Appleton Homes

Allegation investigated: Staff do not ensure resident is allowed to have visitors

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit for the allegation listed above. At approx 09:30 a.m. LPA met with staff and explained the reason for the visit. Administrator Myline Olivas arrived shortly after. At approx 09:35 a.m. LPA conducted physical plant, interviewed staff, residents and reviewed and obtained copies of pertinent documentation relevant to the investigation. It was reported that staff prevented resident from having visitors, as it was alleged on multiple dates, a visitor attempted to visit Resident 1 (R1), but was not allowed to enter the facility. Interviews and a review of records reflected that R1’s Power of Attorney (POA) informed the Administrator that visitation from a specific individual should be restricted. The Administrator stated that the individual has come to the facility to drop off food and snacks for R1. Substantiated Continued from 9099 The Administrator further stated that the individual was informed they are not permitted to visit R1 based on the POA’s direction. At the time of the review, LPA did not observe any restraining orders or court documents in R1’s file authorizing or requiring the restriction of visitation. Based on information gathered during this visit, the department has sufficient evidence to determine this allegation occurred. Therefore, the allegation that "Staff do not ensure resident is allowed to have visitors" has been deemed Substantiated at this time. The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 29-AS-20260212155920

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(11) · Plan of correction due date: Feb 27, 2026

To have their visitors...permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement is not met as evidenced by Based on interviews and record review, the licensee did not comply with the section cited above as staff prevented R1 from having a visitors which poses as a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 20, 2026

Plan of correction: Licensee agreed to review section cited then submit a statement of understanding and a written plan to ensure future compliance and submit to CCLD via email by COB 02/27/2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced visit at the facility in conjunction with investigation of complaint control #29-AS-20260212155920. Upon arrival LPA met with Administrator Myline Olivas and explained the reason for the visit. Prior to today's visit LPA conducted facility file review, which revealed that the facility's licensee AM3 Corporation indicates a suspended status with the Secretary of State of California. Administrator stated they will have it in good standing by next month. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 20, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87205(b) · Plan of correction due date: Feb 27, 2026

If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability.This requirement is not met as evidenced by Based on interviews and record review, the licensee did not comply with the section cited above the as the licensee's corporationwas in a suspended status which poses as a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 20, 2026

Plan of correction: Licensee stated they corporation status will be in good standing by next month. Licensee also agreed to review section cited and provide a statement of understanding and a writted plan to ensure future complaince then send to CCLD via email by COB 02/27/2026

Allegation investigated: Facility did not issue a proper refund Paperwork was not completed in a timely manner

Licensing Program Analyst (LPA) Quoc Huynh conducted a complaint visit to deliver findings for the above allegations. The LPA arrived at 8:57AM and met with Licensee Myline Olivas and explained the reason for the visit. Entrance interview conducted. On 02/27/2025, LPA Brian Balisi conducted an initial complaint visit. Beginning at 10:00AM, LPA Balisi toured the physical plant, interviewed staff, and reviewed and obtained pertinent documents. During today’s visit, LPA Huynh conducted a physical plant tour at 9:12AM to ensure there were no health and safety hazards. The following was then determined: Report Continued on LIC 9099-C Substantiated Allegations: “Facility did not issue a proper refund” and “Paperwork was not completed in a timely manner” It was reported that the Licensee of Appleton Homes did not issue a refund to Resident #1’s (R1) representative and did not complete the required documents prior to admission. R1 was admitted to the facility on 02/14/2025 and was immediately removed by R1’s representative on 02/15/2025. The facility’s resident Admission Agreement stated “Facility charges $500 non-refundable move-in fee. This fee is to be used to review the client’s needs assessments, to process forms. There is no security deposit” and “Prior to admission, RESIDENT or RESIDENT’S responsible person shall furnish to FACILITY a current physician’s medical report, tuberculosis clearance and participate in an assessment evaluation (pre-admission appraisal).” R1’s representative reported that on 02/14/2025 during the admission, the Licensee provided blank forms and requested the representative to sign the documents. Additionally, the resident’s representative was not provided copies of the documentation signed and the Licensee did not review any forms with the representative. Witness #1 (W1) confirmed that blank documents were provided for signatures, documents were not reviewed or explained by the Licensee, and no communication from the facility was reported prior to 02/14/2025. The Admission Agreement, Telecommunications Device Notification, Consent for Emergency Medical Treatment, Personal Rights, and Release of Client/Resident Medical Information were completed and signed on 02/14/2025. R1’s Preplacement Appraisal, Appraisal/Needs and Services Plan, and Theft and Loss Policy were signed on 02/14/2025 and blank. R1’s Identification and Emergency Information was signed, but not dated, was also incomplete. Report Continued on LIC 9099-C The facility’s Refund Policy stated: “As required by law, if the resident is evicted because of … (5) Upon movement or family decided to send love one at home or any preferred Facility … NO REFUND, and should remove personal belongings immediately.” R1’s representative reported they requested a refund, and the Licensee stated they did not owe the representative any money. Interview with the Licensee revealed the resident’s representative requested a refund and per the admission agreement, they needed to give at least a 30-day notice. The Licensee stated “they showed up the next day and moved (R1) out.” The facility’s Admission Agreement also stated under the Conditions For Termination of Agreement: “This agreement may be terminated by RESIDENT upon thirty (30) days’ written notice to FACILITY.” R1’s representative provided a written and signed notice on 02/15/2025 at 3:05PM, during the removal of R1. Based on interview and record review, the Licensee did not abide by the policies written in the admission agreement. R1 was not assessed prior to admission, forms were not processed, and a Physician’s Report without TB result was obtained prior to admission. Additionally, documents provided to R1’s representative during the admission on 02/14/2025 for signatures were not reviewed. The preponderance of evidence standard has been met, therefore the allegations are deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies are cited (Refer to LIC9099-D). Exit interview conducted. A copy of the appeal rights and today’s report was reviewed and provided. Allegation: "Resident was not provided ample storage space for personal items" It was reported that Resident #1 (R1) was not provided ample storage space for their personal items. Title 22 CA Code of Regulation section 87307(a)(3)(B) stated “Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.” Based on LPA Huynh’s observation during the visit, each resident was provided with the listed items with an additional closet space in each bedroom. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited related to the allegation. Exit interview conducted. A copy of today’s report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 8, 2025 · control 29-AS-20250224124702

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87507(f) · Plan of correction due date: Aug 9, 2025

(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as the licensee did not obtain required documents and did not conduct a pre-placement appraisal which poses/posed an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: The Licensee will review their admission agreement and send CCLD a statement of understanding by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87208(a) · Plan of correction due date: Aug 9, 2025

(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so … This requirement was not met as evidence by: Based on interview and record review, the licensee did not comply with the section cited above as the licensee did not issue the resident’s representative a refund which poses/posed an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: The Licensee will issue R1's representative a refund and send CCLD proof by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced visit at the facility in conjunction to an investigation of complaint control # 29-AS-20250224124702. LPA arrived at 8:57AM and met with the Licensee Myline Olivas and explained the reason for the visit. Entrance interview conducted. During today’s visit, LPA Huynh and the Licensee conducted a tour of the physical plant areas at 9:12AM to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was then determined: During the investigation of complaint control # 29-AS-20250224124702, LPA Brian Balisi and Quoc Huynh discovered the Licensee accepted and retained Resident #1 (R1) with a prohibited health condition. R1 had gastrostomy tubes that aided R1 with their feeding. R1 was admitted to the facility on 02/14/2025, and during the admission, was not on hospice due to being discharged from the hospital the same day. R1’s representative stated they signed hospice documents after R1 was admitted to the facility. Solid Hospice confirmed that R1 was admitted to their services on 02/14/2025 in the late afternoon, after the admission, and discharged on 02/15/2025 due to onboarding with another hospice agency. Full Care Hospice confirmed R1 was admitted on 02/15/2025 and discharged on 03/09/2025. The Licensee admitted to LPA Balisi during an interview that staff at the facility did not know how to operate R1’s gastrostomy tubes which resulted in the tubes jamming. Report Continued on LIC 809-C LPA Huynh also had a discussion with the Licensee on ensuring that residents and families have the right to choose their own hospice and home health agencies. Pursuant to Title 22 of the CA Code of Regulations and/or Health and Safety Code, the following deficiency was cited. (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 8, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(2) · Plan of correction due date: Aug 9, 2025

(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section as the licensee retained a resident with a prohibted health condition who was not on hospice during the time of admission which poses/posed an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: The Licensee will review regulations and provide CCLD a statement of understanding by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 8:57AM. The LPA met with the Licensee Myline Olivas and explained the reason for the visit. Entrance interview conducted. Beginning at 9:12AM, the LPA and Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The facility is a single-story residential home. The following was observed: COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The living room had a screened fireplace that was inoperable. Required postings were observed in the living room. The facility maintained a comfortable temperature throughout the visit. The facility had an office area located between the kitchen and entryway hallway. The office area contained a desk with files and furniture in good condition. KITCHEN: The LPA observed knives stored inaccessible in a locked drawer. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable and non-perishable food, as well as emergency food. The LPA observed non-perishable food cans expired between November 2024 and June 2025. Food in the refrigerator and freezer were observed to be of good quality and properly stored. One (1) fire extinguisher was observed and last serviced on 08/09/2025. Report Continued on LIC 809-C The Licensee stated they have a scheduled date the following Wednesday to service the fire extinguisher. The kitchen also had two (2) dressers and a file cabinet. One (1) dresser was locked and contained resident medications and the second dresser contained general utilities. The file cabinet was not locked and contained files and several prescribed medications and ointments. The Licensee stated the medications were old and no longer in use. The LPA addressed the accessibility of the file cabinet to which the Licensee said the handle has a push mechanism to open the drawer. The LPA explained the latch was not a sufficient security measure, and the cabinet was accessible to residents. GARAGE: Attached to the kitchen was the garage. The garage remained inaccessible to residents and contained general storage, laundry machines, and additional food. An extra supply of emergency food and water was stored in the garage. The LPA observed non-perishable food cans expired between March 2025 and May 2025. The Licensee stated they would review the food supply and discard expired food. The food in the extra refrigerator and freezer were of good quality. Laundry machines were observed to be operational. BEDROOMS/RESTROOMS: There were five (5) total bedrooms: One (1) staff room that was not locked and contained staff personal belongings, two (2) private resident bedrooms, and two (2) shared resident bedrooms. Bedrooms #2, #4, and #5 had direct exits to the outside, with Bedroom #5 approved for one (1) bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in the hallway cabinet. Upon entering Bedroom #4, the LPA observed one (1) resident’s bed obstructed the direct exit and the placement of the bed did not allow enough space for a walker or wheelchair to pass through and access the exit. The exit doors were unable to fully open. The Licensee and staff pushed the bed away from the exit and was able to access the exit door. There were two (2) total restrooms in the facility: one (1) shared resident and staff restroom located in the hallway, and one (1) private restroom in Bedroom #5. Report Continued on LIC 809-C Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested in the resident restrooms and measured between 113.9 degrees F and 114.3 degrees F which is within the required range. The Licensee stated the residents in Bedroom #4 utilized the private restroom located in Bedroom #5. The LPA explained to the Licensee that the private restroom can only be used by the residents who resided in Bedroom #5 and the Licensee understood. OUTDOOR AREA: The rear yard had multiple shaded areas with furniture in good condition for resident use. The facility had one (1) emergency side exit with a self-latching mechanism. During this time, the LPA observed items including a bag of recyclable bottles hanging on the exit, a bag of clothes leaning against the exit, a carpet, a tarp, a mop bucket, and a box. The Licensee stated these items needed to be discarded. The LPA stated the exit passageways need to remain unobstructed. RECORDS: Record review began at 9:45AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. Resident #1 (R1) did not have a signed Physician’s Report or a TB test result on file and did not have an Emergency Identification form. R1’s Pre-Admission Appraisal was not signed and R1’s most recent Appraisal was not completed or signed. Resident #2 (R2) did not have a TB test result on file and Resident #3’s (R3) most recent Appraisal was not completed or signed. The Licensee stated that families requested to keep the Appraisals short therefore the Licensee does not fill out the forms completely. The LPA discussed with the Licensee that the Appraisals determine how the facility address the needs and services of residents, and the forms need to be completed in its entirety to monitor the residents’ conditions. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Records were in order. Report Continued on LIC 809-C INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 08/05/2025. Smoke and carbon monoxide detectors were tested at 9:38AM. MEDICATIONS: Medication review began at 11:40AM. Medications were centrally stored and kept inaccessible. Medications were observed for three (3) residents. Medications were labeled and checked for expiration dates and were not properly documented on the centrally stored medications and destruction record (CSMDR). R1 had sixteen (16) prescribed medications, nine (9) of which were PRN (as needed) medications, that were not accurately documented on a CSMDR. R1 did not have a PRN Authorization Letter. R2 did not have a current CSDMR and the Licensee stated R2’s medications were delivered the previous night and staff have not made the updated list because “we are busy.” R2’s most recent CSDMR update was 06/03/2025. Resident #4’s (R4) CSMDR was not accurate or updated. R4’s most recent CSDMR update was 02/07/2025. Staff utilized an app to update resident medications which then converts into an excel sheet. Staff provided the LPA a “master” list of all residents CSDMR. Upon review of the master record, Resident #5 (R5) also did not have a maintained CSDMR with medication information missing. Pursuant to Title 22 CA Code of Regulations and/or Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D). An immediate civil penalty of $500 for a violation of the facility’s fire clearance was issued (Refer to LIC 412M). The Licensee understands that continued violation of the facility’s fire clearance may result in additional civil penalties. An immediate civil penalty in the amount of $250 for a repeat citation was issued (refer to LIC 421FC). The Licensee was informed that failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 8, 2025

Allegation investigated: Staff are not properly supervising residents who may be a fall risk

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced follow-up complaint investigation visit at the facility at 09:56 AM. LPA met with facility staff who contacted the Administrator Myline Olivas the reason for the visit was explained and entrance interview was conducted. The Administrator arrived to the facility at 11:05 AM. During the initial complaint visit on 11/12/2024 LPA Brian Balisi at approximately 1pm, conducted physical plant tour, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the investigation. During today’s visit between 10:00 AM and 11:15 AM LPA Byrne conducted a physical plant tour, interviewed the facility Administrator, conducted a file review for one (1) resident, and collected copies of pertinent documentation. Continued on LIC-9099C. Substantiated The allegation of “Staff are not properly supervising residents who may be a fall risk” alleges that the facility did not provide appropriate supervision and safety measures for resident #1 (R1) which resulted in R1 being hospitalized after experiencing a fall at the facility. LPA observed the resident file for R1. LPA observed the file to contain an LIC 625 Appraisal Needs and Services Plan, a Care Center Discharge Summary, and a Home Health Certification and Plan of Care that indicated R1 had a history of and was at risk for falls. During the initial 11/12/2024 visit LPA Balisi interviewed the Administrator who stated that R1 had bedrails previously equipped on their bed. The Administrator stated that due to them not having an order for bed rails and due to recent visits from licensing they were afraid of getting a citation, so the facility removed the bedrails. The Administrator stated that the bedrails were originally installed at the request of the family, but they were removed pending an order from R1’s home health agency. During today’s visit LPA Byrne interviewed the Administrator. The Administrator stated they were unaware that R1 was a fall risk before they arrived to the facility. The Administrator stated that upon identifying R1 as a fall risk they would place a protective mat on the floor alongside R1’s bed at night to mitigate the fall risk but no additional safety measures were put in place during the day. The Administrator estimated that the approximate time from the home health nurse leaving to when facility staff found R1 was 5-10 minutes. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Staff are not properly supervising residents who may be a fall risk” Therefore, the allegation is deemed Substantiated at this time. Pursuant to Title 22 regulations and/or the Health and Safety Code the following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Mar 13, 2025 · control 29-AS-20241108152932

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.312(a) · Plan of correction due date: Mar 27, 2025

§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision... This requirement is not met as evidenced by: Based on interview and file review the licensee did not comply with the section cited above as R1 suffered a fall at the facility and no safety measures were in place to minimize the risk of falls during the timeframe R1 fell which poses a potential health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Mar 13, 2025

Plan of correction: Licensee will submit their plan on how they will minimize the danger for future fall risk clients, and a statement of understanding confirming that they understand the importance of providing appropriate accomidations and supervision to at risk clients. Licensee will submit POC no later than due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced case management – deficiencies visit at the facility at 09:56 AM. LPA met with facility staff who contacted the Administrator Myline Olivas the reason for the visit was explained and entrance interview was conducted. The Administrator arrived to the facility at 11:05 AM. During the physical plant tour at 10:02 AM LPA observed the back patio of the facility. LPA observed the back patio to contain multiple unsecured tools. LPA observed a hand saw, a crowbar, a circular saw, a box cutter, and other various tools. LPA informed the facility Administrator of the unsecured items. The Administrator stated that a contractor is working to update the kitchen of the facility. The Administrator spoke with the contractor and asked them to secure the tools. The contractor arrived to the facility shortly after and secured the tools at the time of the visit. Pursuant to Title 22 regulations and/or the Health and Safety Code the following deficiency was cited (refer to LIC 809D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.the state’s words, verbatim · CDSS document, Mar 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 13, 2025

87309 Storage Space and Access (a)... the licensee shall ensure that ... knives...tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended... This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above as multiple tools were left unattended on the facility's back patio which poses an immediate safety risk to clients in care.the state’s words, verbatim · CDSS document, Mar 13, 2025

Plan of correction: Licensee secured the tools at the time of the visit. POC cleared.

Allegation investigated: Staff did not provide resident with privacy Staff did not provide a comfortable environment for residents Staff left resident unattended for extended periods Staff did not treat resident with dignity and respect Staff did not ensure that the resident’s broken recliner was replaced with a new one

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. During today’s visit, LPA staff and explained the reason for the visit. Administrator Myline Olivas arrived shortly after. On 08/21/2024, the initial complaint visit was conducted by LPA between approximately 12:20 a.m. - 3:30 p.m. During the visit, LPA’s conducted physical plant, interviewed staff, residents, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. On 10/24/2024, LPA conducted a subsequent visit from approximately 10:30 a.m. – 3:00 p.m. and conducted physical plant, interviewed staff , families / responsible parties of residents in care and reviewed and obtained copies of additional pertinent documentation relevant to the investigation. Today LPA conducted interviews with staff as well as family / responsible parties. Unsubstantiated It was reported that "Staff did not provide resident with privacy" as it was alleged that Resident #1 (R1) was being changed in the open. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated that all resident are always given privacy when staff assist them with changing their clothes. These (3) residents also stated they have never observed any resident being changed while they were sitting on the couch watching television. In addition the (3) residents interviewed did not express any potential or immediate concerns for not being afforded privacy to change while in care. Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed that typically residents are changed in their room in the morning when they wake up and in the evening before they go to bed. If they need to change the resident they would bring them to their room. Each staff interviewed have never observed any staff change a resident in any of the common areas at this time. LPA's interview with five (5) responsible parties / families of residents in care revealed that four (4) out of the (5) parties stated they have never observed a resident changed in the common areas and each they did not express any potential or immediate concerns for residents not being afforded their privacy at this time. One (1) out of the (5) responsible parties / families interviewed stated they have heard of a resident being changed in the common area, but they did not observe it first hand. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not provide resident with privacy” is deemed Unsubstantiated at this time. It was reported that "Staff did not provide a comfortable environment for residents" as it was alleged that while residents were having lunch Resident #2 (R2) was allowed to use their bedside commode in the living room in close proximity to other residents in care. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated that they have never observed R2 use a commode in the living room. Two (2) residents stated that staff assist them to their room or to the restroom while one (1) resident stated they use the restroom in the hallway bathroom without full assistance from staff. Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed they have never observed any staff assist R2 with using the commode in the restroom. Staff also stated that residents are brought to their room or restroom when they need to use the toilet. LPA's interview with five (5) responsible parties / families of residents in care revealed that four (4) out of the (5) parties stated they have never observed any resident use a bedside commode in the common area. One (1) out of the (5) responsible parties / families interviewed stated they have heard of a resident using a bedside commode in the living room , but they did not observe it firsthand. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not provide a comfortable environment" for residents” is deemed Unsubstantiated at this time. It was reported that "Staff left resident unattended for extended periods" as it was alleged that R2 was left in bed for (4) hours on 08/11. Interviews conducted and records review revealed that three (3) out of the five (5) residents interviewed stated that they have never observed R2 left in bed for a prolonged period of time. These (3) residents also stated that R2 is frequently in the living room watching television with other residents. Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed they have never observed R2 left in the bed for a prolonged period of time, however if R2 wanted to lay in bed and not join the other residents in the common area they would let R2 do that as well. In addition, staff stated R2 LPA's interview with five (5) responsible parties / families of residents in care revealed that four (4) out of the (5) parties stated they have never observed any resident left in bed for a prolonged period of time. One (1) out of the (5) responsible parties / families interviewed stated they have heard of a resident being left in the bed for an extended period of time, but they did not observe it firsthand. During LPA's physical plants on 08/15/2021 and 08/21/2024, LPA observed R2 outside of bedroom watching television, eating lunch , having snacks and having conversations with staff. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff left resident unattended for extended periods” is deemed Unsubstantiated at this time. It was reported that "Staff did not treat resident with dignity and respect" as it was alleged that staff say insensitive and unprofessional comments out loud about residents in care. Interviews conducted revealed that three (3) out of the five (5) residents interviewed stated that they have never observed any staff say anything unprofessional or inappropriate about residents in care. These (3) residents also stated that they have no immediate or potential concerns for staff to say anything unprofessional or inappropriate about any residents. Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed they have never observed any staff say anything unprofessional or inappropriate about residents in care. .In addition, staff stated they always have conversations and joke around with residents , but no one ever says anything inappropriate towards other residents. LPA's interview with five (5) responsible parties / families of residents in care revealed that four (4) out of the (5) parties stated they have never observed any staff say anything unprofessional or inappropriate about residents in care. One (1) out of the (5) responsible parties / families interviewed stated they have heard of staff speaking unprofessional and inappropriate about residents in care, but they did not observe it firsthand. During LPA's physical plants on 08/15/2021 and 08/21/2024, LPA observed staff having pleasant conversations and joking around with residents in care. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not treat resident with dignity and respect” is deemed Unsubstantiated at this time. It was reported that "Staff did not ensure that the resident's broken recliner was replaced with a new one", as it was alleged Resident #3 (R3) had a broken recliner, which staff had to use additional objects to prop up feet. Interviews conducted with the Administrator revealed that R3 has never been in a recliner that was in disrepair. LPA observed recliner that R3 was using and it appeared to be in operable condition. Interviews conducted with five (5) residents revealed that three (3) out of the five (5) residents stated that they have never observed any recliner to not function properly or appear to be in disrepair. These (3) staff also stated that if they did observe anything broken that staff would either fix it or replace it right away. Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed that three (3) out of the (4) interviewed have never observed any broken piece of furniture. (1) staff stated that recently they had a broken shower head and it was replaced the next day. LPA's interview with five (5) responsible parties / families of residents in care revealed that all four (4) out of the (5) parties stated they have never observed any broken piece of furniture in use by residents in care. One (1) out of the (5) responsible parties / families interviewed stated when they initially arrived to the home they observed multiple pieces of furniture outside of the home on the sidewalk, but they have never observed any broken piece of furniture in use by residents in care inside of the home. During LPA's physical plants on 08/15/2021 and 08/21/2024, LPA did not observe any broken piece of furniture. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. (Continued on 9099-C) Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not ensure that the resident's broken recliner was replaced with a new one” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issued. It was reported that "Staff did not ensure that the Hoyer lift was properly charged while transferring the resident" as it was alleged that when staff used a Hoyer lift on R3 it was not fully charged and R3 was suspended in the air for 10 minutes. Interviews and records review revealed that on 08/14/2024, R3 was being prepared for a transfer using a hoyer lift with assistance from Staff #1 (S1) and Staff #2 (S2). A family member/responsible party was present in the room at the time. While attempting to lower the hoyer lift to transfer R3 into the bed, the lift became non-operational due to hoyer lift not being fully charged. S1 and S2 contacted Staff #(S3) for assistance and S3 advised S1 and S2 how to operate lift with no power. Staff then raised the bed, placed additional pillows for safety, and manually lowered R3 onto the bed. Staff stated that R3 was suspended in the hoyer lift for approx 5 minutes. On 08/21/2024, 10/24/2024 and 01/29/2025, LPA attempted to contact S1 but was unsuccessful. S1 is no longer employed at the facility. An interview with S2 indicated they did not recall experiencing any issues with operating the hoyer lift during the transfer of R3 on that date. An interview with R3 revealed they did not recall being suspended in the hoyer lift for any extended period. During physical plant inspections, the hoyer lift was found to be fully charged and plugged into an outlet in the living room. There are no residents in care that require the use of a hoyer lift at this time. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that "Staff did not ensure that the hoyer lift was properly charged while transferring the resident" has been deemed Substantiated at this time. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D).Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted, appeal rights discussed and a copy of report issuedthe state’s words, verbatim · CDSS document, Jan 29, 2025 · control 29-AS-20240816153518

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Feb 14, 2025

(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirment wa not met as evidence by: Based on interviews and records review the licensee did not comply with regulation cited as R3 was suspended in their hoyer lift for an extended period of time due to staff failing to demonstrate knowledge for use of hoyer lift, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 29, 2025

Plan of correction: Administrator agreed to review section cited and provide in-service training with staff regarding proper use of hoyer lift then submit proof of training and statement of understanding to LPA via email by COB 02/14/2025.

Allegation investigated: Staff leaves resident in soiled clothing for an extended amount of time. Staff does not provide adequate food portions to residents. Staff are forcing a resident to sleep early. Staff did not administer resident medication as prescribed. Staff did not meet resident's showering needs. Staff not providing residents with laundry service. Staff did not ensure that a resident's was provided their oxygen. Staff confines resident to room.

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. During today’s visit, LPA met with staff and explained the reason for the visit. Administrator Myline Olivas arrived shortly after. On 08/15/2024, the initial complaint visit was conducted by LPA between approximately 09:30 a.m. - 1:45 p.m. During the visit, LPA’s conducted physical plant, interviewed staff, residents, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. At approx. 10:40 a.m. LPA conducted physical plant, interviewed staff , interviewed families / responsible parties conducted medication audit and reviewed and obtained additional pertinent documentation relevant to the investigation. It was reported that "Staff leave residents in soiled clothing for an extended amount of time”, as it was alleged Resident #1 (R1) and other residents do not get their clothes changed in a timely manner. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated they have never observed any residents in soiled clothing and are always dressed in a timely manner. Unsubstantiated Continued from 9099 These (3) residents also did not express any immediate or potential concerns for any residents being left in soiled clothing for an extended amount of time. Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed that residents are changed every morning. If they observe any piece of clothing to be soiled, they change it right away. Each staff interviewed have never observed any resident left in soiled clothing for an extended amount of time. LPA's interview with five (5) responsible parties / families of residents in care revealed they did not express any potential or immediate concerns for residents being left in soiled clothing for an extended amount of time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff leaves resident in soiled clothing for an extended amount of time” is deemed Unsubstantiated at this time. It was reported that "Staff does not provide adequate food portions to residents" as it was alleged that residents were provided small portions of food, and they were not able to get seconds. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated most of the time there is too much food served. These (3) residents also did not express any immediate or potential concerns for asking for a second serving of food or the food portions. Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed they have never observed any staff deny a resident a second serving of food or get served an inadequate portion of food. LPA's interview with five (5) responsible parties / families of residents in care revealed they did not express any potential or immediate concerns for the portion of food served to the residents or residents being denied a second serving of food. During physical plants, LPA observed food served to be sufficient in portions as well as observed at least (2) residents who did not finish their food due to the amount of food served. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff does not provide adequate food portions to residents” is deemed Unsubstantiated at this time. Continued from 9099-C It was reported that "Staff are forcing a resident to sleep early", as it was alleged that staff would force residents to sleep at 6pm. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated that they have never been forced to sleep at a certain time and each have never observed staff force other residents to sleep at a specific time. Additionally, residents interviewed were asked about their daily routine and they mentioned that residents start early every day as they all wake up early. According to residents, breakfast is usually ready before 7:00am, lunch is around 11:00am, and dinner is before 5:00pm. Also, there is no set bedtime for residents. Interviews with residents also revealed, that some residents have dinner then want to settle down in their room. LPA's interview with five (5) responsible parties / families of residents in care revealed they did not express any potential or immediate concerns for the time the residents go to sleep. In addition, they stated if the residents do not complain about their bedtime, they have no problem with it either. Interviews with facility staff revealed residents wake up early in the morning every day. When asked about resident’s daily routine, staff said residents are usually awake while they do their morning routine checks at approx. 06:30 a.m. During the morning routine check, staff take residents out to the living room to have breakfast and start their day. When asked about bedtimes, staff interviews revealed, there is no bedtime, residents ask to go to their rooms shortly after having dinner stating they are tired and would like to go to relax. Furthermore, interview with the Administrator revealed, staff accommodate residents by taking them to their rooms early in the day per resident’s request. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff are forcing a resident to sleep early” is deemed Unsubstantiated at this time. It was reported that "Staff did not administer resident medications as prescribed" as it was alleged that staff are not providing residents with the evening medications. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated they do not recall ever missing a dosage of medication. These (3) residents also did not express any immediate or potential concerns for missing a dosage of medications.Two (2) out of the (5) residents were not able to communicate effectively. LPA's medication review conducted on 10/24/2024 revealed all medications were administered as prescribed at this time. Evening Medications for Resident #2 (R2), Resident #4 (R4) and Resident #5 (R5) were typically administered between 7:00 p.m. - 8:00 p.m. Continued from 9099-C LPA's interview with four (4) staff revealed that residents typically receive their evening medication shortly after dinner between approximately 7:00 p.m - 8:00 p.m.. Each staff interviewed also stated they have never observed any resident miss a dosage of medication in the evening. LPA's interview with five (5) responsible parties / families of residents in care revealed they did not express any potential or immediate concerns for any resident missing a dosage of medication. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not administer resident medications as prescribed” is deemed Unsubstantiated at this time. It was reported that "Staff did not meet resident's showering needs" as it was alleged that staff did not shower residents in a timely manner. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated that residents shower every day. These (3) residents also did not express any immediate or potential concerns for not being showered in a timely manner. Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed that residents are typically showered every morning. If they refuse, they attempt to ask them to shower at least (3) more times. Each staff interviewed also stated they have never observed any resident not showered in a timely manner. LPA's interview with five (5) responsible parties / families of residents in care revealed they did not express any potential or immediate concerns for residents not being showered in a timely manner. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not meet resident's showering needs” is deemed Unsubstantiated at this time. It was reported that "Staff not providing residents with laundry service", as it was alleged that staff are not doing resident's laundry in a timely manner. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated that laundry is completed every day. Staff gather dirty clothes in the morning and the cleaned clothes return to their room folded by the late afternoon. These (3) residents also did not express any immediate or potential concerns for laundry not being completed in a timely manner. Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed that resident’s laundry is completed every day. Continued from 9099-C Staff gather the dirty clothes in the morning. The laundry is usually completed by the afternoon where it is folded and returned to the resident. Each staff interviewed also stated they have never observed any resident’s laundry not being completed in a timely manner. During visit on 08/21 at approx. 01:55 p.m. LPA observed staff remove various garments of clothing then proceeded to fold clothing to return back to resident’s room. LPA's interview with five (5) responsible parties / families of residents in care revealed they did not express any potential or immediate concerns for residents’ laundry not being completed in a timely manner. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff not providing residents with laundry service” is deemed Unsubstantiated at this time. It was reported that "Staff did not ensure that a resident was provided their oxygen" as it was alleged that R2 was not promptly provided their oxygen. Interviews conducted and records review revealed that upon admission on 05/03/2024, R2 did not have an order for oxygen. On 05/04/2024, R2 was assessed by Home Health services which prescribed Oxygen at 2 L/min via nasal cannula continuously to start on 07/03/2024 Records review revealed R2 has been administered oxygen since start date. LPA's interview with R2 revealed they do not recall ever being without their oxygen at this time. LPA's interview with four (4) staff revealed that R2 is administered their oxygen as prescribed. Each staff interviewed also stated they had no concerns for R2 being without their oxygen at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not ensure that a resident was provided their oxygen” is deemed Unsubstantiated at this time. It was reported that "Staff confines resident to room", as it was alleged that Resident #3 (R3) is not allowed outside of their room. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed are free to walk around the home and have never observed any resident not allowed to exit their room. These (3) residents also did not express any immediate or potential concerns for staff confining any resident to their room. Continued from 9099-C Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed that residents are free to walk around the home unless they don't feel like leaving their room. LPA's interview with three (3) responsible parties / families of residents in care revealed they did not express any potential or immediate concerns for any resident being confined to their room. During physical plants on 08/15 and 08/21, LPA observed R3 out of their room and interacting with staff and residents. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff confines resident to room” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issuedthe state’s words, verbatim · CDSS document, Oct 24, 2024 · control 29-AS-20240808150455

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. Upon arrival, there were three (3) staff and four (4) residents present. LPA was greeted by facility staff who contacted the Administrator via telephone. The Administrator, Myline Olivas arrived at 9:57am. Entrance interview conducted. At 9:58am, the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA inspected the kitchen/food service area at 10:01am. Knives and sharps were observed in a locked drawer inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food; properly stored. Refrigerator and food pantry were checked for proper labels and expiration dates. At 10:08am, the hot was temperature was checked in the kitchen sink and it measured 107.6 degrees Fahrenheit. COMMON AREAS: This includes the living room and dining room area. The common areas were furnished appropriately and appeared to be in good condition at the time of the visit. The facility maintained a comfortable temperature. LPA observed required postings throughout the common space. Activities for resident use were observed by the hallway. LPA observed auditory alarms at the time of the visit. There is a working telephone on premises. LPA observed fireplace adequately covered during the inspection. Report Continued on LIC 809C... Report Continued from LIC 809... Fire extinguisher was observed fully charged with a date of 8/09/2024. At 10:19am, the smoke detectors and carbon monoxide detector were tested and operational at the time of the visit. Emergency disaster drills conducted quarterly as per regulation; the last drill was conducted on 08/1/2024. RESTROOMS: The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first bathroom measured at 107.6 degrees Fahrenheit at 10:10am; and the second bathroom measured at 106.8 degrees Fahrenheit at 10:14am. BEDROOMS: There are four (4) bedrooms for resident use; two (2) bedrooms are designated as single occupancy; and two (2) bedrooms are designated as double occupancy. All resident rooms were observed to be furnished appropriately and had sufficient lighting. Additional clean linens, towels, and washcloths were observed in the hallway closet. Staff bedroom observed on premises. GARAGE: The garage is maintained inaccessible to residents in care. LPA observed an additional refrigerator and freezer with food in good condition. There is a washer and dryer inside the garage. Cleaning supplies, detergents, and toxins were observed in a locked cabinet inaccessible to residents in care. Facility has an adequate amount of emergency food and water. LPA observed a sufficient supply of Personal Protection Equipment (PPE). BACKYARD: The backyard has a covered patio area with adequate furniture for resident use. The exterior passageways were clean and clear of any obstructions at the time of the visit. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit. Report Continued on LIC 809C... Report Continued from LIC 809C... RECORDS: LPA reviewed Resident Records at 10:26am and Personnel Records at 11:22am. Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were complete. Three (3) personnel files and the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid / CPR training, and the appropriate training. Although the facility has a designated training binder, the LPA was unable to determine the number of hours completed per regulation for the past 12 months. MEDICATIONS: Medications review began at approximately 12:45pm. Medications are stored in a locked cabinet adjacent to the kitchen inaccessible to residents in care. At 1:15pm, Resident #1’s (R1’s) centrally stored medication and destruction record (CSMDR) does not have PRN medication for Lorazepam 1mg tablet qty-30, date filled 08/12/2024, documented and has been started, as there are fifteen (15) tablets that have been administered. At 1:31pm, Resident #2's (R2's) CSMDR did not have medication Flecainide Acet tabs 50mg, date filled 07/26/2024 documented. Additionally, a separate bottle of Flecainide 50mg, date filled 08/28/2024 was documented on the CSMDR with a start date of 09/07/2024 was counted and had 49 pill remaining; however, there was no refusals documented which would indicate there would be 24 pills remaining. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 26, 2024