications were secured in the medication closet. There were no medication errors observed in review of four out of four residents. Two out of the four residents reported having no issues with their medications. LPA was unable to qualify the remaining two residents due to their medical diagnosis. The investigation revealed that there was insufficient corroborating evidence to prove staff were tampering with R1’s food and water. The Physician’s Report dated January 22, 2025, indicated that R1 did not have a food allergy or a special diet prescribed by the doctor. There was no order suggesting removing garlic from R1’s diet. Therefore, based on the observations made, interviews which were conducted, and the records that were reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the following allegation: Facility is not administering medication as prescribed is deemed UNSUBSTANTIATED. An exit interview was conducted with Lead Caregiver Rosmie Morata, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 22-AS-20250801083105

Type of visit: POC

On this day Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of conducting a plan of correction visit. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Care Give Rosmie Morota. LPA Vanegas explained the purpose of the visit and began to enquire of the citations issued on July 29, 2025. LPA Vanegas was not presented with proof of correction; meaning staff on duty did not present proof of completed training being completed in regards to emergency services being contacted upon an emergency or a fall taking place at the facility, additionally LPA Vanegas was not provided with proof of correction in regards to a large sum of funds being refunded to a previous resident in care. Based on the lack of proof of correction for the citations issued on July 29, 2025 civil penalties were issued on today's date, an exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 12, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Required 1-Year annual evaluation using the Care Inspection Tool. LPA was greeted and granted entry by Caregiver Nancy Villanueva and explained the reason for the visit. Supervisor John Bardon arrived approximately 10:25am to assist with the inspection. Administrator Brian Schott holds a valid certificate expiring on July 3, 2026. The facility is a single story structure and is licensed to provide services for age range 60 and over for six ambulatory residents of which six may be non-ambulatory. A waiver was granted to provide hospice services to six residents at one time. During today's visit, there are three residents under hospice care and three staff on duty. LPA toured the physical plant with Caregiver Villanueva. During the inspection, LPA observed the following areas requiring a deep cleaning and repair: the interior and exterior kitchen cabinets and appliances had evidence of grime and oil residue that require a deep cleaning, pantry needs to be reorganized, cleaned, and relined with a shelf liner, and the fire alarm pull station panel was half detached that needs to be reattached. LPA observed five resident bedrooms and three resident bathrooms. There is one additional staff bedroom occupied by four live in staff. Resident bedrooms had all required furnishings. Bathrooms were found to be in compliance, clean, and operational. The hot water temperature measured at 117.5, 115.7, and 113.7 degrees Fahrenheit. All common areas were inspected including the two car garage. LPA reviewed the Emergency Disaster Plan (LIC610E) and observed sufficient emergency food and water in the garage. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available in the kitchen. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. The exit gate is self-closing and self-latching. LPA observed sufficient seating and shading. The fire extinguisher was purchased on December 17, 2024 per the Home Depot purchase receipt. The auditory devices and smoke/carbon monoxide detectors were tested and operational. Emergency evacuation drills are conducted quarterly, with the last date on April 23, 2025. The Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the correct size in the entryway. LPA conducted a review of all residents and three staff files. No discrepancies noted. Medications for four out of four residents were audited and no discrepancies were noted. Interviews were successfully conducted or attempted with four residents as well as two staff interviews. Based on the observations made during today's visit, no deficiencies are being cited. Technical Violations are being issued. An exit interview was conducted with Supervisor John Bardon, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Aug 11, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained an unexplained fracture while in care. Facility financially abused residents. Facility overcharged resident for rent.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the three allegations listed above and delivering findings to the licensee. LPA was greeted and granted entry by facility staff after stating the purpose of the visit. Administrator Brian Schott was notified via telephone and presented with the allegations as well as the findings. The initial investigation visit was conducted on June 29, 2023, by Licensing Program Analyst (LPA), Jerome Haley. During the visit, LPA toured the facility and conducted a health and safety check. Four residents were observed during the visit and records were obtained. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM LIC9099 Resident 1 (R1) was admitted to Adult Care OC Saturna on August 11, 2021. The Admission Agreement was reviewed and showed a monthly private pay rate of $4,250 for a double room, and no preadmission fee was charged. Resident 2 (R2) and an additional family member are listed as R1’s responsible parties. R1’s Physician Appraisal Report dated July 13, 2021, has an indication of a dementia diagnosis for R1 and shows that R1 was assessed as being unable to manage their own cash resources due to prior stroke. R1 was additionally assessed to be unable to independently transfer to and from bed. R2 paid R1’s monthly rent. The licensee’s email dated April 29, 2024, stated R1 passed away on December 24, 2022, at the facility. No death report was submitted to the Department or provided to the resident’s attorney-in-fact at the time. R2 was admitted to Adult Care OC Saturna on June 11, 2021. The Admission Agreement was reviewed. R2 was listed as self-responsible with a monthly private pay rate in the amount of $4,250 for a double room. A preadmission fee in the amount of $500 was charged. R2’s Physician Appraisal Report dated June 24, 2021, identified R2 had dementia and was unable to manage their own cash resources. A later Physician Appraisal Report dated December 6, 2022, stated R2 was non-ambulatory and had mild cognitive impairment and was unable to manage their own cash resources. Regarding the allegation that Resident sustained an unexplained fracture while in care, the following has been concluded: R2 was admitted at Adult Care OC Saturna on June 11, 2021. Prior to the last unwitnessed fall on October 06, 2022, R2 was ambulatory and able to walk with no assistance. After the fall and hip surgery, R2 used a wheelchair for mobility. R2 had a history of falls prior to becoming wheelchair bound. On or about October 6, 2022, at about 6 AM, R2 had an unwitnessed fall in their room. Staff 1 (S1) and Staff 2 (S2) found R2 on the floor, assessed R2 and placed R2 back in bed. Later that evening R2 complained of pain to their hip and was unable to walk. It is unclear whether staff notified R2’s responsible party. Department did not receive any incident report regarding the fall. Charting notes provided indicate that R2 had been monitored following the initial fall. On October 7, 2022, at about 6:30 AM, staff S1 transferred R2 from their bed to a wheelchair because R2 was still unable to walk, and informed S2 that a bruise was present on the resident’s left hip. Per notes reviewed, S2 asked R2 if R2 was in pain and the resident confirmed. Per statement made by facility acting administrator (AA) May Kwok, on October 10, 2022, at approximately 10 AM, a Hope Hospice nurse visited the facility and assessed R2 and reported that R2 was okay. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C On October 13, 2022, Dr. Homer Lew conducted a facility visit and assessed R2, Dr. Lew recommended staff call 911 to have R2 transported to Saddleback Medical Center for a full medical evaluation. Attending physician findings reported no acute fracture or dislocation is seen. R2 was discharged and returned to facility the same day with instructions to treat a decubitus ulcer on her pelvic area. On November 04, 2022, at about 10 AM, R2 was transported again to Saddleback Hospital due to hip pain. Attending physicians reported that R2 had a fall and had not been able to ambulate or walk for two-three weeks since the fall. X-ray results revealed a closed displaced fracture of the right femoral neck. R2 underwent surgery and was discharged on November 9, 2022, to a skilled nursing facility with no complications. During R2’s stays at the hospital, R2 was receiving care for a decubitus ulcer and was referred to Hospice for wound care. R2 was discharged back to Adult Care OC Saturna on or about December 9, 2022, with no incident. Staff interviewed stated that R2 has no reported falls since R2 continues to use a wheelchair for mobility and is being treated for a pressure injury. After R2 sustained an unwitnessed fall and was found on the floor on October 6, 2022, by staff, R2 verbalized repeated complaints of pain and discomfort as well as signs of injury. R2 who normally walked with no assisted device was utilizing a wheelchair. From October 13, 2022, until November 4, 2022, R2 continued to complain of pain and on November 4, 2022, was sent to Saddleback Hospital where a closed displaced fracture of the femoral neck was diagnosed. R2 underwent surgery and was discharged to a skilled nursing facility where R2 received physical therapy prior to being discharged back to Adult Care OC Saturna. Upon the occurrence of the initial fall, facility staff failed to call 911 in order for R2 to be assessed by paramedics in spite of a continued complaint of pain following the fall. Immediate medical attention was therefore not requested and/or provided to R2. Regarding the allegation that Facility financially abused resident, it was determined that: During the period of admission for residents R1 and R2, AA May Kwok fraudulently acquired durable Power of Attorney over residents’ finance, wrote residents’ personal checks for totaling $1,358, accessed resident’s bank account, and used residents’ funds paying her own business expenses including Southern California Gas Company for $3,871, Southern California Edison Company for $17,927, Orange County Tax Collection for $10,114, and Small Business Administration loan for $86,188. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C Chase Bank financial records were reviewed and showed that AA added her name on residents’ bank account as attorney-in-fact on November 28, 2022. A bank signature card, which is a document that a bank keeps on file to authenticate a customer’s signature for their accounts, also showed AA’s signature. The residents’ cancelled checks reviewed and revealed that AA wrote and signed R2’s multiple checks for cash, memorial care, property records, and Tayani Institute for totaling $1,358. Residents R1 and R2’s bank statement showed an online payment was made out to Southern California Gas Company for $3,871.44 on January 3, 2023. The Department reviewed Southern California Gas Company transaction records which showed the payment had been made for a non-residential address for Pacific West Coin Laundry with AA listed as the customer. Residents’ bank statement showed an online payment was made out to Southern California Edison Company for $17,927.24 on January 6, 2023. The Department reviewed Southern California Edison Company transaction records which evidenced that AA accessed the residents’ checking account and used residents’ funds to pay for a utility bill for the licensed facility Adult Care OC I – 306005939. Residents’ bank statement showed an online payment was made out to Orange County Tax Collection for $10,114.22 on January 3, 2023. The Department reviewed Orange County Tax transaction records which evidence that the tax payment was made through the residents’ checking account ending 0356 in the amount of $10,114.22 for year 2021 – 2022 and year 2022 -2023 unsecured property tax including leased equipment tax and business assessments tax to an account with an associated email address MAYKWOK1416@GMAIL.COM for a taxed property located at 2626 Dupont Dr, Street, Ste A10, Irvine CA 92612. The taxed property is stated to belong to a business entity named Our Secret Place Medical Aesthetic Inc. with a listed business director as AA Kwok. Per the transaction records both Licensee Brian Schott and AA May Kwok are associated with Our Secret Place Medical Aesthetic Inc. Based on the transaction records review, both accessed residents’ bank account and used residents’ funds to pay their business assessment tax and leased property tax. Finally, the residents’ bank statement showed an online payment was made out to a Small Business Administration (SBA) loan for $86,188.50 on February 1, 2023. The Department reviewed SBA transaction records which evidences the payment was made for a sole proprietorship business operated by AA at the address previously shown on a Southern California Gas Company payment also issued from the residents’ account. CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C Based on the transaction records reviewed, AA accessed residents’ checking account and used residents’ funds to pay for personal and business expenses unrelated to the residents’ facility fees. Regarding the allegation that Facility overcharged residents for rent, it was determined that: the licensee financially abused the residents and overcharged residents’ rent for $97,038 based on the following discrepancies observed during the investigation: R1 and R2 had a joint checking account with Chase Bank. This checking account was used for paying rent. Bank statements were reviewed for the period from June 2021 to April 2023. The following discrepancies were noted: Residents’ check dated on 6/9/2021, check #1321, $1,000 was made out to Brian Schott, licensee for preadmission fees. Per R1’s Admission Agreement, no preadmission fees should be charged. R2’s Admission Agreement showed $500 preadmission fee needs to be charged. The licensee overcharged $500 preadmission fees. In June 2021, residents’ check dated on June 11, 2021, check #1322, $8,500 was made out to New Home Senior Care. R1 was admitted to the facility on August 11, 2021. Licensee Schott should not charge R1’s rent for the month of June 2021. Licensee Schott overcharged R1 rent for $4,250. In the month of July 2021, residents’ check dated on June 28, 2021, check #1326, $8,500 was originally made out to Licensee Schott, but then the payee’s name was changed to R2. This check was neither deposited to residents’ savings account nor checking account instead this check was cleared on June 28, 2021, from residents’ checking account. The amount of this check $8,500 is equal to R1 and R2’s monthly rent, $8,500 (R1 $4,250 + R2 $4,250). It appeared this check was paid for R2’s July 2021 rent. Licensee overcharged rent for $4,250 ($8,500-$4,250) because R1 was admitted to facility in August 2021. In the month of August 2021, residents’ check dated on 8/20/2021, check #1325, $4,650 was made out to New Home Senior Care. Since R1 was admitted to facility in August 2021, R1 and R2’s rent payment should be $8,500 ($4,250+$4,250). The rent was undercharged for $3,850 ($8,500 - $4,650). In the month of September 2021, residents’ one check dated on September 9, 2021, check #1424, $8,570 was made out to New Home Senior Care. Another check dated on September 9, 2021, check #1425, $1,700 was made out to Licensee Schott. Two checks were paid to licensee for totaling $10,270 resulting in $1,770 overpayment ($1,0270 - $8,500). In the month of October 2021, residents’ check dated on October 14, 2021, check #1485, $9,000 was made out to New Home Senior Care resulting in $500 overpayment ($9,000-$8,500). CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C Starting in the month of November 2021, the rent was made through online payment. Two online payments were made out to New Home Senior Care on the date of November 9, 2021, and November 23, 2021, for totaling $17,200 resulting in $8,700 overpayment ($17,200-$8,500). In the month of December 2021, one online payment was made out to New Home Senior Care on the date of December 24, 2021, for $8,600 resulting in $100 overpayment ($8,600 - $8,500). In the month of January 2022, one online payment was made out to New Home Senior Care on the date of January 25, 2022, for $8,600 resulting in $100 overpayment ($8,600 - $8,500). In the month of February 2022, three online payments were made out to New Home Senior Care on the date of February 15, 2022, and February 22, 2022, for totaling $18,383 resulting in $9,883 overpayment ($18,383 - $8,500). In the month of March 2022, two online payments were made out to New Home Senior Care on the date of March 25, 2022, for $17,525 resulting in $9,025 overpayment ($17,525 - $8,500). In the month of April 2022, two online payments were made out to New Home Senior Care on the date of April 22, 2022, for $17,525 resulting in $9,025 overpayment ($17,525 - $8,500). In the month of May 2022, two online payments were made out to New Home Senior Care on the date of May 24, 2022, for $17,525 resulting in $9,025 overpayment ($17,525 - $8,500). In the month of June 2022, two online payments were made out to New Home Senior Care on the date of June 24, 2022, for $17,525 resulting in $9,025 overpayment ($17,525 - $8,500). It should be noted after two payments were paid to facility on June 24, 2022, the residents’ account ending balance was “$0”. In the month of July 2022, one online payment was made out to New Home Senior Care on the date of July 25, 2022, for $8,925 resulting in $425 overpayment ($8,925 - $8,500). In the month of August 2022, one online payment was made out to New Home Senior Care on the date of August 25, 2022, for $8,925 resulting in $425 overpayment ($8,925 - $8,500). In the month of September 2022, one online payment made out to New Home Senior Care on the date of September 23, 2022, for $8,925 resulting in $425 overpayment ($8,925 - $8,500). In the month of October 2022, one online payment was made out to New Home Senior Care on the date of October 25, 2022, for $8,925 resulting in $425 overpayment ($8,925 - $8,500). In the month of November 2022, one online payment was made out to New Home Senior Care on the date of November 23, 2022, for $8,925 resulting in $425 overpayment ($8,925 - $8,500). CONTINUED ON FORM LIC9099-C CONTINUED FROM FORM LIC9099-C Based on the evidence gathered, the allegations that Resident sustained an unexplained fracture while in care, Facility financially abused resident and that Facility overcharged resident for rent are all found to be Substantiated, meaning that the preponderance of evidence has been met. See LIC9099-D for cited deficiencies and immediate civil penalty as per Title 22 Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49 (f) An exit interview was conducted with a facility representative and a copy of the present report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 28, 2025 · control 22-AS-20230628144300

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jul 29, 2025

Per CCR87468.2(a)(8): "(...)residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, (...). This requirement is not met as evidenced by: Based on evidence reviewed, after activing administrator May Kwok obtained attorney-in-fact status access to two residents’ bank accounts, multiple payments were evidenced to have been made from those accounts for unrelated business and personal expenses. This constitutes an immediate risk to the health, safety and personal rights of individuals in care. Immediate Civil Penalty Assessed.the state’s words, verbatim · CDSS document, Jul 28, 2025

Plan of correction: Licensee stated they will refund to R2 or R2’s estate all misappropriated funds taken from their account which amounts to a total of $119,459.40.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87507(g)(3)(C) · Plan of correction due date: Jul 29, 2025

CCR 87507(g)(3)(C) regarding Admission Agreements: “Admission agreements shall specify the following: (C)Any fee that is charged prior to or after admission, shall be clearly specified. This requirement is not met as evidenced by: Based on evidence reviewed, facility staff obtained payments in excess of the actual amounts due for R1 and R2 totaling $97,038 of overpayments. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Jul 28, 2025

Plan of correction: Licensee stated that all excessive funds received in payment will be refunded to R2 or R2’s estate in the total amount of $97,038.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jul 29, 2025

CCR 87465 (g) “Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health appropriate to the conditions and needs of residents.” This requirement is not met as evidenced by: Based on the evidence gathered, despite the repeated pain complaints, it was confirmed that facility staff did not obtain adequate medical attention for the residents’ needs which constitutes an immediate risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Jul 28, 2025

Plan of correction: Licensee will conduct an in-service training to caregiving staff to ensure appropriate response to falls incidents resulting in potential injury. Civil penalty assessed.

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit for the purpose of citing deficiencies observed during the investigation of complaint 22-AS-20230628144300 and not related to the allegations investigated. There are six residents in care at the time of the present visit. LPA conducted a tour of the physical plant and requested resident records for all six residents in care. Per the review of records, one resident has been assessed to be bedridden, however the facility only has a fire clearance for six non-ambulatory residents. Type A citation issued and immediate civil penalty assessed. During the investigation of the complaint mentioned above, staff member May Kwok was referred to on multiple occasions as the acting administrator (AA) for the facility. A review of background clearance and staff associations in Guardian demonstrates that AA Kwok criminal record clearance was not associated with the facility’. Type A citation and civil penalty assessed. During the investigation, the death of a resident 1 dated December 24, 2022, and a fall incident resulting in fracture and hip replacement of resident 2 dated October 6, 2022, failed to be reported to licensing staff as required by regulations. Type B deficiency cited. Additionally, it was confirmed that facility staff failed to implement adequate fall prevention planning and measures while providing care for facility resident R2. Type A citation issued. CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 Finally, it was confirmed that AA had obtained power of attorney over the affairs of facility resident R2, which title 22 regulations clearly forbid. Type A citation issued. Based on today’s visit, four type A deficiencies, one type B deficiency and two immediate civil penalties are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with a facility representative and a copy of this report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Jul 29, 2025

CCR 87355(e)(3) on Criminal Record Clearance “All individuals subject to a criminal record review (....) shall prior to working (...) in a licensed facility: (…) (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)”. This requirement is not met as evidenced by: Per a review of the Guardian background clearance system, AA May Kwok was never associated to the present licensed facility. This constitutes an immediate risk to the health, safety and personal rights of individuals in care. Civil penalty assessed.the state’s words, verbatim · CDSS document, Jul 28, 2025

Plan of correction: Licensee stated they will associate AA criminal record clearance by the due date. The Licensee stated they will verify all staff associations for all current employees by POC due date and send confirmation to the LPA.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87466 · Plan of correction due date: Jul 29, 2025

Per CCR 87466: “The licensee shall ensure that residents are regularly observed for changes in physical (..) functioning and that appropriate assistance is provided when such observation reveals unmet needs.” This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, resident R2 had been identified as a fall risk, with multiple occurrences of fall prior and on October 6, 2022. The lack of adequate precautions resulted in the resident becoming injured and requiring surgery. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Jul 28, 2025

Plan of correction: POC: Licensee stated they will review the regulation and forward a statement of understanding to LPA by POC due date along with a fall prevention in-service training verification conducted with current facility staff.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87217(d)(2) · Plan of correction due date: Jul 29, 2025

CCR 87217(d)(2) “Except as provided in approved continuing care agreements, no licensee or employee of a facility shall: accept any general or special power of attorney for any such person” This requirement is not being met as evidenced by: Based on record review and interview, Licensee failed to ensure an employee of the facility was not designated as a power of attorney for R1. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 28, 2025

Plan of correction: Licensee stated they would review the regulations and provide documentation of understanding to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Jul 31, 2025

Per CCR 87211(a)(1) "A written report shall be submitted to the licensing agency (...) within seven days of the occurrence of any of the events specified in (A) through (D) below. (...) (A) Death of any resident from any cause regardless of where the death occurred"” This requirement is not met as evidenced by: No death or incident reports corresponding to the incidents evidenced during the investigation were found to have been submitted to the Department.the state’s words, verbatim · CDSS document, Jul 28, 2025

Plan of correction: Licensee indicated they would conduct an in-service training to staff in charge of reporting serious incidents and deaths. Documentation of training to be provided to the Department.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87606(c) · Plan of correction due date: Jul 29, 2025

Per CCR 87606(c): "To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance." This requirement is not met as evidenced by: Based on facility observation and records review, resident R3 is assessed as bedridden, however the current fire clearance for the facility does not include any provision for bedridden residents. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Jul 28, 2025

Plan of correction: Licensee stated they would submit an updated LIC200 application form to request an update to the current fire clearance.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by Edgardo Dela Cruz, caregiver and LPA explained the nature of the visit. There are five residents at the facility and there are four residents receiving hospice services currently. LPA observed two residents in the living room watching television. LPA began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in a spare refrigerator, freezer and pantry located in the garage. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage closet located in the hallway. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. LPA inspected the bathroom and LPA measured the hot water temperature which measured 111.7 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there are shaded seating areas for residents’ enjoyment. LPA observed a fire extinguisher with service date of July 19, 2023, in kitchen. Fire drills are conducted every three months and LPA reviewed fire drill log. Last fire drill was conducted on March 18, 2024. LPA began review of records. LPA reviewed five resident records. All the Continued on LIC809-C required documentation was present and current in the residents’ files reviewed. LPA reviewed three employee records. All employees present have a criminal record clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the facility representative and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 13, 2024