Aegis Gardens

Type of visit: Required - 1 Year

On 06/19/2026 at 9:00 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Care Director, Rachel Chan and explained the purpose of the visit. Executive Director, Emily Poon arrived shortly after. The facility’s fire clearance was approved for 85 non-ambulatory residents of which 43 residents may be bedridden. LPAs toured the facility inside and out including but not limited to 7 residents' apartments, bathrooms, activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe lighting in all rooms is adequate for the comfort and safety of the residents. Hallway temperature was maintained at 73 degrees F. The hot water temperature in a sample of residents shared bathroom were measured at 117.2, 112.5, 110, 114.4, 116.9, 105.2, and 113 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats and non-skid shower pan. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications is locked and inaccessible to residents in care. Carbon monoxide detectors were in operating condition during visit. Fire Alarm was last inspected on 01/14/2026. Fire extinguisher was last serviced on 07/30/2025 and 07/03/2025. First aid kit was observed to be complete. Fire drill was last conducted on 04/01/2026. At 10:01 AM, LPAs reviewed 7 residents records. At 10:23 AM, LPAs reviewed 7 staff records and 7 of 7 are associated with the facility. At 1:45 PM, LPAs reviewed a sample of resident’s medications. Continue to LIC809... Continued from LIC809... THE FOLLOWING DEFICIENCY WAS OBSERVED DURING VISIT: At 12:20 PM, LPAs observed with Executive Director and Director of Operations that two storage units in the Life's Neighborhood (Memory Care) courtyard was unlocked and accessible to residents in care. Storage units contained chemicals such as paint, Chlorox, and bleach. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted with Executive Director. Appeal Rights and a copy of this report provided via emailthe state’s words, verbatim · CDSS document, Jun 19, 2026

Type of visit: Case Management - Incident

On 01/07/2026 at 2:50 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident that was sent on 12/11/2025. LPA met with Director of Operations, Angel Lee, and explained the purpose of the visit. The Executive Director was not available during today's visit. Incident report indicated that on 12/06/2025, R1 was sent to the hospital for a change in condition. On 12/10/2025, the facility was notified by R1's responsible party that R1 was diagnosed with a stage 3 pressure ulcer. During the visit, interview with S1 and a review of the after-visit summary dated 09/26/2025 and 11/21/2025, R1 was diagnosed with stage 2 pressure ulcer. LPA reviewed and obtained Home Health Care Visit Communication Form, Physician Fax Reports, hospital progress notes, and service plan. Documents reviewed indicated that R1's pressure ulcer would reopened once healed. Interview with S1 and Physician Fax Report dated 06/13/2025, revealed that since June 2025, R1's home health was initiated for wound care and home health has been monitoring the wound. Since R1's hospitalization, R1 has not returned from hospitalization. No deficiencies cited. Exit interview conducted with Lee and copy of this report is provided.the state’s words, verbatim · CDSS document, Jan 7, 2026

Type of visit: Case Management - Incident

On 01/07/2026 at 1:20 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident that was sent on 12/17/2025. LPA met with Director of Operations, Angel Lee, and explained the purpose of the visit. The Executive Director was not available during today's visit. Incident report indicated that Resident 1 (R1) had an unwitnessed fall on 12/16/2025. R1 was experiencing mild pain and was resolved with pain medications. On 12/17/2025, R1 had a change in condition and was sent to the Emergency Room (ER). During the visit, LPA reviewed After Visit Summary, Physician Fax Report Form, Unusual Occurrence Report (Facility Incident Report), Service Plans dated 11/26/2025 and 12/18/2025, and R1's physician report. LPA interviewed 3 staff members. LPA interviewed Staff 1 (S1) and Staff 2 (S2) revealed that R1 is a high risk for falls. A review of R1's service plan indicated that R1 was placed on the additional safety checks throughout the day effective 12/16/2025 and on the Augi sensor system on 11/26/2025. Interview with S2 revealed that communication between family regarding 1:1 care was conducted through the phone after the fall incidents had occured. S3 stated that they heard the motion alarm sound on 12/16/2025, and when they checked on R1, they found R1 on the floor. LPA will be requesting additional communication log between the facility and family regarding 1:1 care services. No deficiencies cited. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 7, 2026

Allegation investigated: Staff are physically abusing resident in care. Staff are emotionally abusing resident in care.

On 11/12/2025 at 11:30 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct a complaint investigation and deliver the findings on the above allegations. LPA met with Senior General Manager, Emily Poon, and explained the purpose of the visit. During the course of investigation, LPA interviewed staff and witness. LPA obtained and reviewed resident roster, staff roster, visitor log dated 10/27/2025 to 10/31/2025, and facility's move-in and move-out report within the last year. It was discovered that complaint was generated under the wrong facility, therefore all allegations are unfounded. We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of report provided. Unfoundedthe state’s words, verbatim · CDSS document, Nov 12, 2025 · control 15-AS-20251104162829

Allegation investigated: Staff obstructed the facility passageway

On 10/29/2025 at 9:35 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct a complaint investigation and deliver the findings on the above allegation. LPA met with the Director of Operations, Angel Lee, and explained the purpose of the visit. Executive Director (ED), Emily Poon, was unavailable during today’s visit. During the course of investigation, LPA interviewed 4 staff, witness, and toured the memory care unit. LPA reviewed and obtained documents including but not limited to Incident Report, Resident Roster, Staff Roster, and Staff Schedule. Continue to LIC9099-C... Substantiated Continue from LIC9099... It was alleged that staff obstructed the facility passageway. During the visit, LPA observed the memory care hallway by the exit door free of obstruction. However, on 10/24/2025, LPA received an incident report from ED verifying that on 10/15/2025 and 10/22/2025, there were chairs blocking the side exit door in memory care to prevent the ball from getting into the hallway. During the visit, interviews with 4 of 4 staff confirmed that the chairs were utilized to block the exit door during games and activities with residents. 4 of 4 staff members also showed LPA where the three chairs would be placed during activities in which LPA observed to be in the hallway in front of the side exit door. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 29, 2025 · control 15-AS-20251023135316

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Nov 7, 2025

87307(d)(6) Personal Accommodations and Services (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by having chairs blocking the side exit door in the memory care unit which posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 29, 2025

Plan of correction: The Administrator agrees to have an in-service training with all staff, create alternative plan for conducting activies in memory care, and send proof to CCLD by POC date.

Type of visit: Case Management - Incident

On 10/29/2025 at 12:00 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. The facility sent in an incident report on 10/27/2025 regarding R1's fracture. LPA met with Health Services Director, Gigi Tamayo, and Director of Operations, Angel Lee, and explained the purpose of the visit. The Executive Director was not available during today's visit. LPA P.Manalo received a self-reported incident report from facility that indicated Resident 1 (R1) had unwitnessed fall on 10/25/2025 and started experiencing pain on 10/26/2025. Responsible party brought R1 to the hospital and was treated with lower leg fracture on 10/27/2025. R1 returned to the facility day of with a leg brace. During the visit, LPA interviewed Health Services Director, Gigi Tamayo, and reviewed R1's Individualized Service Plan dated 10/27/2025 and 09/13/2025, Physician Report, and After Visit Summary. No deficiencies cited during visit. Exit interview was conducted with Tamayo and Lee and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 29, 2025

Type of visit: Case Management - Incident

On 10/08/2025 at 1:05 PM Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. Executive Director self-reported the incident on 10/03/2025. LPA met with Health Services Director, Gigi Tamayo, and Director of Operations, Angel Lee, and explained the purpose of the visit. The Executive Director was not available during today's visit. On 10/04/2025, LPA received an incident report that Resident 1 (R1) was sent to the hospital for a worsening pressure injury on 10/03/2025 and is currently admitted to a skilled nursing facility. During the visit, LPA reviewed and obtained the following documents such as R1's Physician Report dated 10/15/2024, Resident Appraisal, Care Plan dated 08/12/2025, facility's progress notes, and Physician Fax Report. LPA will be requesting for R1's full medical record to be sent to CCLD. LPA may return at a later time. No deficiencies cited during visit. Exit interview was conducted with Tamoyo and Lee and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 8, 2025

Type of visit: Case Management - Incident

On 10/08/2025 at 12:00 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident. The facility sent in an incident report on 08/31/2025 and death report on 10/06/2025 regarding Resident 1 (R1). LPA met with Health Services Director, Gigi Tamayo, and Director of Operations, Angel Lee, and explained the purpose of the visit. The Executive Director was not available during today's visit. LPA P.Manalo received a self-reported incident report from facility that indicated Resident 1 (R1) had unwitnessed fall and was admitted to the hospital for a cervical fracture. On 10/06/2025, LPA received a death report that R1 passed away. LPA reviewed and obtained R1's After Visit Summary dated 04/16/2025, Discharge Summary, Physician Report dated 02/05/2025, Resident Appraisal, Care Plans, and Physician Fax Report. LPA will be requesting full medical record, R1's progress notes dated from April 2025 to October 2025, and death certificate to be sent to CCLD. LPA may return at a later time. No deficiencies cited during visit. Exit interview was conducted with Tamayo and Lee and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 8, 2025

Type of visit: Case Management - Incident

On 06/18/2025 at 2:50 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident that occured on 06/06/2025. Administrator self-reported the incident on 06/06/2025. LPA met with Executive Director, Emily Poon and explained the purpose of the visit. LPA received a self-reported incident report from the facility that indicated that Resident 1 (R1) went AWOL by exiting through the front door. The facility notified the police, and R1 was escorted back by the police couple hours later. Interview with Staff 1 (S1) and Staff 2 (S2) revealed that R1 was wandering around the hallways in the facility and exited through the front door. When night staff went to check outside, staff did not see the resident. S1 and S2 stated that after the incident occured, R1 began wearing a Wanderguard Bracelet, have safety checks, and have the AUGi system installed in their room. During record review, LPA observed R1's physician report dated 02/18/2025 indicating R1 needs to have supervision when leaving the facility. LPA also reviewed the facility's training on Use of Wanderguard, Elopement Protocol, and Redirecting dated 06/07/2025 and R1's Care Plan. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Jul 9, 2025

87468.2(a)(4)Additional Personal Rights of Residents in Privately Operated Facilities (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidence by: Based on record review and interview, the licensee did not comply with the section cited above by not providing supervision causing R1 to leave the facility which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 18, 2025

Plan of correction: The Executive Director agrees to review resident's physician's report, creating a plan on increasing safety checks with residents with elopement or wandering, and conducting training for staff.

Type of visit: Case Management - Incident

On 04/22/2025 at 2:20 PM, Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. Executive Director self-reported the incident on 04/05/2025. LPAs met with Executive Director, Emily Poon, and explained the purpose of the visit. LPA P.Manalo received a self-reported incident report from facility that indicated that the Resident 1 (R1) was taken to the hospital for lower back and rib area pain in which R1 was treated for lumbar fracture. LPAs reviewed the After Visit Summary dated 04/07/2025 and status update from doctor dated 04/10/2025. The status update from doctor shows that the fracture of vertebra was due to osteoporosis, sequela. No deficiencies cited during visit. Exit interview was conducted with Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 22, 2025

Type of visit: Case Management - Incident

On 04/22/2025 at 1:50 PM Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident. Executive Director self-reported the incident on 03/31/2025. LPAs met with Executive Director, Emily Poon, and explained the purpose of the visit. LPA P.Manalo received a self-reported incident report from facility that indicated Resident 1 (R1) was admitted for hospitalization for a UTI and internal brain bleed. LPAs record review of the After Visit Summary dated 04/01/2025 shows that R1's internal brain bleed was due to a hemorrhagic stroke. No deficiencies cited during visit. Exit interview was conducted with Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 22, 2025

Type of visit: Required - 1 Year

On 04/22/2025 at 10:15 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Executive Director, Emily Poon, and explained the purpose of the visit. LPAs toured the facility inside and out including but not limited to residents' apartments, bathrooms, activity rooms, beauty salon, kitchen, common area and courtyard. There are no bodies of water observed. LPAs observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 71 degrees F. The hot water temperature in residents’ shared bathroom were measured at 117.1, 112, and 119 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid shower pan. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 06/20/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 03/05/2025. At 10:20am, LPAs reviewed 7 residents records. At 11:25 am, LPAs reviewed 7 staff records and all are associated to the facility. At 1:20 PM, LPAs reviewed two sample of resident’s medications. All records were observed to be complete and up to date. No deficiencies were cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 22, 2025

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

On this day 09/13/2024 at 2:10 pm, Licensing Program Analysts (LPAs) Patricia Manalo and Luisa Fontanilla arrived to the facility to conduct a case management visit regarding a incident report and met with Executive Director, Emily Poon and explained the purpose of the visit. During the visit, LPAs interviewed R1 and S1 by obtaining an interpreter service. LPAs attempted to interview R1. However, due to R1's dementia, LPAs were unable to obtain relevant information. LPAs interviewed S1 and S1 demonstrated to LPAs how the incident occurred. No deficiencies were cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 13, 2024

Type of visit: Required - 1 Year

On 6/25/2024 at 12:20PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Director of Operations, Angel Lee and explained the purpose of the visit. The facility’s fire clearance was approved for 85 non-ambulatory of which 48 may be bedridden. LPA toured the facility with Director of Operations including but not limited to 6 residents apartments, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 70 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in a sample of residents’ shared bathroom were measured at 109.3, 117.8, 111.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Freezer temperature measured at 0 degrees F and refrigerator measured at 40 degrees F. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguishers was last serviced on 6/20/2024. Emergency Disaster Plan was last posted on 6/13/2024. First aid kit was observed to be complete. Fire drill was last conducted on 5/25/2024. At 1:00pm, LPA reviewed 6 residents records. At 2:00pm, LPA reviewed 7 staff records and 6 of 6 have current first aid training and associated to the facility. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 25, 2024

Type of visit: Case Management - Other

On 2/15/2024, at 10:10am, Licensing Program Analysts (LPAs), L. Hall and T. Syess, arrived unannounced to conduct a case management visit. LPAs met with Gigi Tamayo, Health Services Director, and explained the purpose of the visit. LPAs arrived to deliver complaint findings from amended complaint dated 6/13/2023. 15-AS-20230613151024. LPAs obtained signatures on amended complaint document LIC9099 and LIC9099C. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 15, 2024

Allegation investigated: Staff charged residents for services not received.

On 12/13/2023 at 2:45PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegation above. LPA met with Health Services Director, Gigi Tamayo and explained the purpose of the visit. Senior General Manager, Emily Poon arrived an hour later. During the investigation, LPA L. Fici interviewed staff and representatives of residents. LPA L. Fici obtained billing states for six residents. On 12/13/2023, LPA G. Luk interviewed 4 staff and reviewed documents (service delivery records, notice to resident/family during outbreaks, activities during outbreaks). On 8/24/2023, LPA L. Fici has indicated that residents were not being charged for tray services during the three COVID outbreaks. LPA L. Fici reviewed six resident's statement invoices which revealed no tray service charges to the residents. (Continue on LIC9099C...) Unsubstantiated On 12/13/2023, LPA G. Luk interviewed staff which revealed that escort services were provided to residents. S4 stated that facility was providing small group activities during the 3 COVID outbreaks. S4 stated that residents were escorted to small group activities and walks in the courtyard area. LPA G. Luk reviewed a sample of resident's service delivery records and observed that residents were provided escort services during the 3 COVID outbreaks. Facility emailed residents and family during each COVID outbreak which indicates that dining room will be closed; However, there will be small group activities and exercise in the courtyard was provided. LPA observed activity schedule where small groups activities were conducted at different times. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore these allegation is UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Dec 13, 2023 · control 15-AS-20230817132333

Allegation investigated: Illegal Eviction.

On 10/6/2023 at 9:55 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an subsequent complaint investigation visit and to deliver findings on the above allegation. LPA was greeted by Angel Lee, Director of Operations and explained the purpose of the visit. During the course of the investigation, LPA interviewed three (3) staff members. LPA requested and obtained the following documents: Staff roster with Contact information, residents’ roster, Admission agreement, Physicians reports, Individualized service plan (ISP), Individualized service assessment (ISA), progress notes (July 2022 and June/July 2023), and eviction letter of a sample of 5 of 5 residents. Continue on Lic9099-C Unsubstantiated Continue from Lic9099 It was alleged that, an illegal eviction was given to the resident and the resident’s representative. Based on interviews and record reviews conducted, all 3 staff stated if a resident’s level of care increases and the facility can not meet the care needs for the resident any longer, an eviction notice is given to the resident and the resident's representative explaining the reason for eviction. The facility determined R1’s change of condition by ongoing evaluation for R1 and conducting reappraisals which informs the facility of R1’s higher level of care on June 7, 2023. On July 8, 2022, R1 was admitted into Aegis gardens and an appraisal was conducted. The facility was able to meet R1’s care needs, however, over the course of time, R1’s care needs increased, and the facility was not able to meet R1’s care needs. The facility conducted re-appraisals for R1 when R1’s care increased. Based on Interviews record review conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Director of Operations, and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 6, 2023 · control 15-AS-20230718160825

Allegation investigated: Licensee initiated eviction process in retaliation against resident.

On 10/6/2023 at 9:25 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an subsequent complaint investigation visit and to deliver findings on the above allegation. LPA was greeted by Angel Lee, Director of Operations and explained the purpose of the visit. During the course of the investigation, LPA interviewed three (3) staff members at 12:50 PM. LPA requested and obtained the following documents: Staff roster with contact information, Residents’ roster, Admission agreement, Physicians reports, Individualized service plans (ISPs), Individualized service assessment (ISA), progress notes (July 2022, and June/July 2023), and Physicians report form of a sample of 5 of 5 residents. Continue on Lic9099-C Unsubstantiated Continue from Lic9099 It was alleged that, licensee initiated eviction process in retaliation against resident. Based on interviews conducted, all three (3) staff members stated the reason for eviction is due to a higher level of care. All 3 staff stated when a resident’s care increases, and the facility can not meet a resident’s needs any longer, an eviction process is applied. This eviction process was not due to retaliation of R1. Reporting Party (RP) did not disclose any information to LPA regarding the reason the eviction process was based on retaliation. Based on Interviews record review conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Director of Operations, and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 6, 2023 · control 15-AS-20230711115733

Allegation investigated: Staff improperly administered resident's medication.

On 10/6/2023 at 9:35 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an subsequent complaint investigation visit and to deliver findings on the above allegation. LPA was greeted by Angel Lee, Director of Operations and explained the purpose of the visit. During the course of the investigation, LPA interviewed five (5) staff members and five (5) residents. LPA requested and obtained the following documents: Staff roster with Contact information, residents’ roster, Admission agreement, Physicians reports, Individualized service plan (ISP), Individualized service assessment (ISA), progress notes (July 2022), and Medication administration record (MAR) of a sample of 5 of 5 residents. Continue on Lic9099-C Substantiated Continue from Lic9099 It was alleged that, Staff improperly administered resident's medication. Based on record review conducted, LPA communicated with RP and it was confirmed that R1’s medication was crushed and given to R1 without a physician’s order on July 8, 2023. On July 11, 2023, a request was sent to the primary physician to crush medication for R1 and on July 12, 2023, R1’s physician approved request to crush medication for R1. Based on LPAs observations and interviews which were conducted and record reviews, 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 Exit interview conducted with Director of Operations, and a copy of this report provided along with appeal rights.the state’s words, verbatim · CDSS document, Oct 6, 2023 · control 15-AS-20230712154204

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(e) · Plan of correction due date: Oct 7, 2023

87465(e) Incidental Medical and Dental Care:(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician... This requirement is not met as evidenced by: Based on observation, and record review, the licensee did not comply with the section cited above by crushing R1's medication prior to submitting a physicians order to R1's primary physicians to crush medication which poses/posed a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 6, 2023

Plan of correction: Administrator agreed to submit a self-certification on section 87465(e) Incidental Medical and Dental Care by explaining how will this be avoided in the furture and to understand the reguation. All med techs, administrators, health service directors, nurses, and care directors will date and sign self-certification and submit to CCL by POC due date.

Allegation investigated: Staff did not treat residents with dignity and respect. Staff did not include resident's responsible party in the reappraisal process. Facility is charging resident for services not agreed upon.

On 10/6/2023 at 9:45 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an subsequent complaint investigation visit and to deliver findings on the above allegation. LPA was greeted by Angel Lee, Director of Operations and explained the purpose of the visit. During the course of the investigation, LPA interviewed five (5) staff members and five (5) residents. LPA requested and obtained the following documents: Staff roster with Contact information, residents’ roster, Admission agreement, Physicians reports, Individualized service plan (ISP), Individualized service assessment (ISA), progress notes (July 2022), and Medication administration record (MAR) of a sample of 5 of 5 residents. Continue on Lic9099-C Unsubstantiated Continue from Lic9099 It was alleged that, Staff did not treat residents with dignity and respect and staff did not include resident's responsible party in the reappraisal process. Based on interviews and record review conducted. All 5 staff stated that the care given to residents is good and that the staff tends to residents’ care needs at all times. Residents are treated with respect and cared for when residents needs assistance with anything. 4 of the 5 residents interviewed stated that they do not have any concerns with care and that they are treated well in the community. During record review, LPA communicated with S1 and confirmed that there was a re-appraisal conducted for R1 and R1's representative was notified. It was alleged that, Facility is charging resident for services not agreed upon. Based on interviews and record reviews conducted, family staff communicated with LPA and confirmed that RP was notified regarding R1's level of care is increasing, and that the facility wants to hold a meeting to further speak about R1’s care. Staff stated that R1 is in need for a one on one due to resident’s higher level of care. Based on Interviews record review conducted, Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Director of Operations, and a copy of this report providedthe state’s words, verbatim · CDSS document, Oct 6, 2023 · control 15-AS-20230712154204

Allegation investigated: Staff did not dispense medication according to doctor's orders.

On 9/27/2023, at 1:46 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an initial 10- day complaint investigation visit on the above allegation. LPA was greeted by Gigi Tamayo- Registered Nurse (RN), Angel Lee, Director of operations and explained the purpose of the visit. During visit, LPA collected the following documents for R1, R2, R3, and R4: Residents roster with contact information, staff roster, Incident reports (June and August 2023), Physicians reports, doctors’ orders (June and August 2023), and Medication administrative record (MAR). LPA interviewed 4 staff members at 2:36PM. Continue on Lic9099-C... Substantiated Continued from Lic9099... It was alleged that; Staff did not dispense medication according to doctor's orders. Based on Interviews, and record review conducted, S1, S2, S3, and S4 stated that S4 accidentally grabbed the incorrect eye drop bottle and was about to administer medication to resident on 8/19/2023. Reporting Party (RP) noticed S4 was going to use the incorrect eye drops, and RP stopped S4 before administering the eye drops into R1's eyes. S5 was a witness when RP realized S4 grabbed the incorrect eye drop bottle. The correct eye drops for R1 was grabbed and administered to R1 accordingly. S4 was suspended from the community until the investigation was finished. On 6/23/2023, a different staff had provided multiple drops into R1's right eye and should have only gotten one drop. LPA conducted record review, which confirmed that S4 made a medication error dated 6/23/2023, which was self reported to CCL. Based on LPAs 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. Exit interview conducted with RN, and a copy of this report provided along with appeal rights.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 15-AS-20230822140553

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 30, 2023

87468.2 (a)(4) Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities...(4) To care, supervision, and services that meet their individual needs... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not making sure the physicians order for R1's eye drop medication is being used accordingly. On 6/23/2023, facility staff administered the incorrect amount of eye drops into R1's right eye which poses/posed a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Administrator agreed to set a plan to complete monthly medication training and to complete comtentency check lists every month and to submit proof of medication training and comtentency check list to CCL by POC due date.

Type of visit: Case Management - Other

On 9/29/2023, starting at 10:10 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct a case management visit to deliver amended report originally dated 8/23/2023. LPA met with Gigi Tamayo, Registered Nurse (RN) and informed her the reason for visit. During visit, LPA obtained original report dated 8/23/2023 from RN. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Sep 29, 2023