Assured Care Villa

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Theresa Dompreh-Mensah and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 12:30PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 4-bedroom, 2-bathroom, one-story house with an attached garage that is used as an office. There is a back yard with a patio cover for the residents. LPA and AD observed 2 staff and 5 residents present at the facility. Resident Bedrooms: the 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 117 degrees F in the 2 resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and laundry room. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 10:00AM, LPA reviewed 5 resident files and 3 staff files, interviewed 2 residents and 2 staff, and inspected medications for 5 residents. Facility does not handle resident money. During the inspection, LPA and AD observed the following: based on documents, S2's file did not contain documentation of 20 hours of continuing annual education; based on documents, S2's file did not contain documentation of 8 hours of continuing in-service training on medications; based on documents, the physician's reports for R1, R2, and R3 are on the old form and do not include required information such as behavioral expressions; and based on documents, the physician's reports for R1, R2, and R3 are from 2024 and their files do not contain documentation of annual routine visits. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Mar 4, 2026

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff caused injury to resident while in care. Staff forced resident to take a shower. Staff prohibited a resident from placing a call to a family member.

On July 29, 2025, Licensing Program Analyst (LPA) Jessica Cho made an unannounced subsequent visit for the purpose of delivering the investigation findings into the above allegations. LPA was greeted and granted entry by Caregiver Loreta Angeles and informed Administrator Theresa Dompreh-Mensah by telephone explaining the reason for the visit. On February 25, 2025, the Department received a complaint alleging a violation of personal rights and physical abuse of Resident #1 (R1). The investigation was initiated by the Department on February 26, 2025, followed by a subsequent visit on July 1, 2025. During the course of the investigation, the Department interviewed six residents, five staff, and obtained the following documentation: Resident Rosters, Personnel Reports, Shower Schedule, Staff Tasks, Face Sheets, Physician’s Reports for all residents as well the Incident Report (LIC624) dated February 25, 2025 regarding R1, Admission Agreement dated November 22, 2022, Needs and Services Plan dated January 10, 2025, Care Notes from January 22, 2025 to February 23, 2025 for R1..., Unsubstantiated discharge summary dated February 23, 2024, and the police report. Regarding the allegation, Staff caused injury to resident while in care, it was reported that on February 23, 2025, a staff handled R1 in a rough manner by forcefully grabbing R1 by their left arm forcing resident to shower resulting in a fractured left pinky finger. The investigation is as follows: R1 is diagnosed with Cerebral Palsy per the Physician’s Report dated March 14, 2024 and is limited in their communication. LPA attempted to interview R1 however, LPA was unable to qualify due to their medical condition. In R1’s statement to the police, R1 was questioned if they could demonstrate how the injury was sustained, however R1 was only able to illustrate by gesture by manipulating the bed rail. R1 was unable to provide any clear response. Based on the interviews, two out of the six residents who resided at the facility with R1, indicated not witnessing or having knowledge of other residents being harmed. The remaining two residents were not registered to the facility at the time when the incident occurred while one resident interview was attempted but unable to qualify due to their medical condition. Two out of the five staff who were present on the morning of Sunday, February 23, 2025, indicated R1 was agitated when R1 was asked to shower by Staff #1 (S1). Staff #2 (S2) indicated rushing to R1’s room after hearing a loud bang and observed R1 lying down in bed holding the bed rails on each side shaking vigorously causing the bed to hit against the wall. S2 observed (S1) standing by the corner of the bed away from R1 verbally calming R1 who was flailing their body and kicking the air at the time. S1 and S2 indicated that the movement of the bed had caused R1 to injure their hand in between the wall and bed rail. R1’s representative did not provide clear evidence of how the injury was caused by staff and later confirmed that R1 suffered a finger sprain in lieu of a fracture to the left pinky and was placed with a splint. R1's representative stated that per the urgent care doctor, the finger appeared as if it had been smashed or banged against something or bracing self during a fall. The Kaiser medical discharge summary dated February 23, 2024, corroborated the finger sprain. Regarding the allegation, Staff forced resident to take a shower, the investigation revealed: Based on the review of R1’s physician’s report, R1 requires assistance with showering as R1 is unable to bathe self. On the admission agreement dated November 22, 2022, bathing is included under Basic Services. The shower schedule posted on the kitchen bulletin board documented R1 receiving a shower every Tuesday evening. However, the facility provides showers every day as requested by R1’s representative as confirmed by five out of the five staff. Five out of five staff and four out of six residents indicated showers were not forced. Interviews with the remaining two residents were attempted, however unable to qualify due to their medical conditions. Five out of the five staff indicated that residents, including R1, have the right to refuse showers and are never forced. In the Needs and Services Plan, R1 is noted to display frequent explosive episodes of behavioral outbursts which may become aggressive at times and protests by crying to avoid non-preferable tasks. Five out of the five staff confirmed R1 disliking showers and encourages R1 to shower and educates the importance of personal hygiene. Regarding Staff prohibited resident from placing a call to a family member, it was reported that R1 was restricted from using their personal cell phone. The investigation revealed the following: There is no written rule regarding placing personal phone calls in the evenings, however there is an implied rule per five out of five staff. Based on the interviews, five out of five staff and three out of five residents confirmed residents were able to use the phone during the day with some limitations in the evening out of consideration for other residents who may be sleeping. The three residents indicated that they chose not to use the phone in the evenings and preferred to sleep. Interviews with the remaining two residents were attempted, however unable to qualify due to their medical conditions. Regarding R1’s phone use, five out of five staff indicated that R1 was able to use their phone during the day without having any limitations, however, was refrained most of the time from using their cell phone after 9pm. Based on the interview with R1’s representative, facility was instructed not to allow R1 to place calls to them after 9pm. Based on observations, interviews, and record review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore all allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Theresa Dompreh-Mensah by telephone and consented facility staff to sign the report on their behalf. A copy of this report including the LIC811 were left with Caregiver Loreta Angeles.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 22-AS-20250225150251

Allegation investigated: Wrongful eviction

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegations listed above. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit. Administrator Theresa Dompreh-Mensa was present on the premises. The initial complaint investigation visit took place on December 5, 2024. LPA accompanied by administrator conducted a tour of the facility's physical plant. There were 5 residents admitted to the facility at the time. LPA requested and reviewed resident records for all five current residents in addition to a resident discharged from the facility in July 2024. Admission agreement and house rules were additionally reviewed along with the visitor's log for the months of October and November 2024. Additional witness interviews were conducted over the course of the investigation. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM FORM LIC9099-A During the present visit, LPA conducted additional staff and resident interviews and requested additional records. Regarding the allegation that Facility staff mismanaged resident's medication, the following has been concluded: Based on interviews conducted and records reviewed, resident R1 was prescribed with a Lorazepam prescription, as needed up to twice a day, by R1's primary care physician. Doses administered were adequately reviewed by staff members and do not appear to evidence any discrepancies between the quantities prescribed and the doses delivered by facility staff. Medication Administration Records reviewed did not evidence any discrepancies either. Regarding the allegation that Facility staff did not allow visitors during visiting hours, the following has been concluded: Based on interviews as well as a review of the facility's visitor logs for the period of April to July 2024 along with October and November 2024, it was evidenced that all residents, including R1 were able to receive visitors on multiple occasions. Visiting hours, house rules and admission agreements provided confirmed the agreed upon visiting hours. Multiple visitors were additionally witnessed during both inspections. As a result of the investigation, both allegations are found to be Unfounded, meaning the allegations are false, could not have happened and/or are without a reasonable basis. An exit interview was conducted with facility staff and a copy of this report was provided at the conclusion of the visit. CONTINUED FROM LIC9099 During the present visit, LPA conducted additional staff and resident interviews and requested additional records. Regarding the allegation of Wrongful Eviction, the following has been concluded: Based on interviews conducted and records reviewed, resident R1 was admitted at the facility from Park Regency skilled nursing on May 20, 2024. R1 had a primary diagnosis of a wrist fracture, with additional indications of major depressive disorder and bipolar disorder. Following a reported incident of aggressive behavior towards staff members occurring on June 29, 2024, facility staff called the paramedics and R1 was transferred to St. Jude Hospital and admitted for psychiatric evaluation before eventually being discharged back to a different board-and-care. During the hospitalization, it was stated that hospital staff reached out to facility staff who declined to readmit the resident based on safety concerns. R1's care coordinated agency and responsible party relocated the resident at this time as home care was not an option. R1's responsible party were informed of the safety concerns and licensing staff was stated to have been informed of the situation by the facility's administrator, however no formal 30-day notices or updated reappraisals were conducted by facility staff. As a result, the allegation is found to be Substantiated, meaning that the he Department obtained sufficient evidence to corroborate the allegation mentioned above. The preponderance of evidence standard has been met. An Advisory Note for Technical Violation is issued on an attached for LIC9102. An exit interview was conducted with facility staff and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 10, 2025 · control 22-AS-20241126160403

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Theresa Dompreh-Mensah and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 8:25AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 4-bedroom, 2-bathroom, one-story house with a detached garage that is being used as an office. There is a back yard with a patio cover for the residents. LPA and AD observed 2 staff and 5 residents present at the facility. Resident Bedrooms: the 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 112 degrees F the two resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and laundry room. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 9:30AM, LPA reviewed 5 resident files and 4 staff files, interviewed 2 residents and 2 staff, and inspected medications for 5 residents. Facility does not handle resident money. There were no deficiencies observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jan 6, 2025

Allegation investigated: Staff are not adequately trained. Facility is unsanitary

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator/ Licensee Theresa Dompreh-Mensah arrived during the visit. During the course of the investigation, LPA toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as training records. Regarding the allegations that staff are not adequately trained and facility is unsanitary, the investigation revealed the following: LPA toured the facility during the visit and observed the facility is clean, safe and sanitary. No hazards were observed during the visit. LPA reviewed training records and four out of four staff have required annual training as well as medication training. Based on observations and record review, the allegations are deemed UNFOUNDED, meaning the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to Administrator. Unfoundedthe state’s words, verbatim · CDSS document, May 29, 2024 · control 22-AS-20240521145649

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: May 30, 2024

Basic services shall at a minimum include: Personal assistance and care as needed by the resident... with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications.. This req is not being met as evidenced by: Based on record review, Licensee failed to ensure resident were assisted with administration of prescribed medications. R1 and R2 missed medication administration for 3 days. This poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 29, 2024

Plan of correction: Licensee to get discontinue orders for medications and forward proof to LPA by POC due date.

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Theresa Dompreh-Mensah and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 9:45AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 4-bedroom, 2-bathroom, one-story house with detached garage that is being used as an office. There is a back yard with a patio cover for the residents. LPA and AD observed 2 staff and 4 residents present at the facility. Resident Bedrooms: the 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 111 degrees F in the common resident bathroom and 113.9 degrees in the private resident bathroom. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and laundry room. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 10:15AM, LPA reviewed 4 resident files and 3 staff files, interviewed 4 residents and 2 staff, inspected medications for 4 residents. Facility does not handle resident money. During the inspection, LPA and AD observed the following: the licensee did not ensure 1 out of 4 residents, Resident #1 (R1), received 1 dose of Cyphroheptadine 4MG at bedtime on April 1, 2024, Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Apr 2, 2024

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

Allegation investigated: Staff did not ensure that resident's mental health needs were met.

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced and met with Administrator (Admin) Theresa Dompreh-Mensah for the purpose of continuing the investigation and delivering the findings into the above allegation. LPA explained the reason for the visit and reviewed the allegation with Admin Dompreh-Mensah. On October 10, 2023, LPA initiated the complaint investigation which involved interviews with residents and staff and obtaining pertinent resident records. On today's date, LPA continued the investigation and conducted additional interviews with resident/staff and obtained a missing record that was not provided during the initial visit. The following was determined based on the evidence obtained: It is alleged that the staff did not ensure that the resident’s mental health needs were met. It was noted on the Special Incident Reports (SIRs) and Progress Notes that Resident #1 (R1) expressed homicidal ideations towards Resident #2 (R2) on two occasions: September 12th and September 29th, 2023. Unfounded R1 made an admission during the interview that Staff #1 (S1) did not interfere with the Crisis Assessment Team’s (CAT) ability to conduct an evaluation due to R1’s homicidal ideations. S1 did not corroborate with the allegation. Two out of the two witnesses who were present during the evening of the second incident, September 29, 2023, indicated that the CAT was allowed entry into the facility and was not intervened by S1. Therefore, this agency has investigated the complaint and based on the interviews which were conducted and the records that were reviewed, the following allegation: Staff did not ensure that the resident’s mental health needs were met is deemed UNFOUNDED. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Administrator Theresa Dompreh-Mensah, and a copy of this report including the LIC811s were provided at the end of the visit. Based on the interviews obtained from R1 and Staff #1 (S1), there were conflicting details, therefore LPA is unable to corroborate the allegation. Based on the interviews which were conducted and the records that were reviewed, although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation: Staff threatened resident is deemed UNSUBSTANTIATED. An exit interview was conducted with Administrator Theresa Dompreh-Mensah, and a copy of this report including the LIC811s were provided at the end of the visit.the state’s words, verbatim · CDSS document, Nov 8, 2023 · control 22-AS-20231006142559

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced Plan of Correction (POC) visit to follow up on citation issued on 09/14/2023. LPA was greeted and granted entry into the facility and explained the reason for the visit. *Deficiency cited under Title 22 Regulation 87355(e)(1) pertaining to Criminal Record Clearance has been cleared. Facility provided proof of correction and staff in question has been disassociated from the facility. Licensee has complied with the POC. Licensee has been advised to maintain compliance in any items previously cited. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 2, 2023