Aegis Assisted Living of Laguna Niguel

Allegation investigated: Facility charging extra fees for items which should be provided under basic services

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver revised findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and witness as well as reviewed and obtained pertinent documentation such as admission agreement. Regarding the allegation that Facility charging extra fees for items which should be provided under basic services, the investigation revealed the following: Resident 1 (R1) admitted to Hospice on 05/08/2026 and is providing bathing services for the resident. Individualized Service Plan (ISP) dated 06/04/2026 indicates R1 is receiving bathing from Hospice however is being charged for bathing services. Staff state the reason for the extra charge is if hospice is unable to provide assistance. LPA reviewed facility documentation and there is no documentation showing that the facility had provided any bathing services once the resident admitted into hospice care. LPA did not observe any documentation showing bathing charges on an "As needed" basis either. CONTINUED ON LIC 9099C DATED 09/30/2026 Substantiated Facility admission agreement notates showering as a fee under "Temporary Service Plan" and does not identify in the admission agreement what is an included basic service as required by Tile 22 regulations. Based on the evidence gathered through interviews and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report along with citations and Appeal Rights (LIC 9058 01/16) was provided to facility representative,the state’s words, verbatim · CDSS document, Sep 30, 2026 · control 22-AS-20260626170713

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Oct 14, 2026

Basic services shall at a minimum include: Personal assistance and care as needed by the resident.., with those activities of daily living such as dressing, eating, bathing and assistance.. This req is not met as evidenced by: Based on interviews conducted and record review, Licensee failed to ensure R1 was provided the basic service of bathing. Licensee is charging for the basic service of bathing and not providing the service which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 30, 2026

Plan of correction: Licensee to review billing practices and refund as necessary. Licensee to forward proof to LPA by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to the facility. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPA delivered an amended report along with revised findings for complaint #22-AS-20260626170713. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 30, 2026

Allegation investigated: Facility charging for services not provided

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced complaint visit to deliver findings on the above allegations. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPAs toured the facility and interviewed staff and witness as well as reviewed and obtained pertinent documentation such as admission agreement. Regarding the allegation that facility charging for services not provided, the investigation revealed the following: Resident representative for Resident 1(R1) signed the admission agreement on 12/29/2023. Per appendix A of the admission agreement, ointment administration is an extra charge under "Temporary Service Plan" and was signed by resident representative. When the resident returned from skilled nursing, facility requested a care companion for resident. Three out of three staff stated recommending the facility's preferred provider but that families are free to choose who they want. Per service plan dated 06/04/2026, R1 is charged for transfers including a two person assist. CONTINUED ON LIC 9099C DATED 09/24/2026 Unsubstantiated Per department regulations, care companions are prohibited from providing any kind of care including transfers and therefore are unable to assist with this process. LPA reviewed billing statements and did not observe any charges for assisting with appointments. LPA observed facility documentation showing that the resident is no longer being charged for escorting as the care companion will escort resident to dining room. Based on interviews conducted and records reviewed, the department is unable to corroborate the allegation. Therefore the allegation is deemed Unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. *This is an amended report.the state’s words, verbatim · CDSS document, Sep 24, 2026 · control 22-AS-20260626170713

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to the facility. The purpose of today’s visit was to conduct the annual required inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is licensed for 75 non-ambulatory residents of which 21 may be bedridden. Facility has a hospice waiver for 15 residents and there are 15 residents on hospice during today's visit. The two story facility houses Assisted Living and Memory Care apartments including multiple activity areas, med rooms, two common dining rooms, bistro, reading room and salon as well as an outdoor space. Upon entry, facility appears clean, safe and sanitary. LPAs Lyman and Mendivil along with General Manager Farid Subhani toured the facility at 9:25 AM. LPAs toured the physical plant, checked food service, facility documents and the first aid kit. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPAs observed a leaking sink and water damage by the shower in Resident 3's (R3) room and a hole under the sink in R4's room. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 104.5 degrees F and 118.6 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPAs observed facility is not taking freezer/ refrigerator temps daily as well as gnats and insects flying around the kitchen. Freezer is noted to be 10 degrees F. Kitchen appliances are operational during today's visit. Toxins are secured. Smoke detectors are tested in house with a last testing date of 04/30/2026 and fire alarm inspection was last conducted on 12/04/2025 by South Coast Fire and Security. Fire extinguishers were fully charged. Facility conducts quarterly emergency drills with the last drill conducted on 08/06/2026. Continued ON LIC 809C DATED 09/24/2026 LPAs observed ample emergency food and water as well as evacuation chairs at stairwell. Outside grounds were toured. LPAs observed multiple outside patio areas. There is ample outdoor shaded seating for residents. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. LPAs reviewed select staff and resident files. Resident files included all required documents including updated physician reports, pre-appraisals and admission agreements. Staff files reviewed contained proof of health screen/ TB and criminal record clearance. Five out of five staff do not have proof of required annual training. LPAs observed medication administration and storage. Medications appear to be administered per physician order. Based on the observations made during today's visit, deficiencies are being cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview conducted and a copy of this report along with appeal rights were given at time of visit.the state’s words, verbatim · CDSS document, Sep 24, 2026

Allegation investigated: Staff stole resident’s personal belongings.

Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to continue the investigation into the allegation listed above. LPA met with Executive Director Kurt Knauer and Care Director Gina Pakpahan and explained the reason for the visit. During the visit LPA and staff toured the facility. The investigation into the allegation, staff stole resident's personal belongings, revealed the following. It was reported that between the hours of 9:30 pm on June 28 and 10:00 am on June 29, Resident 1's (R1's) three rings went missing. Witness 1 (W1) reported to the facility that R1's rings were missing. Law Enforcement was contacted and they began their investigation. Their investigation has not been completed. A review of the facility schedule shows 9 staff members were present at the facility from 9:00pm and 10:00am. Video surveillance showed 10 individuals went into the room, 2 hospice staff, 7 facility staff and 1 visitor for R1. LPA viewed the video surveillance with the Executive Director. LPA did not observe anyone taking anything from R1 but the video is not clear enough see all the details of the room or individuals in the room. 9 out of 9 witnesses interviewed who went into R1's room during the time in question denied the allegation. Unsubstantiated 9 out of 9 witnesses interviewed reported they had no knowledge of any of R1's belongings being stolen. W1 did not respond to LPAs request for an interview. The Executive Director reported that staff looked for R1's rings but could not find them. The Care Director reported that their internal investigation could not determine what happened to the rings. A review of R1's file shows R1 did not have an inventory list completed at the time of move in. R1 passed away on July 31, 2025. None of the evidence gathered supports the allegation, therefore the allegation is deemed Unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 22-AS-20250729154116

Allegation investigated: Resident sustained stage 4 pressure injury while in care due to neglect Resident sustained fracture while in care due to lack of care and supervision

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by the Concierge and explained the purpose of the visit. During the course of the investigation, the Department interviewed staff and witnesses; and subpoenaed and reviewed medical records from Kaiser Permanente and Home Health Services. The investigation revealed the following: Resident #1 (R1) was admitted to the facility on November 24, 2022, and resided in Memory Care. Per Physician report dated October 31, 2024, R1 had a diagnosis of Hydronephrosis with renal and ureteral calculous obstruction, sepsis and Mild Cognitive Impairment. Physician report further assessed R1 was non-ambulatory and a maximum assist for all self-care needs and activities of daily living. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) On February 5, 2025, R1 developed a wound on their left hip and on the heels of their feet. R1 received Home Health services through Kaiser Permanente for catheter care and heel wounds. On February 5, 2025, R1 was transported to Kaiser Hospital due to a ruptured urethra and for further evaluation of the hip and heel wounds. R1 returned to the community on February 6, 2025, after hospital treatment with a diagnosis of Urinary Tract Infection and orders for medication treatment. Four days later, on February 10, 2025, the Health Care Director requested R1 be sent out to Kaiser Hospital for further medical evaluation for the hip and heel wounds that were not improving. Resident was treated and admitted to the hospital and was discharged on February 18, 2025, to a Skilled Nursing Facility. During the course of treatment the Power of Attorney (POA) received communication from both facility staff and Home Health regarding the hip and heel pressure wounds. Facility had spoken to the Power of Attorney (POA) on January 29, 2025, requesting the resident receive hospice care for the open wounds in order for the resident to return to the facility. POA declined hospice services due to a scheduled surgery for kidney stones. The physician was notified and the nurse treated the affected area. POA was aware of R1’s declining health and management discussed with POA to consider a personal caregiver to provide supervision to prevent further falls or injuries but family was not able to provide a personal caregiver. Care staff would do frequent body checks and rotate R1, based on R1’s service plan, which was documented by facility staff and Home Health. Due to statements and documents, nurses’ progress notes and home health notes there is not enough information to support the allegation that Resident #1 sustained stage 4 pressure injury while in care due to Neglect/Lack of Care and Supervision. The allegation is Unsubstantiated. It was alleged that Resident sustained a fracture while in care due to lack of care and supervision. Resident #1 (R1) had eleven unwitnessed falls in 2023-2024 in their bedroom; due to R1 getting out of bed and walking. Per Physician’s Report dated October 31, 2024, R1 is unable to transfer to and from the bed and is non-ambulatory. R1 also is diagnosed with Mild Cognitive Impairment. (Continued on LIC 9099-C1) (Continued from LIC 9099-C) The Department reviewed Unusual Incident Reports for R1’s unwitnessed falls for the following dates: 8/10/2023, 8/22/2023, 9/24/2023, 9/25/2023, 10/27/2023, 03/22/2024, 03/25/2024, 04/01/2024, 04/10/2024, 05/04/2024, 05/09/2024 and 07/02/2024. R1’s needs and service plan was updated on 08/22/2023 following their first two falls and again on 12/23/2023 following their next three falls. After continuing to sustain falls, the facility updated the needs and service plan on 03/19/2024; 06/26/2024; 09/21/2024; and 11/20/2024 with suggested fall interventions which included: toilet resident before and after meals and before bedtime, frequent checks, involve resident in activities during the day and monitor for medication side effects. On April 4, 2024, management implemented fall risk prevention measures by requesting a low bed, frequent checks on R1 and discussed extra care and supervision. POA was unable to provide a personal caregiver but facility staff conducted additional status checks, every thirty minutes on R1 to prevent falls. Record review did not report any injuries related to the falls; both by the facility and home health. On February 10, 2025, R1 was transported to Kaiser Hospital due to pressure wounds not improving and to be evaluated by an orthopedic surgeon regarding a fracture. R1 was diagnosed with a left femur fracture. . The surgeon reported the fracture to be old, chronic and nonoperative and the fracture was healing and surgery was unnecessary. No time frame was provided and the injury was reported to be old. Facility staff accompanied R1 to appointments and there is no documentation regarding R1 having a fractured hip prior to diagnosis. R1 was treated at the hospital and was given medication for pain and discomfort. Although R1 had multiple falls and sustained a fracture, it remains unclear the source of cause for the fracture and therefore whether it was due to neglect. There is not enough information to support the allegation that the: Resident sustained fracture while in care due to lack of care and supervision. Based on interviews conducted and records reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore the allegations that the: Resident sustained a stage 4 pressure injury while in care and the Resident sustained a fracture while in care due to lack of care and supervision are Unsubstantiated. An exit interview was conducted with Kurt Knauer, General Manager, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 22-AS-20250218081943

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by the Concierge and explained the purpose of the visit. During the Department’s investigation for complaint control # 22-AS-20250218081, the following was discovered: Resident #1 (R1) was admitted to the facility on November 24, 2022, and resided in Memory Care. Per Physician report dated October 31, 2024, R1 had a diagnosis of Hydronephrosis with renal and ureteral calculous obstruction, sepsis and Mild Cognitive Impairment. Physician report further assessed R1 was non-ambulatory and a maximum assist for all self-care needs and activities of daily living. On December 4, 2024, facility progress notes document that, “the resident’s left heel is noted with a small purple/red discoloration non-blanchable. The care team was instructed to reposition resident every two hours, elevate the resident’s legs and support R1’s heels with a pillow for support.” LPA spoke with Health Service Director if facility has a log that tracks how often a resident is turned. The facility currently does have a log to track frequency of turning of residents. On December 5, 2025, facility progress notes by LVN at 8:04pm document, “Pt noted to have unstageable wound on Left heel.” Care staff continue to observe the unstageable pressure injury in the progress notes and applied foam dressing and wound care. On January 16, 2025 Home Health delivered heel protectors to apply in heels daily. (Continued on LIC 809-C) (Continued from LIC 809) Home Health Notes from January 29, 2025, documented a large eschar on the left heel of R1 and an appointment was scheduled with Primary Care Physician at 3:30pm. R1’s Power of Attorney (POA) was notified. Physician addressed pressure ulcer of left heel, unstageable pressure injury and gave a referral order for hospice. Home Health notes confirm this diagnosis and nurse applied Betadine to the area on February 1, 2025. R1 was sent out to the hospital on February 5, 2025, for further evaluation of a urethral rupture and Urinary Tract infection. R1 returned to the facility on February 6, 2025, at 12:30am with antibiotics. On February 10, 2025, R1 is noted with a pressure injury on the right hip, as well as the unstageable wound on left heel. General Manager (GM) and nurse spoke with POA about wound concerns and R1 was transported to Emergency Room for further evaluation. Facility Progress notes dated on February 18, 2025, document that POA spoke with GM and reported R1 was in a Skilled Nursing Facility (SNF) and would be discharged from Aegis Senior Living. Based on Department record review and interviews, it is determined that Resident #1 (R1) was diagnosed with an unstageable pressure injury on R1’s left heel on December 5, 2024. The facility retained the resident with a prohibited health condition until February 10, 2025. The following is being cited per California Code of Regulations, Title 22. 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 Kurt Knauer, General Manager, and a copy of this report, the LIC 809-D, the LIC 421IM and Appeal Rights were provided to the facility.the state’s words, verbatim · CDSS document, Sep 25, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Sep 26, 2025

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition...shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on Department record review and interviews Resident #1 (R1) was documented to have an unstageable pressure injury on 12/5/24, which is a prohibited condition, and remained in the facility until 2/10/25. This poses an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: General Manager (GM) will speak with VP of Nursing and Nursting staff to provide staff-inservice on Prohibited Conditions; which include Pressure Injuries. GM will email LPA documentation of inservices by end of business 9/27/2025.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by the Concierge and explained the purpose of the visit. During the Department’s investigation for complaint control # 22-AS-20250218081, the following was discovered: Resident #1 (R1) was admitted to the facility on November 24, 2022, and resided in Memory Care. Per Physician report dated October 31, 2024, R1 had a diagnosis of Hydronephrosis with renal and ureteral calculous obstruction, sepsis and Mild Cognitive Impairment. Physician report further assessed R1 was non-ambulatory and a maximum assist for all self-care needs and activities of daily living. On December 4, 2024, facility progress notes document that, “the resident’s left heel is noted with a small purple/red discoloration non-blanchable. The care team was instructed to reposition resident every two hours, elevate the resident’s legs and support R1’s heels with a pillow for support.” LPA spoke with Health Service Director if facility has a log that tracks how often a resident is turned. The facility currently does have a log to track frequency of turning of residents. On December 5, 2025, facility progress notes by LVN at 8:04pm document, “Pt noted to have unstageable wound on Left heel.” Care staff continue to observe the unstageable pressure injury in the progress notes and applied foam dressing and wound care. On January 16, 2025 Home Health delivered heel protectors to apply in heels daily. (Continued on LIC 809-C) (Continued from LIC 809) Home Health Notes from January 29, 2025, documented a large eschar on the left heel of R1 and an appointment was scheduled with Primary Care Physician at 3:30pm. R1’s Power of Attorney (POA) was notified. Physician addressed pressure ulcer of left heel, unstageable pressure injury and gave a referral order for hospice. Home Health notes confirm this diagnosis and nurse applied Betadine to the area on February 1, 2025. R1 was sent out to the hospital on February 5, 2025, for further evaluation of a urethral rupture and Urinary Tract infection. R1 returned to the facility on February 6, 2025, at 12:30am with antibiotics. On February 10, 2025, R1 is noted with a pressure injury on the right hip, as well as the unstageable wound on left heel. General Manager (GM) and nurse spoke with POA about wound concerns and R1 was transported to Emergency Room for further evaluation. Facility Progress notes dated on February 18, 2025, document that POA spoke with GM and reported R1 was in a Skilled Nursing Facility (SNF) and would be discharged from Aegis Senior Living. Based on Department record review and interviews, it is determined that Resident #1 (R1) was diagnosed with an unstageable pressure injury on R1’s left heel on December 5, 2024. The facility retained the resident with a prohibited health condition until February 10, 2025. The following is being cited per California Code of Regulations, Title 22. 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 Kurt Knauer, General Manager, and a copy of this report, the LIC 809-D, the LIC 421IM and Appeal Rights were provided to the facility.the state’s words, verbatim · CDSS document, Sep 25, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Sep 26, 2025

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition...shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on Department record review and interviews Resident #1 (R1) was documented to have an unstageable pressure injury on 12/5/24, which is a prohibited condition, and remained in the facility until 2/10/25. This poses an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Sep 25, 2025

Plan of correction: General Manager (GM) will speak with VP of Nursing and Nursting staff to provide staff-inservice on Prohibited Conditions; which include Pressure Injuries. GM will email LPA documentation of inservices by end of business 9/27/2025.

Allegation investigated: Staff physically abused resident in care. Resident sustained injuries while in care. Facility does not have adequate staffing to meet resident's needs.

LPA Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Executive Director Kurt Knauer and explained the reason for the visit. During the course of the investigation, Department staff inspected the facility, interviewed witnesses, and staff, and obtained and reviewed records, including Resident 1’s (R1) physician’s report dated April 16, 2021, R1’s facility assessment\care plan dated April 21, 2021. R1’s Admission Agreement dated April 21, 2021. R1’s Medication Administration Record (MAR) for September 2021, R1’s medication list for September 2021. R1's emergency contact information sheet. Staff roster and schedule for September 2021. The investigation into the allegation, staff physically abused resident in care, revealed the following, on September 21, 2021, at or around 6:30 pm Resident 1 (R1) was walking down the hall toward their room and had a bowel movement. Unsubstantiated Witness (W1) reported it to Staff 1 (S1). R1 resides in memory care which has a secure perimeter with delayed egress exits. S1 attempted to assist R1 but R1 was not responding to S1. S1 called for Staff 2 (S2) to assist. W1 reported to law enforcement that S1 and R1 began punching each other. W1 reported to LPA that they did not actually see S1 hit R1 but assumed they were being hit because R1 was yelling. W1 reported to law enforcement that R1 was yelling, “Kill her. Kill her.” W1 reported to LPA they didn’t remember what R1 said. S1 reported that R1 had defecated in the hallway, and they wanted to get them out of their clothing and shoes because they were soiled. S1 stated that R1 became combative and tried to hit them. S1 stated that R1 started to lose their balance and started to fall so S1 held them up so they would not fall. S1 stated that they called S2 who came and took off R1’s shoes and asked R1 to walk to their room and R1 started to walk to their room. S1 and S2 both reported that once in the room they showered R1, put clean clothes on R1 and put R1 to bed. S1 denied hitting R1 and reported they have never abused any residents. S2 reported they did not witness S1 hit or abuse R1 in any way. No other staff members or witnesses were present during the incident. Law enforcement took a report on September 23, 2021, but did not take any action. LPA attempted to interview R1 but R1 did not recall the incident. Based on the evidence gathered, the allegation is deemed Unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. The investigation into the allegation, resident sustained injuries while in care, revealed the following. It was alleged that Resident 1 (R1) sustained bruises on their forearms which were caused by facility staff. R1 was interviewed but did not recall how their arms were bruised. 5 out of 5 staff interviewed were unaware of R1 bruising until they were told about it. 5 out of 5 staff interviewed denied causing any injuries to R1 or any residents. The General Manager stated that R1’s responsible party informed them of the bruise and asked staff about it but no one could explain how it occurred. None of the staff interviewed could explain how R1 sustained their bruises. R1 resides in memory care which has a secure perimeter. R1 is on 2 medications, that can cause bruising, Quetiapine Fumarate and Lorazepam, but it is rare. The facility does not have any surveillance cameras. R1’s responsible party reported the unexplained bruises could have been caused by facility staff. The facility General Manager reported that they spoke to memory care staff, and no one reported any falls or incidents regarding R1 that could explain the bruises. LPA toured the memory care unit and R1’s room. No obstacles or hazards were observed. A review of facility documents for August 2021 and September 2021 do not list R1 as having any accidents or injuries. It is unknown how R1 sustained their bruises. None of the evidence gathered supports the allegation, therefore the allegation is deemed Unsubstantiated, meaning that although the allegation may have happened or is valid there is not a preponderance of the evidence to prove that the alleged violation did or did not occur. Regarding the allegation, the facility does not have adequate staffing to meet residents’ needs, the investigation revealed the following. It was alleged that the facility is understaffed in memory care and that the residents may not get their meals. No other specific details were provided concerning the lack of staff at the facility other than care would not be provided. At the time of the report the facility census was 70, with 22 of the residents residing in memory care. A review of the facility schedule shows the facility has an average of 25 care staff working each day including medication technicians, 13 for assisted living and 12 for memory care. For the months of August and September 2021 the Agency (CCL) received a total of 6 incident reports (LIC 624). None of the incident reports received give cause for concern for residents’ health and safety and none of them warranted a follow up visit. During the visit on January 27, 2022, LPA observed all the residents in memory care eating in the dining area. There have been no other reports that the facility does not have adequate staffing. Based on the information gathered through observation and a review of records, the allegation that the facility does not have adequate staffing to meet resident’s needs is deemed Unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 24, 2025 · control 22-AS-20210927111109

Type of visit: Required - 1 Year

On September 22, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. General Manager (GM) Kurt Knauer was present and assisted on today's inspection. LPA observed that Kurt Knauer has a valid Administrator certificate which expires on May 16, 2026. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for ninety six residents, of which twenty one may be bedridden, and has a hospice waiver for fifteen. The facility is a two story building with resident bedrooms on the first and second floor, bathrooms are located in each resident apartment, a commercial kitchen, three dining halls, three activity rooms, two medication rooms, multiple staff offices, and a courtyard in the center of the facility. The facility has two memory care units and the rest of the facility operates as Assisted Living. On today's visit, there are seventy one residents in care, of which five are on hospice. LPA, accompanied by the GM, conducted a tour of the interior portion of the facility. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA randomly inspected resident bedrooms on the first and second floors of the facility. Resident bedrooms were clean and free of hazards. Resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. Resident beds had clean linens and blankets. LPA also inspected the bathrooms in each of the resident apartments inspected. Bathrooms were clean. Bathrooms were equipped with grab bars and non skid floors. Faucets and toilets were operational. Hot water temperature measured between 105.6 to 116.2 degrees Fahrenheit. CONTINUED ON LIC809-C LPA inspected the commercial kitchen and observed it to be clean. The kitchen has a two day perishable and a seven day non-perishable food supply on hand. Kitchen knives and sharps are stored inaccessible to residents in care. LPA also observed the facility has a three day emergency food and water supply stored in the kitchen pantry. LPA inspected all other facility common areas such as the dining halls, activity rooms, storage rooms, and observed them to be clear of any hazards. LPA observed emergency evacuation chairs in each of the facility stair wells. LPA observed the facility passed their most recent fire inspection on March 11, 2025, in which the facility's fire sprinklers were tested. LPA observed fire extinguishers mounted on the walls on the first and second floors of the facility. Fire extinguishers were observed to be charged and serviced as of March 12, 2025. LPA observed the facility conducted their most recent emergency disaster drill on August 20, 2025. LPA observed the centrally stored medications to be kept in locked medicine carts located in the medication rooms on the first and second floor. LPA observed each medication room to have a First Aid Kit and they had all the required components. LPA reviewed eight resident files. All the required documents were present and current in the resident files reviewed. LPA reviewed residents' medication and medication records. LPA reviewed eight staff files. All staff are background cleared and associated to the facility. Based on the observations made during today's visit, no deficiencies are being cited per the Title 22 of the California Code of Regulations. An exit interview was conducted with General Manager Kurt Knauer and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 22, 2025

Allegation investigated: Facility staff is violating resident’s personal rights by not allowing visitors to see the resident. Staff member was engaged in a verbal altercation in the presence of the residents

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting a follow-up investigation visit and delivering findings regarding the two allegations listed above. LPA was greeted and granted entry by facility front desk staff after introducing himself and stating the purpose of the visit. Wellness Director Francisco Delgado was present and assisted with the visit as General Manager Kurt Knauer was out accompanying a resident to a medical appointment. An initial complaint investigation visit took place on August 16, 2024. During that first visit, LPA requested the current facility census as well as resident records for four currently admitted residents and reviewed their admission agreements, individual needs and services plans as well as physician reports on file. LPA conducted resident and staff interviews. Witness interviews also conducted via telephone at a later time. During the present visit, LPA requested the facility's staff schedule and conducted six additional staff interviews. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Regarding the allegation that Facility staff is violating resident’s personal rights by not allowing visitors to see the resident, the following has been concluded: Based on records reviewed and interviews conducted, resident R1 as well as staff members and witnesses interviewed deny any interference from facility staff into R1's ability to receive visitors as he pleases. R1 stated that he is fully able to receive visits from whoever he would like. A review of resident records for R1 additionally allowed LPA to verify the identity of R1's responsible party and attorney-in-fact. A signed letter from the resident's stated primary care physician dated February 29, 2024 indicates that "Due to [R1's] age and chronic medical conditions, I request that his life not be disturbed at this time by visits from other family than his daughter who has been instrumental in acting in his behalf to help him recover from recent physical trauma and hospitalization and securing an appropriate series of care facilities that meet his physical and emotional needs." The letter further states that "[R1] was seen in my office on 02/26/24 where I thoroughly interviewed him and found him physically improved and mentally competent to understand his life situation and make informed decisions as to his preference to not be unduly disturbed or manipulated." Regarding the allegation that Staff member was engaged in a verbal altercation in the presence of the residents, the following has been concluded: Based on witness, staff and resident interviews conducted, no instances of staff engaging in loud arguments, altercations or talking inappropriately to visitors could be corroborated. Multiple statements to the opposite were however made, emphasizing how nice and welcoming the facility feels overall. As a result of this investigation, both allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred. An exit interview was conducted with General Manager Kurt Knauer who authorized facility staff to sign on his behalf and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Oct 17, 2024 · control 22-AS-20240812111855

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Joseph Alejandre and Rose Rupert made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted entry by staff. LPAs met with General Manager Kurt Knauer and explained the reason for the visit. LPAs and General Manager toured the facility. The facility has a capacity of 96, 75 non-ambulatory, of which 21 may be bedridden and a hospice waiver for 15. The facility is a two story building with a central courtyard in the center. The facility has one kitchen with multiple dining and activity rooms. All the rooms are private with the their own bathroom. The memory care units are on the first floor, one unit (Golden Lantern) is on the North side of the building and the other unit (Blue Lantern) is on the South side of the building. Both memory care units have delayed egress exits. The LPAs tested the delayed egress exits and they are operational. LPAs observed the See Something Say Something poster (PUB 475) posted in the main entry way of the facility. LPAs observed each stairway had an emergency evacuation chair. All fire extinguishers are fully charged. LPAs inspected seven resident rooms. LPAs observed each resident room inspected was clean and had the required furnishings. Hot water was measured in each room inspected. Hot water measured from 105.9 to 118.9 degrees Fahrenheit. LPAs observed emergency food and water stored in a supply closet. LPAs toured the kitchen and dining room. The kitchen is clean and organized. LPAs observed temperature logs for the refrigerators and freezers posted in the kitchen. The refrigerators and freezer are kept at the required temperatures. LPAs observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The last fire drill was conducted on August 6, 2024. LPAs observed the medication cart is kept locked in the health and wellness office. LPAs inspected the first aid kit. The first aid kit did not contain a first aid manual. LPAs and the General Manager toured the courtyard. No bodies of water observed. The fountain has been converted into a large planter. There are numerous tables and chairs with umbrellas to sit outside. During the visit LPAs observed residents playing bingo in the activity room and LPAs observed a sing a long in the activity room. The fireplaces in the library and the downstairs parlor are screened. No obstacles or hazards observed inside or outside of the facility. LPAs reviewed 7 resident files, no discrepancies observed. LPAs reviewed 5 staff files, no discrepancies observed. Staff files reviewed had the required training including CPR/First aid. LPAs interviewed staff and residents. All staff interviewed and files that were reviewed are background cleared and associated to the facility. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Sep 20, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

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 11/27/23 regarding Resident #1 (R1). LPA met with Administrator (AD) Kurt Knauer and discussed the purpose of the inspection. During the inspection, LPA and AD toured the facility and inspected R1’s room. LPA conducted health and safety checks on 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, the electricity and water were running, the facility had soap and paper towels, and the medications, sharps, and toxins were properly stored. LPA interviewed AD and staff and requested and reviewed copies of R1’s resident file. LPA and AD observed the following: R1’s most recent Physician’s Report was completed on 06/10/22 and states R1 has Dementia. 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, Dec 20, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Jan 17, 2024

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment… This requirement was not met as evidenced by: Based on documents, the licensee did not ensure R1 received an annual medical assessment when R1’s last medical assessment was conducted on 06/10/22, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: Licensee stated they will ensure all residents with Dementia have Physician's Reports completed within the last year and will submit proof to LPA by POC due date. Licensee stated they have a protocol for obtaining annual Physician's Reports for residents with Dementia and will submit a copy to LPA by POC due date.