Apple Ridge Assisted Living

Type of visit: Required - 1 Year

On 7/23/26 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at for the purpose of conducting a required 1 year annual inspection. LPA met with Director of Nursing (DN), Kyle Riley and together conducted a tour of the facility. LPA and DN evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor and clean. LPA did observe some tiles in the kitchen and shower room in need of repair. LPA observed some dented cans in the kitchen that are required to be discarded or returned to vendor. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA observed one of the windows on the door to the interior courtyard is in need of repair and has exposed glass edges that pose a potential hazard to residents. LPA measured the water temperature, temperature measured at 122 degrees F which does not meet the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications. LPA did observed two medication carts in memory care that were unlocked. LPA observed one medication cart in Assisted living with a drawer that would not lock. Report Continued on LIC 9099-C LPA observed several closets or storage rooms/sheds that were not locked and contained items that pose a potential hazard and are required to be locked and secured. LPA observed laundry detergent accessible in unlock laundry room. LPA observed some furniture in memory care is nearing the end of their life span and will soon be in need of replacement. Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 23, 2026

Allegation investigated: Staff did not allow resident back into the facility

On 7/1/2026, Licensing Program Analyst (LPA) Johnson conducted an investigation regarding concerns that the facility failed to allow R1 did not allow resident back into the facility. LPA interviewed Kyle Riley (S1) and reviewed available facility records. It was observed in notes that former RCC (Resident Care Coordinator) Mitchell reported that R1 expressed a desire to transfer to a skilled nursing facility (SNF) to receive physical therapy (PT) and occupational therapy (OT). S2 confirmed that the decision to pursue skilled nursing was R1’s choice, and that R1 wanted additional therapy services at the time. S2 stated R1 had returned to his baseline functioning and did meet criteria for continued skilled nursing placement. Unsubstantiated LPA obtain medical records from the post acute hospital and Fair Oaks Care Center; however, no records were available from the time of R1’s stay. S2 reported that Fair Oaks was the third SNF R1 had been referred to during that period due to insurance complications. Regarding the facility evaluation, RCC Mitchell stated that former RCC Hakim was expected to complete an assessment for R1’s return, but there is no documentation indicating that Hakim conducted or submitted an evaluation. S2 stated the evaluation was intended to determine whether R1 could safely return to the facility. S2 reported R1 required two person assistance at the time and did not qualify for a hospital bed through insurance. R1 reportedly already had a hospital bed available elsewhere but did not want a twin sized bed. S2 also stated they were not familiar with restricted or prohibited health conditions and were unsure what requirements applied to R1’s return. Based on interviews and available information, there is no evidence that the facility refused R1’s return, failed to coordinate care, or violated Title 22 requirements. The information gathered indicates R1 independently pursued skilled nursing services, and information reviewed confirmed the need for a higher level of care. Therefore, the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Jul 1, 2026 · control 27-AS-20260318141417

Allegation investigated: Facility staff did not keep residents' health care confidential.

Licensing Program Analyst (LPA) Albert Johnson conducted an unannounced complaint investigation at Sierra Loma Assisted Living RCFE on 6/4/26 to deliver findings for the complaint allegation mentioned above. Based on interviews and records review, the allegation that staff failed to maintain resident confidentiality and made inappropriate, derogatory statements about a resident’s health condition is unsubstantiated. Resident (R1) reported that staff member (S1) discussed her private health information in a public hallway where other staff could hear. R1 stated that S1 told staff that R1 “always has UTIs,” “is bleeding,” and made a derogatory comment that R1 “has an ugly face.” R1 reported that MedTech (S2) was present and witnessed S1 making these statements. Continued Unsubstantiated Interviews with S2 corroborated that S1 discussed R1’s health condition in a non-private area and made inappropriate remarks. S1 denied making derogatory comments and denied discussing R1’s health condition “in passing” with other staff. S3 could not remember hearing information about R1's health condition and did not deny that it may have happen. S3 stated that they could not recall witnessing anything that S1 may have said about R1 at anytime that S1 was employed with the facility. The department has investigated the allegation that the facility staff did not keep residents' health care confidential. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 27-AS-20260203145929

Type of visit: Case Management - Other

An unannounced case management visit was conducted by the Licensing Program Analysts (LPAs) Avelina Martinez and Arielle Pascua on May 13, 2026, at 2:00 PM. LPAs met with Kyle Riley and explained the purpose of the visit. The purpose of the visit is to follow up on resident 1 (R1) property. It was learned that the facility does not have the following requested documents on site: property inventory document and discharge property paperwork. LPAs requested that the document be emailed to Community Care Licensing Department (CCLD) by May 18, 2026, 5:00 PM. LPAs also followed up on change of ownership status and change of administrator documentation. The following administrator documents are being requested for Steve Bush: Letter from the Licensee requesting to appoint a new administrator to the facility. Copy of current administrator certificate Any documentation that meets the education and/or experience requirement LIC 308 Designation of Facility Responsibility LIC 200 signed by the Licensee or Designee. (update Administrator section) LIC 500 Personnel Report LIC 501 Personnel Record Fingerprint and association documentation (Guardian Report) Please email document to your assigned LPA, Avelina Martinez, by May 18, 2026, by 5:00 PM. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, May 13, 2026

Allegation investigated: Other: Staff mishandled a resident's personal belongings

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Sierra Loma Assisted Living RCFE on 3/27/26 at 9:30am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff, Kyle Riley and together discussed the investigation details. Based on the interviews and statements obtained during the investigation process, the allegations are substantiated. LPA conducted two interviews with staff members and one interview with the resident's responsible party. Interviews conducted corroborated the allegations. Per staff and responsible party statements, residents personal property was not adequately secured while resident was at the hospital for an extended period of time. Once it was determined resident was not returning to the facility, residents personal property was boxed up and left in the resident's room, which was not secured and other residents, staff and visitors would have access to the individuals personal belongings. Report Continued on LIC 9099-C. Substantiated The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Personal Rights is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.the state’s words, verbatim · CDSS document, Mar 27, 2026 · control 27-AS-20260302112333

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(25) · Plan of correction due date: Apr 10, 2026

Additional Personal Rights of Residents in Privately Operated Facilities: To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154. This requirement was not met as evidenced by staff and other interviews, the facility did not make reasonable efforts to ensure the former resident's personal property was secured as items were stored in an unsecured room with resident, staff and visitor access which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: Facility has agreed to update their theft loss policies and provide in writing the current theft loss policy at the facility. this policy will also include once a resident is absent from the facility for an extended period of time, the steps facility staff will make to ensure thier personal property is secured.

Allegation investigated: Staff does not answer resident's call button in a timely manner.

On March 19, 2026, at 10:00 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Kyle Riley and explained the purpose of today's visit. Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and resident records. Confidential interviews were conducted with eleven individuals during the period of November 17, 2025, to March 19, 2026. LPA Martinez reviewed resident 1 (R1) November 13, 2025, through November 17, 2025, call button records. During this period, R1 pressed their call button pendant a total of forty-six times. Based on call button records, the shortest amount of time R1 waited for care was 00:15 seconds and the longest amount of time R1 waited for care was 42minutes:23seconds. Overall, R1 waited more than ten minutes for care on twenty call button requests. Continued... Substantiated R1’s individualized service plan also reported that R1 has a history of refusing care. Based on the obtained information there is not sufficient evidence to support that R1 was left in a soiled brief for an extended period of time. Due to the above noted information, 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, and therefore the allegations are unsubstantiated As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D page, per Title 22 Regulations. An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights document were provided to the facility.the state’s words, verbatim · CDSS document, Mar 19, 2026 · control 27-AS-20251115165126

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 30, 2026

87464(f)(1) Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: based on interviews and file review, the Licensee did not ensure staff were responding to R1's call button in timely and providing care in a timely manner. This posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Facility staff has implemented new policies to provide oversight on call button requests and care staff response times. Facility staff agrees to email call button records weekly to LPA Martinez by POC Date 03/30/2026 and continue to send weekly records until 04/12/2026.

Type of visit: Case Management - Deficiencies

An unannounced case management visit was conducted by the Licensing Program Analyst (LPA) Avelina Martinez on March 19, 2026, at 10:00 AM. LPA Martinez met with Kyle Riley and explain the purpose of the visit. The purpose of the visit today, is in response to learned deficiencies. It was learned that resident 1 (R1) is legally blind, and requires reasonable accommodation. R1's was not provided a third party witness during the review of the admission agreement and facility documents. Based on interviews resident 1 (R1) was not fully informed of the documents they were signing. It was also learned facility staff 1 (S1) served as R1's witness, which is a conflict of interest. Additionally, facility staff accepted R1 at a basic Supplemental Security Income (SSI) income rate. However, R1 is being charged above their basic SSI income rate of $1,206.94 causing additional charges to R1. R1 accrues a balance of $213.13 each month. As a result, of the above mentioned deficiencies the facility will be cited 1569.269 (a)(16) Enumerated rights; severability and 87464(e) Basic Services. The deficiencies can be found on the 809 D page. An exit interview was conducted, and a copy of this 809 report, 809-D Page, and Appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Mar 19, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.269(a)(16) · Plan of correction due date: Apr 9, 2026

1569.269 (a)(16) Enumerated rights; severability: Residents of residential care facilities for the elderly shall have all of the following rights: reasonable accommodation of individual needs and preferences in all aspects of life in the facility...This requirement was not met as evidence by: Based on file review and interviews, the Licensee did not ensure R1 was provided a third party witness during the review of Admission Agreement and facility documents, causing R1 to not be fully informed of the admission agreement and facility documents. This posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Facility staff agrees to review the admission agreement and resident fund management service document with R1. Facility staff agrees to invite a third party (Ombudsman) witness to the review of documents. By POC date 04/09/2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR87464(e) · Plan of correction due date: Apr 9, 2026

87464(e) Basic Services: If the resident is an SSI/SSP recipient, then the basic services shall be provided and/or made available at the basic rate at no additional charge to the resident. This requirement was not met as evidence by: Based on file review and interviews, the Licensee did not ensure R1 was not charged above their basic SSI rate. This posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Facility staff agrees to review R1's SSI rate. Facility staff agrees to invite a third party (Ombudsman) witness to the SSI review with R1. By POC date 04/09/2026

Type of visit: Case Management - Deficiencies

On 3/11/26 at 12:00pm Licensing Program Analyst (LPA) Kevin Gould conducted an case management deficiencies inspection to address deficiencies observed during an unrelated complaint investigation. LPA met with staff member Steven Bush who assisted LPA with obtaining records and documentation. LPA review the current staff roster and schedule. Upon review, LPA observed 10 staff members with criminal record clearances that have not been associated to the facility and two staff members without criminal record clearance (see LIC 421BG for individuals identified as un-associated or without criminal record clearance. Per the California Code of Regulations, Title 22, the following deficiencies are cited. Immediate civil penalties were generated as a result of the observed deficiencies. Exit interview conducted and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Mar 11, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Mar 12, 2026

Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c) this requirement was not met as evidenced by a review of current staff roster, and associated staff members, LPA observed 10 staff member who have not had their criminal record clearance associated to the facility which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Licensee will ensure all identified staff members are associated to the facility and provide a written statements of the policies and procedures facility will take to ensure staff have a criminal record clearance and associated to the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: Mar 12, 2026

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c) this requirement was not met as evidenced by LPA review of staff records and observed two staff member without a criminal record clearance which poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Licensee will ensure all identified staff members obtain a criminal record clearance and are associated to the facility and provide a written statements of the policies and procedures facility will take to ensure staff have a criminal record clearance and associated to the facility.

Allegation investigated: Staff leave residents unsupervised for an extended period of time

Licensing Program Analyst Avelina Martinez conducted an unannounced complaint inspection with the above facility on February 13, 2026 at 9:15 AM and met with Steven Bush. The purpose of the inspection was to deliver complaint findings for the above allegation. Confidential interviews were conducted with eleven individuals during the period of December 22, 2025, to January 21, 2026. Based on interviews conducted and records reviewed, it was determined that there was not sufficient evidence to indicate that residents were left unsupervised for an extended period of time on December 12, 2025. The Administrator reported there were sufficient staff members working on December 12, 2025. The Administrator also provided work schedule documentation to show that the facility was fully staffed on December 12, 2025. Continued.. Unsubstantiated five out of five facility staff members reported that the facility is not short staffed, and there were sufficient staff members working on December 12, 2025, to supervise residents. Three out four residents reported having no issues with staff supervision. One out four residents reported they were left unsupervised for an extended period of time. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Feb 13, 2026 · control 27-AS-20251212160853

Allegation investigated: Staff did not prevent the spread of a lice.

On February 04, 2026, at 12:25 PM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA Martinez met with Steven Bush and explained the purpose of today's visit. Throughout the course of this investigation, LPA Martinez conducted interviews, reviewed facility records, and resident records. Confidential interviews were conducted with eight individuals during the period of December 08, 2025, to January 21, 2026. Based on record reviews, it was confirmed that there was one resident with lice. During two confidential interviews, LPA Martinez was informed that there was a second resident confirmed with lice; however, the interviewees were not able to provide the name of the resident. Based on four staff interviews, there was only one resident diagnosed with lice. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 4, 2026 · control 27-AS-20251204100110

Type of visit: Case Management - Incident

On February 04, 2026 at 2:20 PM, Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA Martinez met with Steve Bush and explained the purpose of the visit. The purpose of today's visit is to discuss an Administrator change. LPA Martinez requested the following documents: Letter from the Licensee requesting to appoint a new administrator to the facility. Copy of current administrator certificate Any documentation that meets the education and/or experience requirement LIC 308 Designation of Facility Responsibility LIC 200 signed by the Licensee or Designee. (update Administrator section) LIC 500 Personnel Report LIC 501 Personnel Record Fingerprint and association documentation (Guardian Report) Please email document to LPA Martinez by February 09, 2026, by 5:00 PM.the state’s words, verbatim · CDSS document, Feb 4, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on February 04, 2026, at 12:45 PM to conduct a case management visit. LPA Martinez met with Steve Bush and explained the purpose of the visit. The purpose of the visit today is to discuss the following deficiency: Incidental and Medical. During record reviews, it was learned that facility staff did not assist resident 1 (R1) with their prescribed medications as needed. On November 20, 2025, R1 was prescribed a permethrin topical cream. The facility staff did not assist with acquiring the medication. As a result, the resident did not receive the required medication treatment to treat lice. The facility will be cited 87465 Incidental Medical and Dental care. The deficiency can be found on the 809-D page. An exit interview was conducted, and copy of this 809 report, 809-D page, and appeals rights were given to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Feb 3, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 18, 2026

87465(a)(4) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by: Based on observation, records review, and interviews, the Licensee did not ensure staff assisted R1 with their medications. This posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Facility staff agrees to conduct a medication audit by POC date February 18, 2026. Facility staff will email audit documentation by POC Date February 18, 2026 by 5:00 PM.

Allegation investigated: Facility staff did not keep resident's health care records confidential.

Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced complaint inspection with the above facility on January 16, 2025, at 10:00 AM and met with Ilona Corpus. The purpose of the inspection was to deliver complaint findings for the above allegations. During this investigation, LPA Martinez conducted interviews, reviewed records, obtained media post pictures, and reviewed facility social media posts. Based on LPA Martinez's observations and investigation, it was learned that the facility did not safegaurd R1's and R2's health care records and did not keep their health care records confidential. LPA Martinez reviewed facility social media posts on Facebook. On Tuesday January 13, 2026, at 2:45 PM, LPA Martinez observed that on December 26, 2025, the facility posted a picture of a facility staff member posing in front of residents' care records. The post revealed R1’s name and last name initial and bowel movement dates and times. Additionally, the post revealed resident 2’s name and last name and turning times and dates. Continued... Substantiated LPA Martinez conducted a second review of the facility’s social media posts on Facebook on January 15, 2026. As of this date, the December 26, 2025, post remains posted on the facility’s Facebook Page. The social media post was removed on January 16, 2026. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D page, per Title 22 Regulations. An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights document were provided to the facility.the state’s words, verbatim · CDSS document, Jan 16, 2026 · control 27-AS-20260113125202

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: Jan 13, 2026

Resident Records 87506(c)(1): All information and records obtained from or regarding residents shall be confidential. The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. This requirement was not met as evidence by: Based on observation, the licensee did not ensure R1's and R2's health care record was safeguarded and kept confidential. This posed a potential health and safety risk to R1 and R2.the state’s words, verbatim · CDSS document, Jan 16, 2026

Plan of correction: Facility removed the social media post on 01/16/26. Provide social media in-service training to facility staff. Staff agrees to email training documents by POC date 01/13/26 by 5:00 PM.

Allegation investigated: Staff did not notify resident's responsible party of a change in resident's condition.

Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced complaint inspection with the above facility on January 16, 2025, at 10:30 AM and met with Ilona Corpus. The purpose of the inspection was to deliver complaint findings for the above allegation. During this investigation, LPA Martinez conducted confidential interviews and reviewed records. During the investigation, LPA Martinez obtained two care plans for resident 1 (R1). One care plan (Service Plan) was completed by facility staff on November 23, 2024, and was signed by R1's responsible party. The second care plan (assessment tool) was completed by a third-party social worker. The information on the assessment tool was obtained from R1 and the facility wellness director. This assessment tool was not signed by R1’s responsible party. Continued... Substantiated In addition, LPA Martinez toured the facility on October 27, 2025; November 06, 2025; and December 22, 2025. LPA Martinez did not observe pest. The facility has a pest control company that conducts pest treatments regularly. During the above stated tours, the facility was not malodorous. LPA Martinez also reviewed the cleaning schedule, which shows cleaning of the facility is done daily. Due to the above noted information, 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, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility The June 11, 2025 tool assessment indicated R1's had a decline in physical functioning. It was also noted facility staff were concerned due to R1's increased depression and decreased appetite. The tool assessment also indicated R1 had scabs on their face and nose, and was declining to visit their primary care physician in person. After the June 11, 2025, tool assessment was completed, facility staff did not update the November 23, 2024 service plan. Additionally, there are no facility notes that indicated facility staff informed R1's responsible party that R1 had a change in condition. As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D page, per Title 22 Regulations. An exit interview was conducted, and a copy of this LIC 9099 report, LIC 9099-D page, and LIC appeal rights document were provided to the facility.the state’s words, verbatim · CDSS document, Jan 16, 2026 · control 27-AS-20251104005226

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jan 29, 2026

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning... when such observation reveals unmet needs...the licensee shall ensure that suchchanges are documented and brought to the attention of the resident's physician and the resident's responsible person... This requirement was not met as evidence by. Based on file review /interviews, the Licensee did not ensure R1's change in condition was documented on service plan and communicated to R1's responsible party. This posed a potential health and safety risk to R1.the state’s words, verbatim · CDSS document, Jan 16, 2026

Plan of correction: Facility staff agrees to will conduct an in-service training on assessments by 01/29/26. Facility staff will email training documents to LPA Martinez by 01/29/26 5:00 PM.

Allegation investigated: Licensee does not ensure that resident is accorded privacy while in care. Licensee does not ensure that resident is provided with a comfortable environment while in care. Licensee does not prevent resident from being verbally abused by other resident while in care. Staff retaliate against resident for filing complaints.

Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced complaint inspection with the above facility on January 07, 2025, at 12:40 PM and met with Administrator, Ilona Corpus. The purpose of the inspection was to deliver complaint findings for the above allegations Based on interviews conducted and records reviewed, it was determined that there was not sufficient evidence to prove resident 1 (R1) was not accorded privacy; was not provided a comfortable environment; endured retaliation by staff; and verbally abused by residents. Confidential interviews were conducted with seven individuals during the period of October 27, 2025, to December 22, 2025. Continued... Unsubstantiated When interviewed, R1 alleged that their privacy rights have been violated by their roommate and R3. R1 also alleged that their roommate and R3 created an uncomfortable environment for them. However, based on information obtained from one out three resident interviews, it was alleged that R1 has been verbally abusive towards their roommate and R3. It was also alleged that R1 has been purposely turning off their roommate’s television and causing an uncomfortable environment for them. According to one out of three residents, they did not have any problems or concerns with R1. Due to conflicting statements made by residents during interviews, there was not sufficient evidence to support the allegations being made. Also, during this investigation, four staff members were interviewed. Statements given during staff interviews were consistent that R1’s privacy has not been violated and has been provided with a comfortable environment. It was also learned that facility staff members have offered to move R1 to a different bedroom to better meet their needs, however; R1 declined to move to a different bedroom. In addition, facility staff has addressed privacy concerns with resident 3 (R3) and R1’s roommate. Staff have also addressed verbal abuse concerns with R3. Due to the above noted information, 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, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 7, 2026 · control 27-AS-20251020150935

Allegation investigated: Staff do not ensure resident is changed properly Staff do not have proper training when changing residents

On 12/09/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Executive Director Ilona Corpus and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 80. A brief interview was conducted with Executive Director, Corpus. It was alleged that staff did not ensure residents were changed properly and that staff do not have proper training when changing residents. The investigation included interviews with staff and residents, as well as a review of facility records. During interviews, all 5 staff members reported that, aside from one resident, they had not received any concerns from residents regarding improper change and staff not having proper training. Moreover, the 5-facility staff stated that they were trained in incontinence care. CONTINUED LIC9099-C Unsubstantiated Additionally, 6 out of 7 residents stated they had no concerns about how staff are assisting with changing and stated that staff appeared to be properly trained. A review of 7 staff records indicated that staff had received training that is required for their job responsibilities and duties, which includes resident care. Based on the statement conducted and records reviewed during the investigation process LPA Lee was unable to corroborate the allegations; therefore, the allegations are found to be unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was conducted with Executive Director, Corpus, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 27-AS-20250701115339

Allegation investigated: Staff did not respond to resident's call button in a timely manner Staff do not serve resident food of good quality

On 12/02/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Executive Director Ilona Corpus and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 80. A brief interview was conducted with Executive Director, Corpus. It was alleged that staff did not respond to resident’s call button in a timely manner. The investigation included staff and resident interviews, a review of facility records, and direct observations. During interviews, 3 out of 5 staff members reported that adding one extra staff member per hall would help prevent delays in meeting residents’ needs. Additionally, 5 out of 7 residents stated that there are not enough staff available, particularly when responding to pendant call requests and getting their incontinence brief change. CONTINUED LIC 9099-C Substantiated Residents reported waiting from 30 minutes to several hours to be changed out of their soiled incontinence briefs. Moreover, according to R1’s LIC 602 Physician’s Report dated 09/02/2025, R1 requires assistance with toileting. A review of the facility’s “Past Events” call log showed response times ranging from approximately 30 minutes to three hours. Residents expressed that staff often take a long time to respond or, at times, do not respond at all when the pendant is pressed. Some residents reported leaving their rooms to find staff because their calls went unanswered. During an unannounced visit on 10/03/2025, LPA interviewed two residents, (R1 and R2) who expressed concerns about delayed incontinence care. On the same day, the LPA observed two residents press their call pendants and wait approximately 30 minutes without a staff response. While waiting, the LPA observed two care staff and two med-techs walking past the residents’ rooms, unaware of the pending calls. LPA Lee then notified the Executive Director, Ilona, regarding the residents who had been waiting. LPA confirmed that the call alerts appeared on the monitor at the front desk; however, there was no audible alert unless staff visually noticed the calls on the screen. Additionally, during multiple unannounced visits, LPA noted strong incontinence odors throughout the facility. Based on the statement conducted, records reviewed and observation during the investigation process LPA Lee was able to corroborate the allegation; therefore, the allegation that licensee does not ensure that there are enough staff to meet the needs of residents in care is found substantiated. It was alleged that staff did not serve residents with food of good quality. The investigation included staff and resident interviews as well as direct observations. During interviews, 5 out of 5 staff members stated they were not aware of any residents experiencing food poisoning and denied the allegation. However, 5 out of 7 residents reported dissatisfaction with the quality of the food served, stating that meals were often cold and lacked flavor. During an unannounced visit to the facility on 10/03/2025, LPA observed during a kitchen tour of improper food handling practices. Seven kitchen staff members were observed preparing lunch without wearing required hairnets. LPA Lee also observed a white bucket in the kitchen sink containing three large portions of ground beef submerged in running water to thaw for dinner. LPA also observed another white bucket filled with chicken breast on the counter and was informed that it had been taken out to thaw. In addition, several open food items were stored in the refrigerator without proper labeling, including cube peaches, apricots, and slice pickles, which were covered with plastic wrap but had no label for open dates and expiration dates. Based on the statement conducted and observation during the investigation process LPA Lee was able to corroborate the allegation; therefore, the allegation that staff do not serve resident food of good quality is found substantiated. CONTINUED LIC 9099-C As a result, this allegations are SUBSTANTIATED. The finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. The deficiency related to staff not responding to residents’ call buttons in a timely manner was not cited, as the citation was previously cited on 11/25/2025 under complaint control #27-AS-20250507151513. A deficiency that staff did not serve residents with food of good quality is cited on LIC 9099-D in accordance with Title 22 regulations. An exit interview was conducted with Executive Director Corpus, and copies of the LIC 9099, LIC 9099-D, and appeal rights were provided to the facility. R3’s service plan indicates that they require standby assistance for transfers; however, during the interview, R3 stated they did not press their call pendant to request assistance prior to attempting the transfer and did so only after the fall occurred. Following the incident, R3 was transported to the hospital for further evaluation and care. Based on records review and statement conducted during the investigation process LPA Lee was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director, Corpus, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 27-AS-20251001145547

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(15) · Plan of correction due date: Dec 12, 2025

87555(b)(15) General Food Service Requirements (b) The following food service requirements shall apply: (15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination. This requirement was not met as evidenced by: Based on interviews and observation, the facility did not ensure that residents are provided with food of good quality. This poses an immediate health and safety risk for person in care.the state’s words, verbatim · CDSS document, Dec 2, 2025

Plan of correction: The administrator agrees to conduct general food service requirements and provide LPA Lee with staff training materials used and staff sign in and out sheets. POC due by 12/12/2025 end of day 5:00 PM.

Allegation investigated: Staff leave resident in soiled clothing for an extended period of time

On 12/02/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Executive Director Ilona Corpus and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the above allegation. The current census is 80. A brief interview was conducted with Executive Director, Corpus. It was alleged that staff did not respond to resident’s call button in a timely manner. The investigation included staff and resident interviews, a review of facility records, and direct observations. During interviews, 3 out of 5 staff members reported that adding one extra staff member per hall would help prevent delays in meeting residents’ needs. Additionally, 5 out of 7 residents stated that there are not enough staff available, particularly when responding to pendant call requests and getting their incontinence brief change. CONTINUED LIC 9099-C Substantiated Residents reported waiting from 30 minutes to several hours to be changed out of their soiled incontinence briefs. Moreover, according to R1’s LIC 602 Physician’s Report dated 09/02/2025, R1 requires assistance with toileting. A review of the facility’s “Past Events” call log showed response times ranging from approximately 30 minutes to three hours. Residents expressed that staff often take a long time to respond or, at times, do not respond at all when the pendant is pressed. Some residents reported leaving their rooms to find staff because their calls went unanswered. During an unannounced visit on 10/03/2025, LPA interviewed two residents, (R1 and R2) who expressed concerns about delayed incontinence care. On the same day, the LPA observed two residents press their call pendants and wait approximately 30 minutes without a staff response. While waiting, the LPA observed two care staff and two med-techs walking past the residents’ rooms, unaware of the pending calls. LPA then notified the Executive Director, Ilona, regarding the residents who had been waiting. LPA confirmed that the call alerts appeared on the monitor at the front desk; however, there was no audible alert unless staff visually noticed the calls on the screen. Based on the statement conducted, records reviewed and observation during the investigation process LPA was able to corroborate the allegation; therefore, the allegation is found to be substantiated. The deficiency related to staff not responding to residents’ call buttons in a timely manner was not cited, as the citation was previously cited on 11/25/2025 under complaint control #27-AS-20250507151513. An exit interview was conducted with Executive Director, Corpus, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 27-AS-20250701115339

Allegation investigated: Facility staff did not respond to resident's calls for assistance

On 12/02/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Executive Director Ilona Corpus and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 80. A brief interview was conducted with Executive Director, Corpus. It was alleged that staff did not respond to resident’s call button in a timely manner. The investigation included staff and resident interviews, a review of facility records, and direct observations. During interviews, 3 out of 5 staff members reported that adding one extra staff member per hall would help prevent delays in meeting residents’ needs. Additionally, 5 out of 7 residents stated that there are not enough staff available, particularly when responding to pendant call requests and getting their incontinence brief change. CONTINUED LIC 9099-C Substantiated Residents reported waiting from 30 minutes to several hours to be changed out of their soiled incontinence briefs. Moreover, according to R1’s LIC 602 Physician’s Report dated 09/02/2025, R1 requires assistance with toileting. A review of the facility’s “Past Events” call log showed response times ranging from approximately 30 minutes to three hours. Residents expressed that staff often take a long time to respond or, at times, do not respond at all when the pendant is pressed. Some residents reported leaving their rooms to find staff because their calls went unanswered. During an unannounced visit on 10/03/2025, LPA interviewed two residents, (R1 and R2) who expressed concerns about delayed incontinence care. On the same day, the LPA observed two residents press their call pendants and wait approximately 30 minutes without a staff response. While waiting, the LPA observed two care staff and two med-techs walking past the residents’ rooms, unaware of the pending calls. LPA Lee then notified the Executive Director, Ilona, regarding the residents who had been waiting. LPA confirmed that the call alerts appeared on the monitor at the front desk; however, there was no audible alert unless staff visually noticed the calls on the screen. Additionally, during multiple unannounced visits, LPA noted strong incontinence odors throughout the facility. Based on the statement conducted, records reviewed and observation during the investigation process LPA Lee was able to corroborate the allegation; therefore, the allegation that licensee does not ensure that there are enough staff to meet the needs of residents in care is found substantiated. As a result, this allegation is SUBSTANTIATED. The finding that the complaint is substantiated means that the allegation is valid because the preponderance of the standard has been met. The deficiency was previously cited on 11/25/2025 under complaint control #27-AS-20250507151513; therefore, no citation was issued. An exit interview was conducted with Executive Director, Corpus, and a copy of this report was provided to the facility. R1 was also interviewed and stated they have no concerns about going to the dining room for meals but occasionally prefer to eat in their room. R1 added that, in the past, it took staff longer to assist with transfers from bed to wheelchair; however, this issue has been addressed with Executive Director Corpus and is no longer a problem per R1. Based on R1’s needs and service, R1 requires minimal assistance with meals. Meal logs indicate that R1 has, on multiple occasions, declined to eat meals in the dining room. Moreover, during multiple unannounced facility visits, LPA Lee observed that R1 was either in the dining room for their meals or, if not, in their room having their meals. Based on records review and statement conducted during the investigation process LPA Lee was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Executive Director, Corpus, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 27-AS-20250825143955

Allegation investigated: Staff do not change residents depends/clothes timely

On 11/25/2025 Licensing Program Analyst (LPA) Pang Lee and Avelina Martinez arrived unannounced to this facility to conduct a complaint visit. LPA met with Executive Director Ilona Corpus and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 80. A brief interview was conducted with Executive Director Corpus It was alleged that staff do not change residents depends/clothes timely. The investigation included staff and resident interviews, a review of facility records, and direct observations. During interviews, 3 out of 5 staff members reported that adding one extra staff member per hall would help prevent delays in meeting residents’ needs. Additionally, 5 out of 7 residents stated that there are not enough staff available, particularly when responding to pendant call requests and getting their incontinence brief change. CONTINUED LIC 9099-C Substantiated Residents reported waiting from 30 minutes to several hours to be changed out of their soiled incontinence briefs. Moreover, according to R1’s LIC 602 Physician’s Report dated 09/02/2025, R1 requires assistance with toileting. A review of the facility’s “Past Events” call log showed response times ranging from approximately 30 minutes to three hours. Residents expressed that staff often take a long time to respond or, at times, do not respond at all when the pendant is pressed. Some residents reported leaving their rooms to find staff because their calls went unanswered. During an unannounced visit on 10/03/2025, LPA interviewed two residents, (R1 and R2) who expressed concerns about delayed incontinence care. On the same day, the LPA observed two residents press their call pendants and wait approximately 30 minutes without a staff response. While waiting, the LPA observed two care staff and two med-techs walking past the residents’ rooms, unaware of the pending calls. LPA Lee then notified the Executive Director, Ilona, regarding the residents who had been waiting. LPA confirmed that the call alerts appeared on the monitor at the front desk; however, there was no audible alert unless staff visually noticed the calls on the screen. Additionally, during multiple unannounced visits, LPA noted strong incontinence odors throughout the facility. Based on the statement conducted, records reviewed and observation during the investigation process LPA Lee was able to corroborate the allegation; therefore, the allegation that licensee does not ensure that there are enough staff to meet the needs of residents in care is found substantiated. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies was not cited since it was already cited on complaint control #27-AS-20250507151513. An exit interview was conducted with Executive Director Corpus and a copy of this LIC 9099 report was provided to facility.the state’s words, verbatim · CDSS document, Nov 25, 2025 · control 27-AS-20250929115641

Allegation investigated: Staff are mismanaging resident's medication resulting in hospitalization.

On 11/25/2025 Licensing Program Analyst (LPA) Pang Lee and Avelina Martinez arrived unannounced to this facility to conduct a complaint visit. LPA met with Executive Director Ilona Corpus and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 81. A brief interview was conducted with Executive Director Corpus It was alleged that staff were mismanaging residents’ medications, resulting in hospitalization. The investigation included interviews with staff and residents, as well as a review of facility records. During the interviews, 6 of 7 residents reported no concerns regarding medication management and stated that they are receiving their medications from staff. Additionally, 5 out of 5 staff members interviewed denied the allegation and stated that residents receive their medications according to physician orders, with documentation maintained in the Medication Administration Record (MAR) or residents’ files. CONTINUED LIC 9099-C Unsubstantiated Staff also denied that any residents had been hospitalized due to medication mismanagement. A review of Resident 1’s (R1) MAR from July through November showed no discrepancies. R1’s seizure medications were administered as prescribed, with occasional refusals by R1 documented. According to R1’s LIC 624 Incident Report dated 09/17/2025, on 09/11/2025, paramedics were called after R1 was found on the floor in their room and reported feeling like vomiting; therefore, R1 was transported to the hospital. Hospital records indicate that R1 was admitted on 09/11/2025 due to a seizure and discharged on 09/12/2025. During two unannounced facility visits on 09/25/2025 and 11/17/2025, LPA Lee reviewed the medications of R1 and Resident 2 (R2) and found no discrepancies. Based on interviews and the record review conducted during the investigation, LPA Lee found no corroborating evidence that staff mismanaged residents’ medications resulting in hospitalization. Therefore, the allegation of medication mismanagement by staff is unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was conducted with Executive Director Corpus and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 25, 2025 · control 27-AS-20250916183948

Allegation investigated: Facility staff did not provide residents with appropriate sleeping accommodation. Facility staff did not provide residents with proper wheelchairs. Staff did not accord with resident privacy.

On 11/25/2025 Licensing Program Analyst (LPA) Pang Lee and Avelina Martinez arrived unannounced to this facility to conduct a complaint visit. LPA met with Executive Director Ilona Corpus and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 81. A brief interview was conducted with Executive Director Corpus It was alleged that facility staff did not provide a resident with appropriate sleeping accommodation and that staff did not provide a resident with proper wheelchair. The investigation included interviews with staff, residents and resident’s responsible party (RP), as well as a review of facility records. During interviews, 5 out of 5 staff members reported that the facility does meet residents’ sleeping needs and that they were not aware of any resident concerns regarding proper wheelchair needs. CONTINUED LIC 9099-C Unsubstantiated Additionally, 7 out of 7 residents interviewed stated they have no concerns regarding their sleeping accommodation and not be provided with proper wheelchair. In an interview Resident 1 (R1) reported no current concerns, explaining that their responsible party (RP) brought R1’s wheelchair from home to the facility and that the facility is currently assisting R1 in obtaining a hospital bed through Home Health. Moreover, R1’s RP confirmed that R1 independently chose to discontinue hospice services and that they have no concerns regarding R1’s care, stating the facility is doing its best to meet R1’s needs. The investigation found that R1 was placed on hospice on 03/05/2025 and was provided durable medical equipment (DME), including a hospital bed and wheelchair. Records show that R1 was discharged from hospice on 05/09/2025 after expressing wanting to begin physical therapy for strengthening. As a result of the hospice discharge, R1’s DME was retrieved by the hospice provider and since R1’s insurance would not cover for a new hospital bed the facility attempted to obtain a hospital bed through R1’s RP since R1 has an extra hospital bed at RP’s home and the facility confirmed that it would be acceptable with a physician’s order. However, R1’s RP did not follow through, and the hospital bed was not delivered to R1. Moreover, Resident Care Coordinator Hakim spoke with R1’s PCP, who agreed to place R1 on Home Health, which will allow R1 to receive a hospital bed through their services. Based on the statement conducted and records reviewed during the investigation process LPA Lee was unable to corroborate the allegation; therefore, the allegation staff are mismanaging residents’ medications is determined to be unsubstantiated. It was alleged that staff did not accord with resident privacy. The investigation included interviews with both staff and residents. 5 out of 5 staff members interviewed reported that they had neither witnessed nor heard of any staff peeking through door cracks while residents were showering and denied the allegation. Similarly, all 7 out of 7 residents interviewed stated that they had not witnessed or heard of any staff peeking at residents during showers. Additionally, Resident 1 (R1) stated that they did not recall making any allegations or complaints regarding this matter. Based on the statements collected during the investigation, LPA Lee was unable to corroborate the allegation. Therefore, the allegation that staff do not accord with resident privacy is determined to be unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was conducted with Executive Director Corpus and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 25, 2025 · control 27-AS-20250811212520

Allegation investigated: Licensee does not ensure that there are enough staff to meet the needs of residents in care.

On 11/25/2025 Licensing Program Analyst (LPA) Pang Lee and Avelina Martinez arrived unannounced to this facility to conduct a complaint visit. LPA met with Executive Director Ilona Corpus and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 80. A brief interview was conducted with Executive Director Corpus It was alleged that the licensee does not ensure that there are enough staff to meet the needs of residents in care. The investigation included staff and resident interviews, a review of facility records, and direct observations. During interviews, 3 out of 5 staff members reported that adding one extra staff member per hall would help prevent delays in meeting residents’ needs. Additionally, 5 out of 7 residents stated that there are not enough staff available, particularly when responding to pendant call requests and getting their incontinence brief change. CONTINUED LIC 9099-C Substantiated Residents reported waiting from 30 minutes to several hours to be changed out of their soiled incontinence briefs. Moreover, according to R1’s LIC 602 Physician’s Report dated 09/02/2025, R1 requires assistance with toileting. A review of the facility’s “Past Events” call log showed response times ranging from approximately 30 minutes to three hours. Residents expressed that staff often take a long time to respond or, at times, do not respond at all when the pendant is pressed. Some residents reported leaving their rooms to find staff because their calls went unanswered. During an unannounced visit on 10/03/2025, LPA interviewed two residents, (R1 and R2) who expressed concerns about delayed incontinence care. On the same day, the LPA observed two residents press their call pendants and wait approximately 30 minutes without a staff response. While waiting, the LPA observed two care staff and two med-techs walking past the residents’ rooms, unaware of the pending calls. LPA Lee then notified the Executive Director, Ilona, regarding the residents who had been waiting. LPA confirmed that the call alerts appeared on the monitor at the front desk; however, there was no audible alert unless staff visually noticed the calls on the screen. Additionally, during multiple unannounced visits, LPA noted strong incontinence odors throughout the facility. Based on the statement conducted, records reviewed and observation during the investigation process LPA Lee was able to corroborate the allegation; therefore, the allegation that licensee does not ensure that there are enough staff to meet the needs of residents in care is found substantiated. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Executive Director Corpus and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. A review of records confirmed that R1’s topical cream is being administered as ordered, and that a PRN cream is either being administered and or refused by R1. Based on the statement conducted and records reviewed during the investigation process LPA Lee was unable to corroborate the allegation; therefore, the allegation that a resident developed a rash due to staff neglect is unsubstantiated. It was alleged that staff are mismanaging residents’ medications. The investigation included staff and resident interviews, as well as a review of facility records. During interviews, 7 out of 7 residents reported having no concerns regarding medication management by staff. R1 stated that they are receiving their medications and no longer have any concerns. Additionally, 5 out of 5 staff denied the allegations and confirmed that residents receive their medications according to the physician’s orders, with documentation recorded in the Medication Administration Record (MAR) or in the residents’ files. A review of R1’s MAR from March to November showed no discrepancies. During two unannounced facility visits conducted on 09/25/2025 and 11/17/2025, LPA Lee reviewed the medications for R1 and R2 and found no discrepancies. Based on the statement conducted and records reviewed during the investigation process LPA Lee was unable to corroborate the allegation; therefore, the allegation staff are mismanaging residents’ medications is determined to be unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was conducted with Executive Director Corpus and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 25, 2025 · control 27-AS-20250507151513

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Dec 5, 2025

87464(d) Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs... This was not met as evidenced by: Based on observation, review records and interviews, the licensee/administrator did not ensure that residents’ needs were being met by facility staff. This posed an immediate health and safety risk to R1the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: Administrator agrees to conduct Basic Services training for all staff. Administrator will read and understand the regulation cited and provide LPA Lee with a letter of acknowledgment of the regulation cite review. The admininistrator also stated that audio was added to the call lights and facility work phones. Administrator will email documents used for training and training sign in sheet by POC Date 12/05/2025 at the end of day 5:00 PM.

Allegation investigated: Staff did not get timely medical care for resident Staff are not following physician’s orders

On 10/31/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Executive Director Ilona Corpus and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. A brief interview conducted with Executive Director Corpus. The current census is 83. It was alleged that staff did not obtain timely medical care for a resident and that staff are not following physician’s orders. The investigation included a review of records, residents’ medications, observations, and interviews with staff, residents, resident's responsible party (RP) and an outside agency. Based on record review and interviews, Resident 1 (R1) was sent to the hospital on 01/30/2025 for dermatitis and was prescribed medications for skin itching and redness. On 07/19/2025, R1 was again sent to the hospital for two separate rashes, and new medications were prescribed. CONTINUED LIC 9099-C Unsubstantiated Review of R1’s Medication Administration Record (MAR) from February 2025 through October 2025 revealed no gaps or missed doses related to rash or scabies medications. During two separate unannounced visits on 07/29/2025 and 10/27/2025, LPA Lee reviewed medications for R1, and did not observe any deficiencies. Interviews were conducted with seven residents, all of whom stated they had no concerns regarding staff obtaining timely medical care, and their medications being administered. R1 also confirmed that they receive their prescribed medications and apply their rash medication independently and have no concerns about their medications. Interviews with five facility staff also stated that medications are administered to residents as well as residents’ rash medications. Interview with R1's responsible party (RP) also stated no concerns with the allegations. An interview with an outside agency confirmed that skin scraping is the proper way to diagnose scabies and noted that R1 did not undergo this procedure. The outside agency also explained that emergency departments often prescribe similar medications for both rash and scabies as a precaution. Based on the records review and statements conducted during the investigation process LPA Lee was unable to corroborate the allegation that staff did not obtain timely medical care for a resident and that staff are not following physician’s orders. The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegations is found to be UNSUBSTANTIATED. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Executive Director Corpus, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 31, 2025 · control 27-AS-20250724091520

Allegation investigated: Staff did not seek timely medical attention for residents Staff are not meeting residents’ personal hygiene needs

On 10/17/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. PA Lee met with the Executive Director Ilona Corpus and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the above allegation. The current census is82. A brief interview conducted with Executive Director Corpus. It was alleged that staff did not seek timely medical attention for residents. The investigation was conducted, including a review of relevant documentation, interviews with facility staff, residents in care and the residents’ Responsible Party (RP). Throughout the investigation it was learned that on 02/17/2025, resident 1 (R1) experienced a fall and was transported to the hospital for evaluation. The discharge diagnosis noted eyebrow abrasion, and discharge instructions advised a follow-up with the primary care provider (PCP) within one week. CONTINUED LIC 9099-C Unsubstantiated On 03/25/2025, R1 sustained another fall, and again received emergency medical attention. Hospital discharge instructions recommended follow-up care with a PCP or orthopedic specialist. While follow-up appointments were recommended in both instances, records confirmed that R1 did not attend the follow-up visits. Interviews and records revealed that R1 has a Durable Power of Attorney for Health Care and Finances, executed on 08/13/2022, which grants the RP full authority over R1’s healthcare decisions. The facility did notify R1’s responsible party of both incidents. In a statement, RP stated that RP resides out of state and acknowledged being unable to arrange follow-up care, despite being aware of their legal authority and responsibility and was notified of the incidents. In an interview with 4 out of 4 facility staff all denied that R1 staff did not seek timely medical attention to R1. In an interview with 7 out of 7 residents who all stated no concerns with facility staff, not providing timely medical attention to residents in care. Additionally, R1’s responsible party expressed no concerns about the care being provided and stated that the facility staff are doing their best. Based on interviews and records review during the investigation process LPA Lee was unable to corroborate the allegation. It was alleged that staff are not meeting residents’ personal hygiene needs. The investigation included observations, record reviews, and interviews with staff, residents in care and a resident’s responsible party. During facility visits on 07/10/2025 and 10/03/2025, LPA Lee observed residents in the memory care unit to be groomed, with no signs of unmet personal hygiene needs. Review of R1’s chart notes and shower logs indicated that activities of daily living (ADLs), including showering and dressing, were being completed despite R1 exhibiting agitation and violent behavior. Moreover, R1 were sent to the hospital on 02/06/2025 due to anxiety and were discharged with a diagnosis of behavioral disturbance. Documentation revealed that R1 occasionally refused showers and being changed. Three staff interviews indicated that R1’s personal hygiene care was being provided, although care was brief due to R1’s agitation and aggression and that R1 occasionally refused showers and being changed. Interviews with 7 out of 7 residents who stated no concerns about their personal hygiene’s needs not being met by facility staff. Moreover, in an interview with R2’s responsible party who occasionally visits R2 has no concern with their family member’s personal hygiene needs not being met. Additionally, R1’s responsible party expressed no concerns about the care being provided and stated that the facility staff are doing their best. Based on interviews and records review during the investigation process LPA Lee was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 27-AS-20250326150306

Allegation investigated: Staff forced resident in care to shower Staff did not ensure that a comfortable facility temperature was maintained for resident in care

On 10/17/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Executive Director Ilona Corpus and explained the purpose of the visit. The purpose of this visit is to deliver a complaint finding for the above allegations. The current census is 82. A brief interview conducted with Executive Director Corpus. It was alleged that staff forced residents in care to shower. An investigation was conducted, which included a review of records and interviews with both staff and residents. According to the records, Resident 1 (R1) was originally scheduled to shower on Mondays and Fridays. It was learned that R1 wanted to change the shower days to Sundays and Tuesdays and had expressed this concern to Executive Director Corpus. In response, Executive Director Corpus updated R1’s shower schedule to Mondays and Wednesdays on the same day the concern was raised. CONTINUED LIC 9099-C Unsubstantiated LPA Lee interviewed all seven residents. Each stated they were not forced to shower and had never witnessed any other residents being forced to do so. During an interview, R1 expressed frustration, noting that the concern had initially only been communicated verbally to care staff and not directly to management. However, once R1 addressed the issue with Executive Director Corpus, the schedule was adjusted on the same day. Additionally, six facility staff members were interviewed. All confirmed that they had neither witnessed nor were aware of any instances where staff forced residents to shower. Based on the interview’s statements conducted during the investigation process, LPA Lee was unable to corroborate the allegation. It was alleged that staff did not ensure that a comfortable facility temperature was maintained for residents in care. An investigation was conducted, including observations and interviews with both staff and residents. During visits to the facility, LPA Lee recorded temperatures of 72°F on 09/04/2025, 76°F on 09/25/2025, 74°F on 10/03/2025 and today’s visit 10/17/2025 at 75*F. During these visits LPA Lee did not observe any residents expressing discomfort or concerns related to the temperature. LPA Lee interviewed 6 out of 7 residents, all of whom stated they had no concerns regarding the facility's temperature. Additionally, five staff members were interviewed and also expressed no concerns about the temperature being too cold. Based on the interview’s statements conducted during the investigation process, LPA Lee was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 27-AS-20250902151357

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to conduct a case management visit on October 17, 2025. LPA Lee met with Executive Director Ilona Corpus and explained the purpose of the visit. The census is 82 Today's visit was conducted to follow up on a LIC 624 Incident Report received by the Department on October 4, 2025, concerning an Absence Without Leave (AWOL) incident that occurred on October 4, 2025. The report indicates that at 7:20 AM during room checks staff alerted Med-tech that resident 1 (R1) was not in R1’s room. A search of the community and surrendering area was immediately conducted. R1 then was located approximately four blocks from the building on the ground. According to R1’s LIC 602 Physician’s Report, dated November 18, 2024, R1 is diagnosed with dementia and is not able to leave the facility unassisted. Based on today's case management visit, The following deficiency was identified and cited in accordance with the California Code of Regulations, Title 22, and the California Health and Safety Code. An immediate civil penalty was accessed today, for an immediate health and safety and a repeat violation in the amount of $1000 since this violation was also cited on 07/29/2025. The deficiency can be found on the LIC 809-D page. An exit interview was conducted, and a copy of the LIC 809 report, LIC 809-D page, LIC 421IMsand appeal rights were given to the facility.the state’s words, verbatim · CDSS document, Oct 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.312(a) · Plan of correction due date: Oct 24, 2025

1569.312(a) Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidence by: Based on records review and interviews with the facility staff, the facility did not comply with the section cited above. R1 left the facility unsupervised and then was located approximately four blocks from the building on the ground. The LIC 602 states R1 was not allowed to leave the facility unassisted. This results in an immediate health and safety risk for the residents in care.the state’s words, verbatim · CDSS document, Oct 17, 2025

Plan of correction: The Licensee/Administrator stated that she has conduct an in-service training from an outside agency with facility staff to go AWOL and basic services. Administrator stated that she will conduct another training course on preventing AWOL and that she shall send the in-service training materials, and a signature sheet of all staff who attended the in-service. The Administrator also stated that same day of the incident a door alarm was installed that she reviewed all residents LIC 602 and wander guard was ordered for all residents whose LIC 602 states that residents have dementia and cannot leave the facility unassisted. Administrator stated that 24/7 staff will be up in the front desk at all times. Training, statement of acknowledgement and receipt of purchase of wander guards will be provided to be provided to LPA Lee by POC 10/24/2025 end of day 5:00 PM

Allegation investigated: Staff are not intervening between verbal interactions of residents.

On 09/25/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Ilona Corpus and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 82. A brief interview conducted with the administrator Corpus. It was alleged that staff are not intervening between verbal interactions of residents. During the course of the investigation, the Licensing Program Analyst (LPA) conducted interviews with facility staff and residents, as well as reviewed relevant records. Based on interviews with staff and all 5 out of 5 residents, there is not a preponderance of evidence to substantiate the allegation referenced above. None of the staff and residents interviewed confirmed that staff are not intervening between verbal interactions of residents. CONTINUED LIC 9099-C Unsubstantiated The residents interviewed reported feeling safe and expressed no concerns about living in the facility. During an interview with Resident 1 (R1), R1 reported being in the dining room watching cartoons when another resident requested a channel change, commenting that cartoons are for children. R1 stated that staff intervened during the disagreement and redirected both residents, assisting them in calming down. R1 also shared feeling frustrated and subsequently filed a complaint. A review of records confirmed that no incident report was filed, as the situation did not escalate into a physical altercation and remained a verbal disagreement over the television program. As a result of the investigation, LPA finds the allegation above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of the report was provided upon exit.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 27-AS-20250508133712

Allegation investigated: Staff handle resident in a rough manner. Staff speak inappropriately to residents in care

On 09/25/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Ilona Corpus and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 82. A brief interview conducted with the administrator Corpus. It was alleged that staff handled resident in a rough manner and it was alleged that staff speak inappropriately to residents in care. During the course of the investigation, the Licensing Program Analyst (LPA) conducted interviews with facility staff and residents, as well as reviewed relevant records. Based on interviews with staff and all 7 out of 7 residents, there is not a preponderance of evidence to substantiate the allegations referenced above. CONTINUED LIC 809-C Unsubstantiated None of the interviewed confirmed that staff are handling residents roughly and making inappropriate comments toward residents in care. The residents interviewed reported feeling safe and expressed no concerns about the care they receive. Resident 1 (R1), who shares a room with Resident 2 (R2), stated that they have never observed Staff 1 (S1) treating R2 roughly and speaking to them inappropriately. Resident 3 (R3), who regularly visits R1, also confirmed that they have not witnessed any rough handling and inappropriate behavior toward R2 by S1 or any other staff members. Additionally, R2 reported that most staff are kind, greet R2 and that R2 have no issues with the facility, stating that "most staff are great." S1 denied making any inappropriate comments and handling R1 roughly. A review of facility records revealed that R1 has a history of using inappropriate language toward staff, both in person and via email. Based on the interviews conducted, there is insufficient evidence to determine whether the alleged allegations occurred. As a result of the investigation, LPA finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of the report was provided upon exit.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 27-AS-20250711104308

Allegation investigated: Staff did not ensure residents personal property was safely secured

On 09/25/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with administrator Ilona Corpus and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegation. The current census is 82. A brief interview conducted with the administrator Corpus. It was alleged that staff did not ensure resident personal property was safely secured. During the course of the investigation, the Licensing Program Analyst (LPA) conducted interviews with facility staff and residents. Based on interviews with staff and all 5 out of 5 residents, there is not a preponderance of evidence to substantiate the allegation referenced above. None of the staff and residents interviewed confirmed that staff are not ensuring that residents personal property was safely secured. Residents interviewed reported no concerns with the laundry services and confirmed that their clothing is being returned to them. CONTINUED LIC 9099-C Unsubstantiated During an interview, Resident 1 (R1) stated that R1’s laundry was being washed and expressed concern that R1’s pants might not be returned in time for an upcoming court appearance. However, R1 confirmed that the laundry, including the pants, was returned the same day and that R1 had appropriate clothing for the court hearing. R1 also reported feeling frustrated at the time and filed a complaint, but stated they have no concerns regarding laundry services. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was conducted, and a copy of the report was provided upon exit.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 27-AS-20250822082812

Allegation investigated: Staff are not meeting residents’ needs resulting in injuries

On 09/04/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at this facility to conduct a complaint visit. LPA met with facility designated administrator (FDA) Ilona Corpus and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 79. A brief interview conducted with FDA Corpus. It was alleged staff are not meeting residents needs resulting in pressure injuries. During the investigation, the Licensing Program Analyst (LPA) interviewed staff and residents and reviewed relevant records. Based on these interviews it was learned that 7 out of 7 staff members have not seen any pressure injuries to residents in care. Moreover, R1 stated that the staff members have been changing R1 on time. R2 stated that they are dry and changed on time. LIC 9099-C Unsubstantiated On 01/31/2025, LPA Renee Campbell went out to the facility to open the complaint and interviewed 4 residents, and all 4 residents stated they did not have pressure injuries and while observing staff cleaning residents after experiencing incontinence, no sores or wounds were observed but there were areas of redness. On 02/13/2025, 04/21/2025 and 04/22/2025, LPA Holly Williams also went out to the facility to follow-up on the complaint and interviewed both residents and facility staff and there were no residents in care with pressure injuries. On 07/10/2025, LPA Pang Lee visit the facility to follow-up on the allegation and based on interview with, residents, facility staff there were no residents with pressure injuries. Based on records, review R1 has a history of skin breakdown and is placed on hospice. Based on the information, there is not a preponderance of the evidence to substantiate this allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. However, resident 1 (R1) R1 stated that staff sometimes use only one person to assist with transfers. R1’s Needs and Services Plan states two-person assistance with toileting and transfer and according to the medical assessment R1 is bedridden. Moreover, R1 reported that staff rarely use the Hoyer lift and instead one staff will lift them manually by swinging their legs over the bed and transferring them into a wheelchair. According to the facility’s Plan of Operation it states the following: The licensee shall ensure that there is an adequate number of caregivers to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. If any resident requires two staff members to assist or transfer a resident or for any other reason, adequate staff shall be on hand to assist the resident. Based on the information gathered, there is a preponderance of evidence to substantiate the allegation. It was alleged that staff are not ensuring that residents’ rooms are kept clean. During the investigation, Licensing Program Analyst (LPA) conducted interviews with both residents and staff and made direct observations during facility visits. Based on interviews, it was revealed that seven out of ten residents do not have a laundry hamper in their rooms, resulting in residents placing dirty clothes on the floor, often in the corners of their rooms. Additionally, 13 out of 14 staff members confirmed that residents do not have hampers and store dirty clothing on the floor. During LPA Williams' facility visits on February 13, 2025, and April 21, 2025, the following conditions were observed in residents' rooms: · Showers with dirty towels on the floor · Food found on a resident's pillow · Dirty sheets on the shower floor · Closets containing soiled clothing with a strong urine odor · Piles of dirty clothes in corners of rooms · Rooms containing food, urinals, and clothing in the same area CONTINUED LIC 9099-C · Food placed next to urinals · Old food and garbage, including containers and cups, left in the rooms · Soiled towels and sheets on the floor · Cluttered living conditions · Old pizza boxes left in residents’ rooms During another visit conducted by LPA Lee on 07/10/2025, LPA Lee observed two residents’ rooms had a strong incontinence smell. According to the facility’s Plan of Operation, caregiver duties include “maintaining the facility in a neat, safe, and sanitary condition.” Based on the information obtained through interviews and direct observations, there is a preponderance of the evidence to substantiate the allegation that staff are not ensuring residents room are kept clean. It was alleged that staff are not meeting residents’ laundry needs. During the investigation, Licensing Program Analyst (LPA) Holly Williams conducted interviews with residents and staff and made direct observations during multiple facility visits. Of the seven staff members interviewed all seven reported that the facility’s laundry services need improvement. They stated that residents’ clothing is not labeled, which frequently results in laundry being lost or mixed up. Staff also reported that the laundry room doors are often left open and accessible to residents, further increasing the risk of clothing being misplaced. Interviews with residents revealed that 13 out of 14 residents reported missing articles of clothing after the laundry is returned. Additionally, the residents do not have laundry hampers in their rooms to keep their clothing together or labeled, further contributing to laundry mix-ups. During LPA Williams’ visits to the facility on February 13, April 21, and April 22, 2025, the laundry room door was observed to be left open on each occasion. LPA Williams also observed that multiple residents’ rooms did not contain hampers, and dirty clothing was seen placed on the floor in the corners of the rooms not collected for wash. CONTINUED LIC 9099-C Additionally, in one resident’s room, dirty clothes were observed on the floor of the closet, with a strong odor of urine. According to the facility’s Plan of Operation, staff are required to: “Perform resident laundry service to include: 1. Strip bedding and replace. 2. Wash and return all clothes, linen and towels within 24 hours.” Based on staff and resident interviews, as well as direct observations, there is a preponderance of the evidence to substantiate the allegation that the facility is not meeting residents’ laundry needs. Due to this investigation, the Department finds the allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with administrator Corpus and a copy of the LIC 9099 report, LIC 9099-D, and appeal rights were given to the facility.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 27-AS-20250128120542

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Sep 17, 2025

87464(d) Basic Services: (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by: Based on statements obtained from residents, facility staff and records review indicated the facility did not provide 2-person assistance to meet the resident's needs per their physician report and residents’ assessment plan. which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: The administrator will conduct staff training in basic service to include two-person assist. Training materials used for the training, staff sign in sheet for the training and a statement of acknowledgement of understanding the regulation cited will be provided to LPA Lee by POC date 09/17/2025 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 17, 2025

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on statements obtained from residents, facility staff and observation the facility staff did not ensure that the facility was in clean and sanitary condition, which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: The administrator will conduct staff training in maintenance and operation to ensure that the facility is clean and sanitary for all residents in care. Training materials used for the training, staff sign in sheet for the training and a statement of acknowledgement of understanding the regulation cited will be provided to LPA Lee by POC date 09/17/2025 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(F) · Plan of correction due date: Sep 17, 2025

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodation and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (F) Basic laundry service (washing, drying, and ironing of personal clothing). This requirement was not met as evidenced by: Based on statements obtained from residents, facility staff, records review and observation, the facility did not meet residents’ laundry needs by ensuring that resident laundry was being done and ensuring that residents laundry are returned to the residents.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: The administrator will conduct staff training for personal accommodation and services to laundry services and ensure that residents’ clothing is returned. Training materials used for the training, staff sign in sheet for the training and a statement of acknowledgement of understanding the regulation cited will be provided to LPA Lee by POC date 09/17/2025 end of day 5:00 PM.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to conduct a case management visit on 07/29/2025. LPA Lee met with Business Office Manager Lisa Johansen and Executive Director Ilona Corpus and explained the purpose of the visit. The census is 82. Today's visit was conducted to follow up on a LIC 624 Incident Report received by the Department on July 28, 2025, concerning an Absence Without Leave (AWOL) incident that occurred on July, 26 2025 .The report indicates that Resident 1 (R1) left the facility unassisted during the morning of July 26, 2025. According to an interview with the Resident Care Coordinator (RCC), RCC was notified via walkie-talkie that a staff member observed a resident outside the facility. Per both RCC and the LIC 624 report, R1 was located by RCC down the street at the corner of Annadale Lane and Auburn Road, appearing distraught. At this time, it remains unclear how R1 exited the facility. According to R1’s LIC 602 Physician’s Report, dated November 29, 2024, R1 is diagnosed with mild cognitive impairment and is not capable of leaving the facility unassisted due to their cognitive condition. Based on today's case management visit, a citation is issued under Title 22, Division 6. An immediate civil penalty in the amount of $500 is assessed today July 29, 2025, due to lack of care and supervision and immediate health and risk to R1. During the visit, LPA Lee also followed up on a pending administrator on boarding. Business Office Manager Lisa provided the following documentation related to Staff 1 (S1): · LIC 501 Personnel Record · LIC 9182 Criminal Background Clearance Request · Current California I.D/driver license CONTINUED LIC 809-C · Health screening with TB/Chest x-ray results · LIC 308 Designation of Facility Responsibility · LIC 500 · Current First Aid/CPR certificate · Current administrator certificate LPA Lee did inform Lisa that the following documents are still needed from the facility · High school diploma or equivalent certification · College transcript or degree · LIC 200 signed by the licensee An exit interview was conducted with Executive Director Ilona Corpus. A copy of this LIC 809, LIC 809-D, LIC 421-IM and appeal rights were provided to the facility at the end of the visit.the state’s words, verbatim · CDSS document, Jul 29, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Aug 5, 2025

1569.312(a) Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidence by: Based on records review and interviews with the facility staff, the facility did not comply with the section cited above. R1 left the facility unassisted and was found down the street at the corner of Annadale Lane and Auburn. The LIC 602 states R1 was not allowed to leave the facility unassisted. This results in an immediate health and safety risk for the residents in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: The Licensee/Administrator shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL and basic services. License/Administrator shall send the in-service training materials, plan on how staff will ensure residents do not AWOL and a signature sheet of all staff who attended the in-service. The License/Administrator will also provide LPA Lee with an updated LIC 500 to ensure sufficient staffing at all times. POC due to LPA Lee by 08/05/2025 end of day 5:00 PM

Allegation investigated: Staff refused to provide accommodations to resident in care

On 6/20/25 Licensing Program Analysts (LPA) Holly Williams arrived unannounced to deliver findings on this complaint investigation. LPA met with the facility designated administrator (FDA) Business Office Manager Lisa Johansen who was briefly interviewed at this time. LPA called the interim administrator Brandon Collins and Collins gave permission for FDA to sign. The purpose of this visit was to deliver the findings of this investigation to this facility, and it's representative, at this time. It is alleged that staff refused to provide accommodations to resident in care. During the course of the investigation, LPA reviewed records, interviewed staff members, and residents. In an interview, R1 stated that they wanted a certain part positioned where R1 was not in pain or medically compromised. R1 felt that S1 was not listening to R1. When speaking to R1 they stated that they did not want to file the complaint any longer and that R1 was getting frustrated at the time. S1 stated that S1 was trying to accommodate the resident. When speaking to both S1 and R1 they had talked, there was a communication issue, and both hugged each other and wanted to start over. Unsubstantiated As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility. Exit Interviewthe state’s words, verbatim · CDSS document, Jun 20, 2025 · control 27-AS-20250609092802

Type of visit: Case Management - Other

On 6/13/25 Licensing Program Analyst (LPA) Holly Williams conducted a case management inspection to address issues that LPA observed and issues residents reported. LPA called the facility designated administrator (FDA) and the FDA gave permission for Lisa Johansen to receive and sign the report. LPA met with Business Office Manager Lisa Johansen (BOM) and together discussed the report. LPA conducted an inspection to look into an incident that happened on 6/2/25 and will return once additional interviews are completed. LPA obtain additional medical records and and related incident reports for one of the residents. During the visit LPA followed up with Brandon Collins the FDA about the new administrator. The FDA stated that they have hired someone, they are waiting for a start date, and the FDA will start getting the new administrators paper work together. Exit interview conducted and a copy of this report and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Jun 13, 2025

Type of visit: Case Management - Deficiencies

On 6/6/25 Licensing Program Analyst (LPA) Holly Williams conducted a case management visit to address the issue that LPA Williams did not include the 9099-D citation pages with the visit, dated 6/5/25 - Case #27-AS-20250108121017. LPA Williams will add the citations to this report. LPA called the facility designated administrator (FDA) Brandon Collins over the telephone and the FDA gave permission for Engagement Director (ED) Mary Schooley to sign and accept the report. LPA met with engagement ED and together discussed the report. The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. A civil penalty in the amount of $250 for a repeat violation of regulation 87309(a) was assessed. An exit interview was held with the ED. Appeal rights were printed and a copy was given to the ED at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jun 6, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87208 · Plan of correction due date: Jun 7, 2025

87208 Plan of Operation(a)The licensee shall have and maintain a current, written definitive plan of operation for the facility...This requirement was not met as evidenced by: Based on record review and interviews the facility mismanaged the residents medication which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Jun 6, 2025

Plan of correction: FDA agrees to conduct a 1 hour training on medication management. FDA agrees to send a plan of training by the POC due date. FDA agrees to conduct training, sent contents of training, and sign in sheet to LPA by 6/13/2/5.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87207 · Plan of correction due date: Jun 7, 2025

87207False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility... This requirement was not met as evidenced by: Based on record review and interview staff members indicated that medications were administered when they were not which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Jun 6, 2025

Plan of correction: FDA agrees to conduct a 1 hour training on the ethical and legal obligations of accurate MARS documentation and send LPA sign in sheet due by 6/13/25. FDA agrees to send a statement of understanding of the regulation and plan for training to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jun 7, 2025

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions... This requirement was not met as evidenced by: Based on observation and interviews the facility had bleach in the shower room accessible to residents which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Jun 6, 2025

Plan of correction: FDA agrees to conduct a 1 hour training on the storage of cleaning products and send the contents of the training and sign in sheet to LPA by 6/13/2025. FDA agrees to send a statement of understanding of the regulation to LPA by the POC due date.

Allegation investigated: Unexplained death Staff did not ensure that a resident's incontinence needs were met Staff did not observe resident for a change in condition Staff did not answer resident's call button

On 6/5/25 Licensing Program Analysts (LPAs) Holly Williams and Charlie Yang arrived unannounced to deliver findings on this complaint investigation. LPAs met with the Brandon Collins who was briefly interviewed at this time. The purpose of this visit was to deliver the findings of this investigation to this facility, and it's representative, at this time. It is alleged that there was an unexplained death at the facility. During the course of the investigation, LPA reviewed records, interviewed Reporting Party (RP), and interviewed staff members. RP stated that R1 had a gash on R1’s forehead and bruising to the side of R1’s eye according to postmortem pictures sent to the LPA. Staff 9 (S9) and S1 in an interview stated that when they found Resident1 (R1) they had fallen out of the chair onto R1’s face Based on the death certificate R1 died of cardiac arrest and other Unsubstantiated health issues that contributed to the death. In 2021 R1 had suffered a stroke and has a history of hypertension. According to record review R1 has several visits to the hospital in 2025. Based on the information, there is not a preponderance of the evidence to substantiate this allegation. It was alleged that staff did not ensure that a resident's incontinence needs were met. During the course of this investigation, LPA reviewed resident records, interviewed reporting party (RP), and interviewed staff. Based on those interviews and record reviews, LPA discovered that the RP would get to the facility in the morning and there were several times that R1 was laying in their feces and urine. In an interview, with S1 they stated that R1 never complained about not being changed. S1 stated R1 complained about the urinal not being emptied. S1 stated that R1 could transfer from bed to wheelchair by themselves. LPA could not find anyone that had seen R1 laying in R1’s feces or urine. LPA reviewed discharge documents from the hospital, and they do not state R1 had ever had a rash or problems from not being changed. According to interviews no one except for the RP has seen R1 unchanged or laying in R1’s own feces and urine. LPA did find staff that stated that they heard him complain about not being changed but they did not see it. Based on the information, there is not a preponderance of the evidence to substantiate this allegation. It is alleged that staff did not observe resident for a change of condition. During the course of the investigation, LPA interviewed staff members and the RP. The RP stated that the change of condition was the staff not finding R1 deceased until AM shift. LPA interviewed S1 and S1 stated that S1 saw R1 alive between 3-4 AM and R1 was asking about the internet that was not working at the time and then S1 went back to check on R1 at 5 AM and found R1 deceased. According to S9 they found R1 deceased at 5 AM before the AM shift. Based on the information, there is not a preponderance of the evidence to show that staff did not observe a change in condition. It was alleged that staff did not answer residents call button. During the course of the investigation, LPA reviewed call logs. On 2/2/2025 the call log says fault and R1 died on 2/4/2025. According to the call logs R1 did not press the call button on the day of his death 2/4/2025 or the day before on 2/3/2025. S14 states that at times when someone’s call button is being reset, or battery is low it can be a fault reading. S14 stated that R1 has had several pendant replacements. Based on the information, there is not a preponderance of the evidence to show staff did not answer resident call button. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility. Exit Interviewthe state’s words, verbatim · CDSS document, Jun 5, 2025 · control 27-AS-20250205094444

Allegation investigated: Staff are not providing residents with snacks

On 6/05/25, Licensing Program Analysts (LPAs) Holly Williams and Charlie Yang arrived unannounced to this facility to conduct a complaint visit. LPAs met with Facility Designated Administrator (FDA) Brandon Collins and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Current Census was 83. A brief interview with the FDA was conducted. Facility is not providing residents with snacks: During the course of the investigation, LPA interviewed five residents, nine staff, and reviewed the menu with the including snack times. LPA went to the facility three times and the first time on 1/16/25 there were snacks, the second time on 4/8/25 no snacks, and the third time on 4/21/25 there were oranges. Two out of five residents state there are snacks sometimes and then sometimes there are no snacks Unsubstantiated According to the facility menu, snacks are given three times a day at 10:30 AM, 2:30 PM, and 7:30 PM. three out of five residents state snacks are available. R2 states that the facility does have snacks 3 times a day but because the residents hoard the snacks the snacks run out fast. R3 states that she always sees snacks out even in the middle of the night however, they are just Cheezits, and they do not have drinks. Scott states they keep the snacks on the counter in the cafeteria. R5 states that the snacks are given three times a day and they do run out but if there are none if you ask, they will get you a snack. Based on interviews with staff, residents, and LPA observations between meal snacks are available. Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegation. An exit interview was held, and a copy of this report was left with Brandon Collins.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 27-AS-20250108121017

Allegation investigated: Staff are mismanaging resident's medication Staff are falsifying resident's medication administration record Staff used chemicals in an unsafe manner, resulting in injury to resident

On 6/05/2025, Licensing Program Analysts (LPAs) Holly Williams and Charlie Yang arrived unannounced to this facility to conduct a complaint visit. LPAs met with Facility Designated Administrator (FDA) Brandon Collins Current Census was 83. A brief interview with the FDA was conducted. Staff are mismanaging residents’ medication: During the course of the investigation, LPA Williams reviewed facility documents and conducted interviews of nine staff members and five residents. In addition, LPA reviewed the Medication Administration Record (MAR), PRN notes, exception records and the Controlled Substance Medication Record (CSMR). LPA observed that on 11/27/2024, the Controlled Substance Medication Record (CSMR) for R6 states Substantiated medication was given. However, the actual MAR does not show the medication was given. According to the PRN log the medication was not given and the exception log states R1 was out of the facility. LPA Williams asked S6 why would it show that the medication was given in the narcotics log and not in the MAR? S6 stated, “I do not know.” LPA Williams asked S8 why would it be documented in the CSMR and not in the MAR? S8 stated, “Then it was done in error.” S1 stated that they do not know why there would be a medication logged in the CSMR and that could not be done in error while the exception log stating out of the facility and the MAR not initialed at all. In an interview, LPA Charlie Yang learned from S6 that the last audit that they had at the facility was in the month of 1/2025. LPA Charlie Yang asked S6 if there were going to be holes in the MARS, and they stated that they could not confirm if there are going to be holes in the MARS, meaning places the medication was skipped or not given to the resident. S6 stated that they don’t have the training or the time to conduct a proper audit. When LPA Charlie Yang reviewed the MARS of R6 for the day of 4/3/2025 on 4/19/2025 the AM and the PM were missing three times, and the medication was given 1 to 2 hours earlier than it was prescribed. LPA has requested R6’s CSMR from S5 for the time of 11/1/2024 to 11/21/2024 3 times and the facility has not been able to find it. LPA asked S5 why the logs were missing and S5 said they could not find them but then said the resident R6 did not take any narcotics during that time. During review, the exception log and the PRN log, which is part of the MAR, all entries between 11/15/2024 to 11/21/2025 were missing and same with the exception log. All the other dates and times were there with a notation, and it said out of facility, but these dates are just missing. This allegation is substantiated Staff are falsifying resident's medication administration record: During the course of this investigation, LPA conducted record review, interviews with staff members, and residents. LPA conducted a record review of the facility’s Medication Administration Record (MAR) and Controlled Substance Medication Record (CSMR) for the dates between 11/24/2024-11/27/2024 for R6. Based on the record review conducted it was learned that S1 had initialed the Controlled Substance Medication Record on 11/27/2024 at 1:29am for R6’s medication to reflect administration and narcotic count. However, a review of the MAR shows that there were no initials for the date of 11/27/2024 for this medication. In addition, a review of the facilities exception log shows that R6 was out of the facility from 11/24/2024 at 10:58 AM to 11/27/2024 at 7:24pm. It was learned during an interview with S7, that S7 witnessed S6 drop the medication on the floor, throw it away in the trash bin, then initial the MAR to reflect that it was administered. S7 stated that they have witnessed S6 state that they are too busy and write in the MAR that the resident received their medication. 1 out of 5 staff members stated they have witnessed falsifying of the MAR by staff. Based on the information gathered, the facility staff are falsifying resident’s MARS. Staff used chemicals in an unsafe manner: During the course of the investigation, LPA conducted interviews with nine staff members and five residents. Based on interviews conducted S4 stated said they try their best to make sure the resident is not in the shower but sometimes they don’t have time, and staff just spray the shower with bleach while the resident is in the shower room. S3 stated that the bleach spray runs out, and instead of getting the bleach out of the locked cabinet, they leave it in the shower to make it easier to fill the spray bottle up. Two out of the four staff members interviewed stated that there was bleach in the shower accessible to residents. According to an interview with S5 and R6, R6 did go to the hospital because of eye irritation from the bleach being sprayed in the shower while R6 was in the shower room and received medication on 4/13/2025. LPA Williams observed in the shower room, written on an empty spray bottle stating, “bleach” and “do not leave in the shower room”. This allegation is substantiated As a result, the above allegation has been deemed to be SUBSTANTIATED. A finding that the complaint allegation was substantiated meant that the allegation was valid because the preponderance of evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal rights were printed, and a copy was given to the FDA at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jun 5, 2025 · control 27-AS-20250108121017

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Holly Williams and Charlie Yang arrived unannounced to conduct an annual inspection. Conducted a brief interview on the phone with facility designated administrator (FDA) Brandon Collins. LPA Williams reviewed 8 resident files (R1-R8) and eight staff files (S1-S8). S7 did not have a Tuberculosis test in their chart. LPA Williams toured the facility with Brittany Ragan and inspected common areas, the kitchen, bedrooms, bathrooms, and court yard areas. Furniture and furnishings were sufficient to meet the needs of residents. LPA observed outside of memory care a gate that is broken at the bottom and is sharp. S7's bed is broken at the foot of the bed and is sharp to the touch. The facility temperature was 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 111 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Williams observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Williams observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Williams observed the locked medication room and conducted a review of the narcotics log for 5 residents. Staff members counted out the pills and all 5 resident logs were correct. LPA observed cabinets that are locked for the storage of medication. LPA Williams observed locked cabinets for the storage of cleaning solutions and knives. In memory care the laundry room was unlocked and detergent was accessible to residents. LPA observed a cockroach in the shower on the floor. [Continued on 809-C] LPA Williams interviewed four staff members (S5-S9) and five residents (R8-R12). The following deficiencies were observed and cited on the following LIC 809D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal rights were printed and a copy was given to the facility designated administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jun 5, 2025

Type of visit: POC

On 4/22/2025 Licensing Program Analyst (LPA) Holly Williams arrived unannounced to conduct a plan of correction visit. LPA Williams met with Martin Nichols and explained the purpose of the visit. As of 4/17/24 LPA Williams have not received all proof of corrections as agreed upon in the plans of correction. LPA has not received the two plan of actions from the facility and they were due on 4/17/2025. Civil penalties were assessed for failure to correct the previously issued citations issued on 4/16/24. A civil penalty in the amount of $100 per day for a total of five days for each plan of correction for failure to correct on both citations is hereby assessed. An exit interview was held with Nichols. Appeal rights and a copy of this report were handed to Nichols.the state’s words, verbatim · CDSS document, Apr 22, 2025

Type of visit: Case Management - Deficiencies

On 04/16/2025 Licensing Program Analysts (LPA) Holly Williams arrived unannounced to conduct a case management visit. LPA Williams met with the Health and Wellness Director Brittany Ragan who was briefly interviewed at this time. LPA Williams received a incident report stating there was an elopement on 04/09/2025. Based on interviews and record review, it was learned that at 6:30 AM the resident (R1) was found off property at a nearby cross street. In an interview, S1 stated that R1 was found wandering at 4 am in the facility and was redirected. In an interview, S1 stated that S2 heard the alarm, opened the door, went out and looked for anyone that might have gotten out, reset the alarm, and came back in. In an interview, S3 stated that the alarm was not working and that sometimes they could push the door between room 37 and 38 open. In an interview, S4 stated that the alarm was broken and was fixed on 04/10/2025 or 04/11/2025. According to the medical assessment, R1 is not able to leave the facility unattended. LPA Williams was in a resident room and observed a strong urine odor and dirty towels on the ground. LPA Williams was standing next to the bed and as LPA Williams moved aside LPA Williams leg touched the blanket hanging off the bed and then felt something wet on the LPA's leg. There was a large wet urine spot on LPA's leg. LPA Williams observed the bed and blankets to be full of urine. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal rights were printed and a copy was given to the facility designated representative at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Apr 16, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(e)(5) · Plan of correction due date: Apr 17, 2025

87705 Care of Persons with Dementia (5) Facility staff shall ensure the continued safety of residents if they wander away from the facility without violating... This requirement was not met as evidenced by: Based on interviews and record review R1 eloped from the facility which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Apr 16, 2025

Plan of correction: Licensee agrees to conduct a 1 hour training on elopement or care and supervision within 1 week of the POC due date. Licensee will send a sign in sheet and training subject matter to LPA WIlliams. Licensee agrees to send a plan of when the training will be done. by POC due date. Holly.williams@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR87625(b)(3) · Plan of correction due date: Apr 17, 2025

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be... This requirement was not met a evidenced by: Based on observation and interview resident incontinence was not managed or cleaned up which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Apr 16, 2025

Plan of correction: Licensee agrees to conduct a training within a week for 1 hour in length on managing incontinence. Licensee agrees to send the subject matter of the training and sign in sheet toLPA Williams. Licensee agrees to send a plan of when the training will be by POC due date.

Allegation investigated: Staff are charging resident in excess of the rate allowed under the Medi-cal Assistance Program (ALW) Staff did not accord resident privacy and interfered with resident's visit Resident left the facility unattended due to lack of care or neglect from staff Facility staff did not safeguard resident funds

On 4/8/2025 Licensing Program Analyst (LPA) Holly Williams arrived unannounced to deliver findings on this complaint investigation. LPA Williams met with Regional Director of Operations Brandon Collins and explained the purpose of the visit. This investigation consisted of record review and interviews with staff and residents. A brief interview was held with Brandon Collins. Allegation: Resident left the facility unattended due to lack of care or neglect from staff. It is alleged that the resident left the facility unattended. In an interview, R1 said R1 has never left the facility unattended. In an interview, Alfredo Cruz the prior administrator of Apple Ridge Assisted Living, LLC said that R1 never left the facility while Cruz was there R1 always had a staff member with R1 when leaving the facility. 3 out of 3 staff said that R1 has never left the facility without a staff member. Based on interviews and record review it is unclear if R1 left the facility unattended. [Continue on 9099-C] Unsubstantiated Allegation: Staff did not accord resident privacy and interfered with resident's visit. It was alleged that staff did not accord resident privacy and interfered with resident visit. During the course of the investigation, LPA interviewed R1, R1 stated that R1’s privacy was not compromised on the visit. R1 stated that it was a resident who was trying to help and R1 wanted the resident to help. Staff members were not aware of this incident. Based on an interview with the resident it is unclear that the staff did not accord resident privacy and interfered with the resident’s visit. Allegation: Staff are charging resident more than the rate allowed under the Medi-Cal Assistance Program (ALW) It was alleged that staff charged more than the allowed rate under the Medi-Cal Assistance Program (ALW) During the course of the investigation, LPA Williams went through the ledger in the month of December 2024 and R1 was not charged 2 times for rent. The payment was reversed because there was not enough money in the account. LPA Williams obtained a document from Department of Social Services showing that the allowable rate raised to $1420.07. Based on interview and record review it is clear that R1 was not over charged. Allegation: Facility staff did not safeguard resident funds. It was alleged that staff did not safeguard resident’s funds. During the course of this investigation, LPA interviewed staff, residents, and reviewed records. Based on interviews, R1 said that R1 refused to let anyone manage R1’s money. According to the physician’s assessment LIC 602 it states that R1 cannot handle R1’s own money. According to the pre appraisal, it states that R1 is managing his own money. In an interview, S1 stated that R1 refused to let the facility handle R1’s money. R1 let another resident have his debit card and the pin and money was stolen. A police report was filed. R1 now has a card file and anyone that goes with R1 to the store must record it and include the receipts. Based on interviews and record review it is unclear that staff did not safeguard resident funds. Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegation. An exit interview was held, and a copy of this report was left with Brandon Collins.the state’s words, verbatim · CDSS document, Apr 8, 2025 · control 27-AS-20241217132635

Allegation investigated: Facility accepts residents for care however the staff cannot meet their needs. Facility staff yell at residents

Licensing Program Analysts (LPA) Holly Williams made an unannounced visit to conclude the investigation of the above allegations and to deliver the findings. LPAs Williams met with facility administrator Charles White and together discussed the investigation details. This investigation consisted of interviews, observations. LPA Williams interviewed White, six staff members (S1-S6) and eight residents (R1-R9). In an interview, R2 said they have heard staff members yelling at residents. In an interview, S3 stated that she has heard staff members yell "just sit down!" because they were frustrated. In an interview, R9 states that staff members yell at R all the time. S1 said they had a client complain of overnight staff members have treated them residents badly. S3 stated that the facility is neglectful, and they do not treat the residents good. S3 said they are severely [Continued on 809-C] Substantiated short staffed and that S3 had to do a two person assist by herself because there was not enough staff to help. S3 stated that R7 was not liked by staff members and R7 was very vocal about what was wrong. S3 said that the staff members would leave R7 for long periods to be wiped and the staff members would take too long to respond to R7. S3 said that R8 was sitting out in the hallway waiting for her shower and R8 was there for like 2-3 hours and there was no staff around. S3 stated that R8 said I don’t know where they went. In an interview with S5 said that she does have R8 wait out in the hall in their nightgown and at times does get busy helping other residents. S3 stated that S3 finally just gave R8 a shower. In an interview, R3 said they keep skipping R3 for showers. R3 said R3 hasn't had a shower in a week. R3 stated that R3 pushes the button for help and staff members walk in turn the button back on and leave. In an interview, R7 and R5 have both complained about their beds that are broken and have not been fixed. R5 said R5’s bed will not recline or come back up and R7 states the safety bar is broken and there are holes in the foot board that are sharp and can hurt R7’s feet. LPA Williams went into R4 and R5’s room to talk with R4 and it smelled strong of urine. LPA Williams and LPA Pang Lee observed in the shower room there was a bag of soiled linens and the whole shower smelled so strong we could not enter, and the exhaust fan was covered in dirt and dust, and it extended to the wall. The floors were not clean in all rooms we went in. On 1/16/25 when LPA Williams walked into the facility it smelled of urine. Based on interviews the above allegations are SUBSTANTIATED, which means that the allegations are valid because the preponderance of the evidence standard has been met. This facility is hereby cited per 22 CCR Sections 87468.1(a)(1), 87464.1(f)(1). An exit interview was conducted with White. A copy of this report and appeal rights were left with White.the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 27-AS-20241014150651

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jan 17, 2025

(a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews personal relationships with staff are not handled with dignity which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Jan 16, 2025

Plan of correction: Licensee agrees to email a plan for training including date and times and subject matter. Once training is completed Licensee agrees to send sign in sheet to LPA Williams. Holly.Williams@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 17, 2025

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).s This requirement was not met as evidenced by: Based on observation and interview residents are not receiving the basic services that they need which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Jan 16, 2025

Plan of correction: Licensee agrees to email a plan for training including date and times and subject matter. Once training is completed Licensee agrees to send sign in sheet to LPA Williams. Holly.Williams@dss.ca.gov

Allegation investigated: Comfortable temperature is not maintained at the facility as required Facility staff are unable to assist resident in moving out of bed due to lack of staff

Licensing Program Analyst (LPA) Holly Williams made an unannounced visit to conclude the investigation of the above allegations and to deliver the findings. LPAs Williams met with facility administrator Charles White and together discussed the investigation details. This investigation consisted of interviews, observations, and record review. LPA Williams interviewed White, staff six members (S1-S6) and nine residents (R1-R9). In an interview, S2 states that they try to get the residents who have Hoyer lifts, up for at least one meal a day. In an intIn an interview, R6 states that the staff members get R6 in and out of bed with the Hoyer Lift just fine. R6 said she has no issues. In an interview, R5 said R5 needs a Hoyer Lift to get out of bed. R5 states he gets his showers on time, and he gets out of bed when R5 needs to. In an interview, R2 said the temperature is good and the place is clean. In an interview, R3 stated that the temperature is good. In an interview, R4 said the temperature is good. Based on interviews and observation, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with White Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 16, 2025 · control 27-AS-20241014150651

Allegation investigated: Facility staff did not meet resident's incontinence care needs Facility staff did not answer resident's call button Facility staff yelled at resident(s) Facility staff spoke inappropriately to resident(s)

On 10/24/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Alfredo Cruz and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegation above. Current census was 83. A brief interview with FDA Cruz was conducted. Allegation: Facility staff did not meet resident's incontinence care needs It was alleged that facility staff did not meet resident’s incontinence care needs. During this investigation, the LPA reviewed facility documentation and conducted interviews with both staff and residents. Interviews with nine staff members revealed that 5 out of 9 believe they can adequately address residents' incontinence care needs, yet they have observed that some colleagues on certain shifts fail to provide this care. These staff members reported instances where they found residents soiled in urine, with messes extending from incontinence pads onto bedding at the start of their shifts. 4 out 9 staff members denied any inability to assist with incontinence care. Substantiated Interviews with 9 residents indicated that all require assistance with incontinence care and showering. 7 out 9 residents reported being left in soiled incontinence briefs for approximately 3 to 7 hours, stating that staff are aware of their condition but do not provide the necessary assistance. In addition, LPA Pascua conducted 3 unannounced visits on 07/16/2024 at 1:30pm to 5:00pm, 09/19/2024 at 10:00am-5:00pm, and 10/18/2024 at 6:30am-11:00am. During these visits, LPA Pascua observed a strong urine smell in consistently detected in hallways 2 and 3. Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This deficiency is addressed on the complaint investigation dated 10/24/2024 and a plan of correction has been established. Therefore, there will not be a LIC9099-D page for this substantiated finding. Allegation: Facility staff did not answer resident's call button It was alleged that facility staff did not answer resident’s call button. During the course of this investigation, this LPA reviewed facility documentation and conducted staff and resident interviews. 9 staff members were interviewed, 5 out of 9 acknowledged that they do not always answer call buttons immediately and that it may take some time to respond due to assisting other residents. They indicated that staff are expected to respond within 15 to 30 minutes, although they admitted that actual response times are often longer. In contrast, 4 out of 9 staff members denied any issues with responding to call buttons. Interviews with 9 residents revealed that 8 had used their call buttons but had stopped doing so due to delays in response. Many reported being left unanswered for extended periods, sometimes for hours or even overnight. A review of the facility’s call button log from May to August 2024 showed average response times of 3 to 6 hours in May and June, and 2 to 3 hours in July and August. Based on the information gathered, the facility staff did not answer the resident’s call button. Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. Allegation: Facility staff spoke inappropriately to resident(s) It was alleged that the facility staff spoke inappropriately to residents. During the course of this investigation, this LPA conducted staff and resident interviews. Based on interviews with 9 staff members, 5 out of 9 reported having heard colleagues speak inappropriately to residents. They noted that while many of these staff members have been fired or no longer work at the facility, some continue to engage in such behavior. 4 out 9 staff members denied ever hearing or participating in inappropriate communication. Interviews with 9 residents revealed that 8 out 9 have heard staff speak inappropriately, with 7 out 9 stating they have personally experienced inappropriate comments from staff, such as “This is why you are in a facility because you cannot help yourself”. Only 1 resident reported not having heard any inappropriate remarks directed at them or others. Residents also mentioned that many staff members who previously spoke inappropriately are no longer employed at the facility. However, it was noted that some staff occasionally make inappropriate comments in front of residents, even if not directed at them. Additionally, residents frequently hear inappropriate language in the hallways. Based on the information gathered, facility staff spoke inappropriately to residents. Based on the information gathered, facility staff spoke inappropriately to residents. Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. Allegation: Facility staff yelled at resident(s) It was reported that staff at the facility yelled at residents. During this investigation, the LPA conducted interviews with both staff and residents. Out of 9 staff interviews, 5 staff members indicated they had heard colleagues yelling at residents. They noted that most of those who yelled have since been fired or no longer work at the facility, although some staff still engage in this behavior. Conversely, 4 staff members denied having heard or participated in any yelling with residents. Interviews with 9 residents revealed that 8 of them had heard staff yelling. Only one resident reported no instances of staff yelling at them. Residents also mentioned that many of the staff who yelled no longer work there but acknowledged that staff sometimes yell in front of them, even if not directed at them. Additionally, it was noted that residents frequently hear staff yelling in the hallways. A review of facility town hall notes indicated that this issue has been addressed, with staff being encouraged to use walkie-talkies or phones for communication. Based on the gathered information, facility staff have yelled at residents. Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. An exit interview was conducted, appeals rights, and a copy of this report was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 27-AS-20240731123011

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 25, 2024

(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This is not met as evidenced by: Based on record review and interview, the licensee did not ensure that there are sufficient staff to ensure that call buttons are met within a sufficient period. It was learned that the facilities best practice is to answer call buttons within a 15-30 min period, however based on interviews conducted with staff and residents’ response time can vary past 2 hours or even overnight due to assistance with other residents. LPA reviewed facility call button logs which confirm this response time. This poses an immediate health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: Administrator stated that a statement of acknowledgement and correction shall be sumbitted to the LPA by the POC date 10/25/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Oct 25, 2024

(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This is not met as evidenced by: Based on interviews, the Licensee did not ensure that facility staff did not ensure that facility staff did not speak inappropriately to residents in care. It was learned that staff would often speak to residents while providing assistance and make commentary that would be inappropriate to say to the resident and around others. This poses an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: Administrator stated that a statement of acknowledgement and correction shall be submitted to the LPA by the POC date 10/25/2024. Copies of training will be submitted to LPA by 11/25/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 25, 2024

(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This is not met as evidenced by: Based on interviews and record review, the Licensee did not ensure that the facility staff did not yell at the residents. It was learned that often times, residents would hear staff members yelling at other residents or staff while caring for others. This poses an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: Administrator stated that a statement of acknowledgement and correction shall be submitted to the LPA by the POC date 10/25/2024. Copies of training will be submitted to LPA by 11/25/2024.

Allegation investigated: Staff left residents in a soiled diaper for a long period of time Staff did not shower residents in care

On 10/24/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Alfredo Cruz and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegation above. Current census was 83. A brief interview with FDA Cruz was conducted. Staff left residents in a soiled diaper for a long period of time It was alleged that facility staff did not meet resident’s incontinence care needs. During this investigation, the LPA reviewed facility documentation and conducted interviews with both staff and residents. Interviews with 9 staff members revealed that 5 believe they can adequately address residents' incontinence care needs, yet they have observed that some colleagues on certain shifts fail to provide this care. These staff members reported instances where they found residents soiled in urine, with messes extending from incontinence pads onto bedding at the start of their shifts. 4 staff members denied any inability to assist with incontinence care. Substantiated Interviews with 9 residents indicated that all require assistance with incontinence care and showering. 7 out 9 residents reported being left in soiled incontinence briefs for approximately three to seven hours, stating that staff are aware of their condition but do not provide the necessary assistance. In addition, LPA Pascua conducted 3 unannounced visits on 07/16/2024 at 1:30pm to 5:00pm, 09/19/2024 at 10:00am-5:00pm, and 10/18/2024 at 6:30am-11:00am. During these visits, LPA Pascua observed a strong urine smell in consistently detected in hallways 2 and 3. Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This deficiency is addressed on the complaint investigation dated 10/24/2024 and a plan of correction has been established. Therefore, there will not be a 9099D page for this substantiated finding. Allegation: Facility staff did not provide showers It was alleged that staff did not shower residents in care. During the course of this investigation, this LPA reviewed facility documentation, and conducted staff and resident interviews. Interviews were conducted with 9 staff members, 5 of 9 who reported that they provide showers for residents. However, they noted instances where other staff claimed to have given showers or attempted to do so, but the shower logs indicated that residents had refused. Additionally, 5 staff members mentioned that many residents often complain about not having received a shower in the past week or are unsure of when their last shower took place. In a separate interview with 9 residents, 7 reported that they do not receive regular showers, averaging only 2 showers per month. In contrast, 2 residents stated that they do not have any issues accessing showers. The LPA also reviewed the facility’s AM and PM shower schedule, which showed that residents are scheduled for full showers two to three times a week. Based on the information gathered, the staff did not shower residents in care. Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This deficiency is addressed on the complaint investigation dated 10/24/2024 and a plan of correction has been established. Therefore, there will not be a 9099D page for this substantiated finding.An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit. This deficiency is addressed on the complaint investigation dated 10/24/2024 and a plan of correction has been established. Therefore, there will not be a 9099D page for this substantiated finding. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit. On June 24, 2024, the new AC unit was delivered and installed by the vendor, with confirmation that it was operational. The final invoice for the AC unit was paid on July 8, 2024. Interviews with nine residents confirmed that the air conditioning had been fixed and that portable units were provided while the main system was down. Three of the nine residents noted some discomfort but found it manageable with the portable units, while six reported no issues at all. A review of invoices from Wallace Heating and Air and Home Depot confirmed the purchase and installation dates of the new AC unit. The facility's Temperature Log showed that from July 2024 to the present, the temperatures in resident bedrooms remained between 71-75 degrees. Additionally, temperature readings taken in ten resident bedrooms indicated temperatures between 70-74 degrees. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Staff did not ensure that residents are fed It was alleged that staff did not ensure that the resident’s are fed. During the course of this investigation, this LPA reviewed facility documentation, conducted observations, and conducted staff and resident interviews. Based on interviewed conducted with 9 staff. All 9 staff members report that they provide meals to residents in their rooms if they prefer not to eat in the dining room. Additionally, snacks are available to residents between meals. None of the staff indicated that residents go unfed. Interviews with 9 residents revealed that all deny not being fed. Five residents expressed a preference for having their meals delivered to their rooms, while four prefer eating in the dining room. All residents reported that their food is served on time. They also confirmed that they can request snacks or access food between meals. During three unannounced visits on 07/16/2024, 09/19/2024, and 10/18/2024, the LPA observed that snacks and food were readily available. Furthermore, the facility has established a café area that residents can access at any time. Based on the information gathered it is unclear if the staff did not ensure that residents are fed. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 27-AS-20240916172545

Allegation investigated: Facility staff did not assist residents with hygiene needs

On 10/24/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility Designated Administrator (FDA), Alfredo Cruz and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegation above. Current census was 83. A brief interview with FDA Cruz was conducted. Allegation: Facility staff did not assist residents with hygiene needs It was alleged that facility staff did not assist residents with hygiene needs. During the course of this investigation, this LPA reviewed facility documentation and conducted staff and resident interviews. In interviews with 9 staff members, 5 out 9 expressed confidence in their ability to assist residents with hygiene but reported witnessing some colleagues neglecting these needs during certain shifts. They noted that upon starting their shifts, they often found residents soiled in urine, with messes extending from incontinence pads onto bedding. Additionally, 5 out of 9 staff members mentioned that residents have complained about not receiving showers for several weeks. Meanwhile, 4 out 9 staff members denied any inability to assist residents with hygiene. Substantiated Interviews with 9 residents revealed that all needed assistance with incontinence care and showering. 7 out 9 residents reported being left in soiled incontinence briefs for 3 to 7 hours, stating that staff are aware of their condition but often do not provide timely assistance. Furthermore, 7 out 9 residents indicated they do not receive regular showers, with some receiving only two showers a month. The LPA reviewed the facility's AM and PM shower schedule, which indicated that residents are scheduled for full showers two to three times a week. Additionally, a review of 9 resident files confirmed that the facility provides support with hygiene needs, including toileting, incontinence care, grooming, and showering. LPA Pascua conducted three unannounced visits on July 16, 2024; September 19, 2024; and October 18, 2024. During these visits, a strong odor of urine was consistently noted in hallways 2 and 3. Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. An exit interview was conducted, appeals rights, and a copy of this report was provided to the facility at the end of this visit. Interviews with 9 residents revealed that 7 reported no missing personal items. However, 2 residents indicated that they had noticed items missing from their rooms but were uncertain whether they had misplaced them or if someone else had taken them. A review of facility documentation indicated recent reports of missing monetary items, headphones, and other miscellaneous belongings. However, the facility could not determine whether these items were misplaced or stolen by staff. Based on the information gathered, it is unclear if the facility staff stole from residents Allegation: Facility air conditioning is in disrepair It was alleged that the facility air conditioning is in disrepair. During the course of this investigation, this LPA reviewed facility documentation and conducted staff and resident interviews. Interviews revealed that on May 31, 2024, the air conditioning unit in Hallway 3 was functioning intermittently. By June 3, the staff discovered that the AC system had completely failed. On the same day, the facility contacted multiple vendors to assess the situation and confirmed the complete failure of the AC unit. A down payment of $10,000 was made for a new system, and the facility purchased nine portable AC units from Home Depot to install in the bedrooms of Hallway 3. Temperature checks were conducted to ensure compliance with regulatory standards. On June 24, 2024, the new AC unit was delivered and installed by the vendor, with confirmation that it was operational. The final invoice for the AC unit was paid on July 8, 2024. Interviews with nine residents confirmed that the air conditioning had been fixed and that portable units were provided while the main system was down. 3 of the 9 residents noted some discomfort but found it manageable with the portable units, while 6 out of 9 residents reported no issues at all. A review of invoices from Wallace Heating and Air and Home Depot confirmed the purchase and installation dates of the new AC unit. The facility's Temperature Log showed that from July 2024 to the present, the temperatures in resident bedrooms remained between 71-75 degrees. Additionally, temperature readings taken in 10 resident bedrooms indicated temperatures between 70-74 degrees. As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Oct 24, 2024 · control 27-AS-20240709170841

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Nov 25, 2024

(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This is not met as evidenced by: Based on observation, record review, and interviews the facility did not provide personal assistance and care with activities of daily living such as incontinence care, bathing and toileting. It was learned that 5 staff members have witnessed facility staff not providing hygiene needs and 7 residents stated that they do not receive consistent hygiene care. Through record review, it was learned that all residents are scheduled and should obtain consistent hygiene care. In addition, LPA observed a strong urine smell in hallways 2 and 3 during a course of 3 unannounced visits. This poses a potential health, safety, and personals rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 24, 2024

Plan of correction: Administrator states statement of correction shall be submitted, along with staff training no less than an 1 hr in duration for the section cited. Copies of correction and staff training shall be submitted to the LPA by the POC date.

Type of visit: Case Management - Incident

On 09/19/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA Pascua was met by Facility Designated Administrator (FDA), Alfredo Cruz and explained the purpose of the visit. Current census was 85. A brief interview with FDA Cruz and a tour of the facility was conducted. The purpose of this visit was to follow up on an incident regarding an elopement from the facility on 09/16/2024. On 09/17/2024, LPA Pascua received a phone call from the facility stating that R1 eloped from the facility. It was stated based on interviews of facility staff, R1 was last seen after dinner on 09/16/2024 around 9:00pm in the courtyard smoking. On 09/17/2024, facility staff checked on R1 in their bedroom where they were not found. At approximately 9:30am, staff notified the Facility Designated Administrator who stated that the facility staff conducted a perimeter search by foot. Additionally, the facility conducted a search in the surrounding areas via car and could not find R1. Staff then notified Sacramento Sheriff's office to report the missing resident. On 09/18/2024, LPA Pascua received notification that R1 was found by Sacramento Sheriff's Department approximately 2.8 miles away from the facility. R1 was evaluated by medical personnel to check their vitals and returned back to the facility before 12:00pm. Upon return to the facility, R1 was unaware that they left the facility and repeated stated their feet hurt. Facility staff conducted additional assessments and observed that R1 was unable to walk around by themselves and needed a wheelchair to ambulate to their room and had several blisters on their feet. It was stated by staff that R1 was able to ambulate and walk around themselves and did not have blisters on their feet prior to the elopement. LPA learned that the facility called Emergency Services and R1 was assessed and treated in the Emergency room and discharged with Home Health Services. LPA reviewed R1's physicians report and care plan which states that this resident has a diagnosis of dementia and was not able to leave the facility unattended with safety checks twice a day conducted by facility staff. It was stated by facility staff that safety checks are done during medication pass, incontinence care checks, however it was not clearly stated in the care plan. In addition, LPA reviewed the facilities staffing records for 09/16/2024 and it was learned that there were 3 staff members present during graveyard shift of which 2 staff members who were hired through an outside agency. It was unclear if the staff member assigned to R1's hall conducted health and safety checks during the course of their shift. R1's care plan also indicates that this resident needs consistent assistance due to disorientation and memory loss. An interview conducted with facility staff revealed that R1 had started showing tendencies to leave the facility to purchase additional cigarettes. Staff state that they worked with the responsible party to obtain additional cigarettes and was believed to help mitigate elopement tendencies. Based on the information gathered, the facility did not ensure that R1 was in secured environment based on the resident's LIC602's indication that R1 could not leave the facility and additional care and supervision needs due to their disorientation and memory loss. As a result, an immediate $500.00 civil penalty shall be assessed on September 19,2024 for bodily injury and severe pain, which posed an immediate threat to the Health, Safety, and Personal Rights of R1. Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, deficiencies were observed during today’s visit. Citations can be found on the LIC 809 – D. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided to facility. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 19, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(d) · Plan of correction due date: Sep 20, 2024

1569.312(d)Basic services requirements: Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement was not met as evidence by: Based on file reviews and interviews, the Licensee did not ensure staff were aware of R1 general whereabouts as R1 was last seen on 09/16/2024 and was not found in their room the next morning. R1 was found outside of the facility on 09/18/2024 by Sacramento Sheriff's department and returned R1 to the facility. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Facility Administrator agrees to conduct elopement drill and training for all staff by POC date 09/20/2024. Facility Administrator will email LPA training logs by POC date 09/20/2024 by 5 PM.

Type of visit: Case Management - Incident

On 09/19/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA was met with Facility Designated Administrator (FDA), Alfredo Cruz and explained the purpose of the visit. Current census was 85. A tour of the facility was conducted and a brief interview with FDR Cruz was conducted. The purpose of this visit was to follow up on 22 incident reports that were received by the department via Fax on from 08/18/2024 to 08/19/2024. Of the 22 incident reports, the facility reported 5 COVID positive residents and 17 incident reports regarding various medical conditions. These incidents reported occurred between the dates of 07/26/2024-07/31/2024 and 08/02/2024-08/08/202/24. All incident reports were reported to the department and time stamped on the dates of 08/18/2024 or 08/19/2024 via fax. Based on the information above, the facility did not report these incidents to the department within the seven days of occurrence. The following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. An exit interview was conducted, appeals rights and a copy of the report was given end the of this visit.the state’s words, verbatim · CDSS document, Sep 19, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1) · Plan of correction due date: Sep 20, 2024

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This is not met as evidenced by: Based on observation and record review, the licensee did not ensure that the facility reported 22 incident reports within seven days of occurrence. LPA reviewed incident reports received by the department on 08/18/2024 and 08/19/2024 and found that the incidents occurred between the dates of 07/26/2024-07/31/2024 or 08/02/2024-08/08/2024 and were reported outside of the seven-day required period. This poses an immediate health, safety and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Licensee to send an acknowledgement of understanding letter regarding 87211 by POC due date of 09/20/2024. Licensee to conduct in-service training on Reporting Requirements and send proof of training by 09/27/2024.

Type of visit: Case Management - Incident

On 09/19/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA was met with Facility Designated Administrator (FDA), Alfredo Cruz and explained the purpose of the visit. Current Census was 85. A tour of the facility was conducted and a brief interview with FDA Cruz was conducted. The purpose of this visit was to follow up on an incident report that was received by the department on 09/17/2024. The incident report states that on 09/14/2024, R1 reported that they had a severe headache and requested for their prescribed medication of Oxytocin, however staff advised that this resident was out of this PRN medication. Subsequently, R1 requested to be sent out via Emergency Services for further evaluation. During the course of this visit, LPA obtained R1's medication administration record, physicians orders, and narcotic log. Due to insufficient time to review documentation, the department will follow up at a later time to complete this case management visit. No deficiencies during the course of this visit. An exit interview was conducted, and a copy of the report was given end the of this visit.the state’s words, verbatim · CDSS document, Sep 19, 2024

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Holly Williams and Vincent Moleski arrived unannounced to Apple Ridge Assisted Living. LPAs Williams and Moleski met with Alfredo Cruz the facility administrator and explained the purpose of the visit. LPAs Williams and Moleski reviewed a facility sketch which was submitted to the Community Care Licensing Division (CCLD) during this facility's change in ownership. A temporary designation was approved for room #41. Cruz has informed LPAs Williams and Moleski that Cruz plans to have his office in #41 temporarily. Cruz agreed to notify licensing when there is a permanent change in use to room #41. Cruz said he would provide LPA Williams an estimated timeline regarding the future use of the room and the permanent placement of the administrator's office. No deficiencies were cited during this visit. Technical assistance was provided regarding notifications of change of use of rooms or buildings. An exit interview was held and a copy of this report was left with Cruz.the state’s words, verbatim · CDSS document, Sep 3, 2024

Allegation investigated: Facility did not pass fire inspection clearance.

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to open this complaint investigation. LPAs Moleski and Williams met with Administrator Alfredo Cruz and explained the purpose of the visit. LPAs Moleski and Williams obtained a fire inspection report for Apple Ridge from Cruz dated 8/22/24. LPAs Williams and Moleski reviewed the inspection report and observed many violations including, but not limited to, many fire doors which need repairs, latches, and smoke seals, and permits for change of use of a resident room. According the fire inspection report, resident room 41 was converted into a administrative office without proper permitting. LPAs Moleski and Williams reviewed a facility sketch which shows the current administrative office labeled as room number 41. LPAs Moleski and Williams were not notified regarding this change of use. In an interview, the fire inspector who authored the report said that this facility's previous fire clearance was granted in error due to these multiple violations which were not previously observed. [continued on 9099-C] Substantiated In an interview, Cruz admitted that this facility had not passed its most recent fire inspection, as described in the fire department's report. The report states that corrections must be made prior to a reinspection on or around 9/19/24. The department has determined the following as it relates to the allegation that this facility did not pass its fire inspection clearance: Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 87202(a). Civil penalties in the amount of $500 were assessed due to a fire clearance violation. An exit interview was held with Cruz. Appeal rights and a copy of this report were left with Cruz.the state’s words, verbatim · CDSS document, Aug 29, 2024 · control 27-AS-20240823155140

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Aug 30, 2024

"(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal." This requirement was not met as evidenced by: Based on interviews and record review, this facility did not adhere to local fire requirements and is currently in violation of its previously issued fire clearance, which poses an immediate health, safety and/or personal rights risk.the state’s words, verbatim · CDSS document, Aug 29, 2024

Plan of correction: Licensee agrees to submit to CCLD a written plan outlining repairs to be made, including a timeline for reinspection, by POC due date. holly.williams@dss.ca.gov Licensee agrees to request a new STD 850 fire clearance after repairs have been made.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit to the facility on today's date for the purpose of delivering an Order To Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion From Facility. LPA Valerio met with Business Office Manger (BOM) Lisa Johansen and explained the purpose of today's visit. Staff (S-1) excluded as a result not related to this facility. LPA Valerio handed the Order to Licensee/Facility of Immediate Exclusion From Facility letter to Lisa Johansen and explained that staff, if present, needed to leave the facility immediately. S1 is to be removed from all shifts and removed from tonight's schedule. An exit interview was held with BOM Lisa, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 22, 2024

Type of visit: Prelicensing

On 6/11/24, Licensing Program Analyst (LPA) Tung Truong arrived announced to conduct a follow up Pre-licensing visit. LPA met with facility staff Alfredo Cruz, who assisted with today’s inspection. Alfredo Cruz is proposed to be the new administrator when the facility license is approved. Alfredo Cruz’s administrator certificate application is currently pending. The licensee was unable to attend today's inspection. LPA toured the facility with Alfredo Cruz. During today's visit, all corrections were completed. - Each resident in assistant living building need to have a call pendant. (Completed) - All heat detector censors shall be functioning. (Completed) Based on a review of this facility during this Pre-licensing visit, it was determined that this facility was found to be in compliance at this time. A Component III was completed at this time with Alfredo Cruz. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. Final approval of the license by the Applications Analyst is pending. Per the California Code of Regulations, Title 22, no violations cited during this visit. Exit interview held, copy of report given.the state’s words, verbatim · CDSS document, Jun 11, 2024

Type of visit: Prelicensing

On 5/30/24, Licensing Program Analyst (LPA) Tung Truong arrived announced to conduct a Pre-Licensing Inspection. LPA met with facility representative/Administrator Aaron Khodorkovsky and explained the purpose of the visit. Administrator Aaron Khodorkovsky and staff Alfredo Cruz assisted with today’s visit. It was learned that this facility will be licensed to serve up to (94) non-ambulatory residents. Facility has two buildings, one for assistant living and one for memory care. All bedrooms are double occupancy and were approved for non-ambulatory or bedridden. Hospice granted for 20 residents. LPA toured and inspected the physical plant inside and outside with the administrator Aaron Khodorkovsky and staff Alfredo Cruz to ensure there were no health and safety concerns on 05/30/2024 at 9:30 AM. There were (77) residents in care at this time. LPA observed the lobby area and common areas were clean and furnished. In addition, resident rooms, kitchen, dining area, laundry room and activity room was toured. LPA observed required furniture and lighting throughout the facility. The hot water temperature was measured at 108*F during this visit which was within the required range of 105-120*F. The temperature inside the facility measured at 72*F which was within the required range of 68-85*F. LPA observed fire extinguisher(s) and central heating and air in the facility were up to date and in good repair. LPA observed no obstruction of emergency exits inside or outside of facility. Continued on 809-C LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. During today's visit, there were a few items that need corrected. The following items that need to be corrected were as follows: - Each resident in assistant living building need to have a call pendant. - All heat detector censors shall be functioning. Based on a review of this facility during this Prelicensing visit, it was determined that this facility has not passed the pre-licensing component of the application process at this time. The Department will return at a later date to complete the pre-licensing. The applicant will correct outstanding issues and inform LPA Truong when the corrections have been completed. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 30, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 94 Census: 74 COMP II Participant: Aaron Khodorkovsky, Administrator Interview Method: Telephone interview On 4/25/24, administrator participated in COMP II. Identification of the administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Apr 25, 2024