Ambassador Care Home

Allegation investigated: Staff neglect and lack of supervision of residents

On 08/03/26 at 3:51PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (ADM) gathered information on the allegation and delivered investigation finding to ADM. LPA explained the purpose of the visit with staff (ADM, S1) during visit. Allegation: Staff neglect and lack of supervision Investigation Finding: Substantiated On 08/03/26 at 3:51PM, LPA interviewed reporting party (RP) and staff (ADM) regarding the allegation of staff neglect and lack of supervision. ADM stated that on 07/21/26, staff (S2) was under the influence of alcohol while on duty and called 911 because she was experiencing abdominal pain. Contra Costa Fire Department responded to the 911 call and Emergency personnel found S2 to be intoxicated, exhibiting a strong odor of alcohol. RP stated that three (3) residents under her care on that day were found foraging for food. Continued on next page, LIC 9099-C Substantiated Antioch Police called ADM to take over the care of the residents while S2 was taken to the hospital for treatment and evaluation. RP stated ADM arrived at the facility 20 minutes after the initial call. ADM stated S2 was terminated immediately after discharge from the hospital. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated. Immediate civil penalty of $500 assessed during visit for immediate health and safety risk to residents. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 3, 2026 · control 15-AS-20260731155414

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 3, 2026

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 evidenced by staff working under the influence of alcohol which posed an immediate health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Aug 3, 2026

Plan of correction: Deficiency was corrected on 07/21/26 by ADM terminating S2’s employment after discharge from the hospital the same day. Immediate civil penalty of $500 assessed during visit.

Type of visit: Required - 1 Year

On 11/25/25 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced annual required inspection. LPA met with Administrator (ADM) and explained the purpose of the visit. At 3:10PM, LPA toured the facility with including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) bedrooms and three and one-half (3 1/2) bathrooms. Swimming pool in back yard is surround and locked with metal gate. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was not working. Residents’ bathrooms are equipped with grab bars. Carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 11/17/25. First aid kit was observed to be complete. At 3:30PM, the following deficiencies were observed during visit: Smell of urine in the dining area Broken towel holder, broken window blinds (3), back door leading to side yard is hard to open Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Continued on next page, LIC 9099-C LPA requested the following documents to be submitted to CCLD by 11/26/25 LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Exit interview conducted. Appeal rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 25, 2025

Allegation investigated: Staff did not assist resident with incontinence care needs in a timely manner

On 07/30/25 at 2:20PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (ADM, S1), gathered information and delivered investigation findings to ADM. LPA explained the purpose of the visit with staff. During investigation, LPA conducted interviews with reporting party (RP), staff (ADM, S1), resident (R1), authorized representative (POA) and obtained the following documents from administrator – Personnel record (LIC500), Residents roster, admission agreement, physician’s report, needs & services plan, physician's report, medication administration records, incident reports. Continued on next page, LIC9099-C Substantiated Allegation: Staff did not assist resident with incontinence care needs in a timely manner Investigation Finding: Substantiated During investigation, LPA conducted interviews with reporting party (RP), authorized representative (POA) resident (R1), staff (ADM, S1) and reviewed resident (R1) documents. LPA interviewed RP and POA who stated that on 07/23/25, RP called POA on his phone around 7:45 AM asking for help because his clothing and bedding were soaking wet and that staff was not responding to his calls (ringing his bell). Staff (S1) confirmed with LPA that they failed to assist R1 timely with his incontinence care needs because the other staff (S2) did not show up for her scheduled work at 6AM that day. LPA also interviewed R1 who stated that another staff (S3) changed his wet clothing, diaper and bedding around 9AM on 07/23/25 since S2 did not arrive at the facility until 10AM. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff did not assist resident with incontinence care needs in a timely manner was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided. Allegation: Staff made inappropriate comments to resident Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), authorized representative (POA) resident (R1), staff (ADM, S1) and reviewed resident (R1) documents. S1 stated that POA arrived at the facility at around 8AM ringing the doorbell, banging the front door and yelling for staff to open the front door. S1 stated that when she opened the front door POA started yelling at her to assist R1 with his incontinence needs. S1 stated she told POA to stop yelling to avoid agitating the other residents. S1 denied making any inappropriate comments to R1 or POA. S1 stated she politely requested POA to leave the facility at around 8:15AM because she was continuing to yell and bang on the door. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff made inappropriate comments to resident is unsubstantiated. Allegation: Staff interfered with resident’s visit Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), authorized representative (POA) resident (R1), staff (ADM, S1) and reviewed resident (R1) documents. Review of R1’s admission agreement dated 02/10/25 showed that visitors’ hours are 7 days a week from 9AM to 7PM. S1 stated that on 07/23/25, POA arrived around 8AM ringing the front door vigorously, banging on the front door and yelling for staff to open the door. S1 stated that when she opened the door, POA went straight in and yelled for staff to R1’s wet diapers, clothing and bedding right away. S1 stated she was never rude to POA and requested her to leave the facility because she was yelling and disturbing the other residents. LPA reviewed S1’s cell phone calls on 07/23/25 which showed S1 called 911 at around 8:39AM which prompted the police to arrive at the facility around 9AM. S1 stated that she allowed POA to come inside the facility around 10:30AM when R1’s transport showed up for his medical appointment. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff interfered with resident’s visit is unsubstantiated. Continued on next page, LIC9099-C pg2 Allegation: Staff retaliated against resident Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), authorized representative (POA) resident (R1), staff (ADM) and reviewed resident (R1) documents. LPA interviewed RP and POA who stated that staff (ADM,S1) started being rude to POA because ADM knew it was the POA who filed the previous complaints against the facility. ADM denied retaliating against POA. ADM stated she let POA attend their barbeque celebration with residents on 07/20/25 when R1 informed her of the event on 07/20/25. ADM also stated she answered POA’s text messages regarding R1’s relocation plans on 07/22/25. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff retaliated against the resident is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 30, 2025 · control 15-AS-20250723135709

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Aug 15, 2025

In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by staff did not assist resident timely with incontinence care needs which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2025

Plan of correction: By POC due date, ADM agrees to complete and submit to CCLD in-service staff retraining by a certified vendor on observation of resident in compliance with Section 87625(b)(3)

Allegation investigated: Staff failed to observe change in resident's condition Staff failed to meet resident's medical needs in a timely manner

On 07/02/25 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (ADM, S1), gathered information and delivered investigation findings to ADM. LPA explained the purpose of the visit with staff. During investigation, LPA conducted interviews with reporting party (RP), staff (ADM, S1), resident (R1), authorized representative (POA) and obtained the following documents from administrator – Personnel record (LIC500), Residents roster, admission agreement, physician’s report, needs & services plan, centrally stored medication logs, medication administration records, after visit summary reports, incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Staff failed to observe change in resident’s condition Investigation Finding: Substantiated During investigation, LPA conducted interviews with, reporting party (RP), authorized representative (POA) resident (R1), staff (ADM) and reviewed resident (R1) documents. Staff (ADM, S1) confirmed with LPA that on 06/23/25 S1 spoke with ADM on the phone around 11AM who requested him to check on R1. S1 stated he checked on R1 and did not notice any change in condition. ADM also spoke with R1 on the phone and told POA that he sounded fine. POA stated she called R1 again and observed R1 have slurred speech and that his face was drooping. She immediately called 911 so that he can be taken to the hospital right away. R1 was taken to the hospital by paramedics and diagnosed with a stroke and urinary tract infection. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff failed to observe change in resident’s condition was found to be substantiated. Allegation: Staff failed to meet resident’s medical needs in a timely manner Investigation Finding: Substantiated During investigation, LPA conducted interviews with, reporting party (RP), authorized representative (POA) resident (R1), staff (ADM) and reviewed resident (R1) documents. LPA interviewed RP and POA who stated that on 06/23/25 while on a Facetime call, POA observed R1 have slurred speech and that his face was drooping. POA immediately called ADM to have staff check on R1. ADM stated that staff checked on R1 around 11:15AM and that he sounded “fine”. POA stated staff did not call 911. R1 called POA again and requested for 911 because staff was not doing anything. R1 was picked up by paramedics on 06/23/25 and was admitted at the hospital with a diagnosis of a stroke and UTI. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff failed to meet resident’s medical need in a timely manner was found to be substantiated. Continued on next page, LIC 9099-C pg2 Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report providedthe state’s words, verbatim · CDSS document, Jul 2, 2025 · control 15-AS-20250624091855

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jul 25, 2025

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by staff failed to observe resident’s change in condition which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: By POC due date, ADM agrees to complete and submit to CCLD in-service staff retraining by a certified vendor on observation of resident in compliance with Section 87466.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(e) · Plan of correction due date: Jul 25, 2025

The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition, as defined in Section 87101, Definitions, to the attention of the appropriate licensed medical professional and if applicable, other specialized care provider… This requirement was not met as evidenced by staff failed to meet resident’s medical needs in a timely manner which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Jul 2, 2025

Plan of correction: By POC due date, ADM agrees to complete and submit to CCLD in-service staff retraining by a certified vendor on proper resident reappraisal in compliance with Section 87463(e)

Allegation investigated: Staff did not meet resident’s hygiene needs which led resident to develop a UTI

On 07/02/25 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (ADM, S1), gathered information and delivered investigation findings to ADM. LPA explained the purpose of the visit with staff. During investigation, LPA conducted interviews with reporting party (RP), staff (ADM, S1), resident (R1), authorized representative (POA) and obtained the following documents from administrator – Personnel record (LIC500), Residents roster, admission agreement, reappraisals, needs & services plan, physician's report, centrally stored medication logs, medication administration records, incident reports. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Staff did not meet resident’s hygiene needs which led resident to develop UTI Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with, reporting party (RP), authorized representative (POA) resident (R1), staff (S1) and reviewed resident (R1) documents. LPA interviewed staff (ADM, S1) who stated that they gave R1 full baths 2X per week and changed his diapers every 3 hours. On 07/02/25 at 2PM, R1 confirmed with LPA that staff changed his diapers 3X per day or as needed and gave him showers 2X per week (every Saturday and Thursday). LPA observed R1 to be clean, odor free and well groomed. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not meet resident’s hygiene needs which led resident to develop UTI is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 15-AS-20250624103807

Allegation investigated: Staff are not ensuring that resident is being assisted with glucose testing Staff falsified resident's glucose readings

On 05/29/25 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (ADM, S1), gathered information and delivered investigation findings to ADM. LPA explained the purpose of the visit with ADM. At 1:10PM, LPA interviewed staff (ADM) and reviewed the following documents: Personnel record (LIC500), Residents’ roster, admission agreement, physician’s report, Hospice care plan, centrally stored medication logs, after discharge summary report, discontinued PCP orders for glucose testing and insulin shots. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Staff are not ensuring that resident is being assisted with glucose testing Investigation Finding: Unsubstantiated During investigation, LPA interviewed reporting party (RP), staff (ADM) and reviewed hospice resident’s (R1) admission agreement, physician’s report, hospice care plan, centrally stored medication logs, after visit summary report, discontinued orders of glucose testing and insulin medication from R1’s PCP. Review of R1’s physician’s report dated 03/28/25 showed he was not diabetic and did not require glucose testing. On 04/29/25, he was sent to the hospital for a change in condition. Review of the hospital after visit report dated 05/03/25 showed doctor’s orders for glucose testing and insulin shots to be administered 2X per day. ADM assisted R1 with glucose testing and insulin shots from 05/04/25 until 05/26/25. LPA reviewed written records of R1’s glucose testing and insulin shots from 05/04/25 until 05/26/25. Review of R1’s medical records showed R1’s glucose testing and insulin medication were discontinued by his PCP on 05/26/25. On 05/27/25 at 3PM, RP confirmed with LPA that R1’s glucose testing and insulin medication were discontinued by his primary care physician (PCP) on 05/26/25 since he was under hospice comfort care. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not ensuring that resident is being assisted with glucose testing is unsubstantiated. Allegation: Staff falsified resident’s glucose readings Investigation Finding: Unfounded During investigation, LPA interviewed reporting party (RP) and staff (ADM) and reviewed hospice R1’s medical records. LPA reviewed written records of R1’s glucose testing and insulin shots from 05/04/25 until 05/26/25. On 05/27/25 at 3PM, RP confirmed with LPA that R1’s glucose testing and insulin medication were discontinued by his primary care physician (PCP) on 05/26/25 since he was under hospice comfort care Staff denied falsifying R1’s glucose readings. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff falsified resident’s glucose readings is unsubstantiated. No deficiencies cited. Exit Interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 29, 2025 · control 15-AS-20250522095120

Allegation investigated: Staff did not meet resident's diapering needs Staff do not respond to resident's call for assistance in a timely manner Staff do not provide adequate food service

On 4/15/2025 at 4:40pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Raufat Ikharo-Umaru, Administrator, and explained the reason for the visit. During the course of the investigation the Department conducted interviews with witnesses, staff, residents, reviewed and obtained records. Allegation: Staff did not meet resident's diapering needs Based on initial interview with W1 it was stated R1 was left in a soiled diaper from 9pm until 6:30am, however, during the day R1 is changed every 3 – 4 hours. Upon LPA’s Continued on LIC9099C. Substantiated Continued from LIC9099. arrival R1 had not been changed since the night prior. S2 stated normally there are two (2) staff at the facility, but there are times there is just one (1) staff to tend to all the residents. R1 and R2 stated there is just one (1) staff at the facility during the day and night. During LPA’s visit on November 12, 2024, there was only one (1) staff (S2) present. LPA observed S2 cooking, passing medication, and cleaning. S3 arrived at approximately 2:30pm. LPA reviewed the personnel report and observed there is only one (1) staff during the day and night. The personnel report indicated S3 works 12:00am – 8:00am. Allegation: Staff do not respond to resident's call for assistance in a timely manner. Based on initial interviews with W1 and W2, R1 must yell for assistance due to there being only one (1) staff on duty and there is not any type of call system. W1 also stated R1 is told staff are busy cleaning and she would have to wait. S2 stated that sometimes a resident will have to wait due to there is only one (1) staff and the other residents needs tending to also. R1 stated the facility does not have any type of call pendent to alert the staff when assistance is needed and if the staff is asleep in the front of the facility, they are not able to hear the residents calling for assistance. LPA observed only one (1) resident was ambulatory. During LPA’s visit LPA witnessed R1 yelling for S2 assistance. Allegation: Staff do not provide adequate food service W1 stated during initial interview the foods provided to the residents are not adequate. The facility offers meals that are heavy in carbohydrates and is not good for the residents with a diagnosis of diabetes. W1 stated during interview that the facility offers a lot of pastas, pancakes, and cereals. Grocery shopping is done by Continued on LIC9099C. Continued from LIC9099C. S1 or S3, stated S2 during interview. R1 stated during interview that her family brings her food often because she is not able to eat most foods provided by the facility. LPA conducted a tour during the annual visit of the facility on November 12, 2024, and observed the facility did not have a 7-day supply of perishables and 2-day non-perishables foods for residents. LPA observed frozen meats, a few canned goods, no vegetables or fruits. LPA cited the facility under the annual inspection visit on November 12, 2024. Based on observations, 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. A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Apr 15, 2025 · control 15-AS-20241104220736

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2) · Plan of correction due date: Apr 22, 2025

(b)...the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement was not met as evidence by: Based on interviews the Licensee did not comply with the section cited above in ensuring incontinent residents are changed checked and changed timely, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 15, 2025

Plan of correction: Administrator agreed submit a written on plan on scheduling for incontinent residents and create a schedule and submit both to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 22, 2025

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (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 interviews the Licensee did not comply with the section cited above in responding to resident in a timely manner, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 15, 2025

Plan of correction: LPA observed upon arrival on 4/15/2025, that each resident had a call bell to notify staff that they need assistance. Deficiency cleared.

Type of visit: Case Management - Other

On 4/15/2025 at 2:50pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Mbidde Nuhun, unfingerprinted staff (S2). LPA spoke with Administrator, Raufat Ikharo-Umaru, via telephone. Administrator arrived at the facility at 4:35pm. While LPA L. Hall was conducting a complaint investigation (15-AS-20241104220736) on 4/15/2025. Upon arrival LPA met with S2 at facility that was not able to communicate in English. Further investigation divulged S2 person was not fingerprinted or associated to the facility. *An immediate civil penalty of $100.00 will be assessed on today's day for fingerprint clearance* Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the LIC421BG, appeal rights, and this report provided.the state’s words, verbatim · CDSS document, Apr 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(d) · Plan of correction due date: Apr 16, 2025

87355 Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement under penalty of perjury. This requirement was not met as evidence by: Based on interview and record review the Licensee did not comply with the section cited above in having S2 fingerprinted and associated to the facility which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 15, 2025

Plan of correction: Administrator agreed to have S2 fingerprinted and submit application to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(d)(3) · Plan of correction due date: Apr 16, 2025

(d) All personnel shall be given on the job training or have related experience in the job... This training and/or related experience shall provide knowledge of and skill... (3) Skill and knowledge required to provide resident care and supervision, including... to communicate with residents. This requirement was not met as evidence by: Based on observation and interview the Licensee did not comply with the section cited above in have a staff available on premises to communicate with residents and other, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 15, 2025

Plan of correction: Administrator agreed to submit a written plan on how the facility will operate when short staff and how S2 will not be left alone with residents after fingerprinted and associated.

Type of visit: Required - 1 Year

On 11/12/2024 at 09:50am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual required inspection. LPA met with Administrator, Bienvenido Espina, Caregiver, and explained the purpose of the visit. LPA spoke with Administrator, Raufat Ikharo, via telephone. LPA toured the facility with including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) bedrooms and three and one-half (3 1/2) bathrooms. Swimming pool in back yard is surround and locked with metal gate. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was not working. Residents’ bathrooms are equipped with grab bars. Carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 9/3/2024. First aid kit was observed to be complete. LPA reviewed four (4) staff files. Three (3) of four (4) were incomplete. LPA reviewed four (4) resident's files and all were incomplete. Continued on LIC809. Continued from LIC809. LPA observed the following deficiencies: At 9:45am, LPA observed trash located on left-side of facility which included a clothes hamper, chandelier, card board boxes, filled garbage bags, a chair, and other items. At 10:05am, LPA observed two (2) tubes of ointment on R1's chest of drawers. At 10:05am, LPA observed comet, glass cleaner, and stain/order remover sitting on bathroom counter in master bathroom. At 10:10am, LPA observed a slide bolt lock on exit door leading to back yard. At 10:10am, LPA observed the door leading to the back yard was broken. Door would not stay closed without the bolt lock. At 10:15am, LPA observed unlocked medicine cabinet in kitchen. Cabinet had pad lock but it was unlocked. At 10:17am, LPA observed patio screen off in den area. At 10:18am, LPA observed sticky trap sitting on kitchen counter with dead insects. LPA also observed several traps around the kitchen. At 10:20am, LPA observed Pine-Sol and Fabuloso in unlocked kitchen cabinet underneath sink. At 10:52am, LPA observed unlocked cabinet full of disinfectants and cleaning supplies in laundry area. LPA requested the following documents to be submitted to CCLD by 11/19/2024. LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Continued on LIC809C. Continued from LIC809C. At 10:55am, LPA observed facility did not have a 7-day supply of non-perishables and 2-day of perishables. At 11:00am, LPA observed there was not any hot water coming out the faucet in the shared bathroom. At 11:30am, LPA observed during record review three (3) of four (4) resident files were missing the admission agreement. None had an appraisal needs and service plan or consent for medical treatment. At 11:35am, LPA observed R1 and R3 glucose was being checked by staff. At 11:40am, LPA observed during record review facility did not have a hospice care plan for R4. At 11:45am, LPA observed during record review facility did not have a health care plan for R2. At 11:55am, LPA observed during record review facility did not have a current and accurate medication list for the residents. At 12:00pm, LPA observed during record review two (2) of four (4) staff was missing first aid and one (1) staff was missing the health screening. At 12:30pm, LPA observed during record review that facility is not conducting fire drills. At 1:30pm, LPA observed during record review that facility had not requested an exception for pressure injury. *An immediate $500.00 civil penalty will be assessed on today's date for fire safety* Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due date, and any repeat violations within 12-month period may result in civil penalties. Exit interview conducted. A copy of appeal rights and this report provided.the state’s words, verbatim · CDSS document, Nov 12, 2024

The state marks this report as 13 pages; the online copy we transcribed has 12. You can request the full file from the county licensing office.

Allegation investigated: Staff made inappropriate comments towards resident Staff yelled at resident

On 07/12/24 at 11:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced visit, interviewed staff (ADM, S1) and resident (R1), gathered information and delivered the investigation findings to the administrator (ADM). LPA explained the purpose of the visit with ADM. During investigation, the department obtained the following documents from the facility: Personnel record (LIC500), Residents’ roster with contact information, R1, R2 admission agreements, Needs & Services Plans, staff training certifications. Continued on next page, LIC 9099-C Unsubstantiated At 12PM, LPA spoke with R1 who stated that staff treat her well, do not call her names and do not yell at her. She stated that on 07/02/24 she was awoken from her sleep to eat breakfast by the caregiver and had an exchange of words with the ADM on the phone. She stated that both ADM and herself settled their differences and apologized to staff. R1 stated staff do not yell at her or call her names. LPA also interviewed staff (ADM, S1) who stated that R1 yells and makes inappropriate comments towards them whenever she is agitated or depressed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation(s) that staff made inappropriate comments towards resident and that staff yelled at resident were found to be unsubstantiated. No deficiencies cited during visit. Exit Interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 12, 2024 · control 15-AS-20240702084132

Allegation investigated: Illegal eviction of resident

On 03/15/24 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit, met with staff (S2) and spoke to administrator (ADM) on the phone who authorized S2 to act on her behalf and sign the reports. LPA explained the purpose of the visit with staff (ADM, S2) and delivered investigation finding. During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, pre-placement appraisal, admission agreement, physicians report, hospice care plan, needs & services plans, 30-day written eviction notice. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Illegal eviction of resident Investigation Finding: Unsubstantiated During investigation, ADM denied illegally evicting resident (R1). On 02/29/24 at 12PM, LPA observed R1 still residing at the facility and witnessed him urinate on the floor while wandering in the common hallway. Staff (ADM, S2) assisted R1 immediately, changed his diaper/clothes and redirected him back to his bedroom. Review of resident’s (R1’s) admission agreement showed R1 was first admitted at the facility on 01/03/24. ADM stated that she has communicated R1’s higher level of care needs several times with R1’s responsible party (POA) since January 2024 with no response. Review of R1’s documents showed that ADM sent a written 30-day notice of eviction to R1’s POA and County Conservator dated 02/29/24 for non- payment of monthly basic fees and additional services from 01/03/24 until current. On 03/15/24 at 12:35 PM, LPA observed R1 relaxing inside his bedroom. ADM stated she is working with R1’s County Conservator in safely relocating R1. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation of illegal eviction of resident and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation of illegal eviction of resident is unsubstantiated. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 15, 2024 · control 15-AS-20240227115411

Type of visit: Required - 1 Year

On 10/26/23 at 1PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 72 deg F. Hot water temperature was measured at 118 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 3 staff and 4 resident files. LPA also conducted 2 staff and 2 resident interviews during visit. LPA observed the following deficiency during visit: Expired fire extinguisher (last purchased 10/05/2021) Missing Carbon Monoxide Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Continued on next page, LIC 9099-C Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  Resident Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 26, 2023

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Oct 26, 2023

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic This requirement was not met as evidenced by expired fire extinguisher which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2023

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Oct 26, 2023

Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections This requirement was not met as evidenced by missing carbon monoxide which posed a potential health & safety risk to residents in care,the state’s words, verbatim · CDSS document, Oct 26, 2023