Astoria Park Senior Living

Allegation investigated: Staff mismanaged resident's medications

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint investigation to investigate the allegations listed above. LPA met with Executive Director Maria Quizon and explained the reason for the visit. The investigation consisted of the following: On 6/19/26 LPA conducted initial visit and obtained copies of staff/resident rosters, copies of Resident #1’s (R1) Medication Record and shower log, copy of R2’s shower log, conducted interview with 1 Staff (S1), 10 Residents (R2-R11) and 1 Witness (W1). During todays visit LPA interviewed 5 staff (S1-S5), reviewed documents gathered during initial visit with Executive Director and Conducted Medication Review. Continued on LIC9099-C Substantiated The investigation revealed the following: Allegation: Staff mismanaged resident's medications It is alleged that staff are not administering R1’s medication as prescribed. LPA conducted medication review and observed 6 PRN medication errors for R11-R16 (the PRN medication is on order but not present at the facility) and 1 routine medication error for R17 (the medication is not at the facility and has missed the medication for today 7/24/26). LPA interviewed 5 staff and staff stated that they try to make sure that residents are administered their medication as prescribed, S1,S4 and S5 stated that there have been errors in the past but they are developing a new system to try and avoid these errors. LPA interviewed 10 Residents and 8 out of 10 Residents denied the allegation and stated they received their medication on time and haven’t had any issues with medication. Immediate $250 Civil Penalty is being assessed to day for a repeated violation as the same medication error citation was issued on 7/2/26. Based on LPAs observations, interviews and medication record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. Exit interview held, and a copy of this report, appeal rights and civil penalties were provided. The investigation revealed the following: Allegation: Resident sustained pressure injury while in care due to staff neglect It is alleged that R1 has a pressure injury to their left foot heel due to improper care at the facility. LPA reviewed R1’s file and found that R1 was observed to have redness to their right foot on 5/6/26 and on 5/21/26 R1’s physician prescribed heal protectors with instructions for staff to notify physician if the pressure ulcer opens, the pressure ulcer was not staged in the documents provided by physician. Per staff there were no indications of there pressure ulcer getting worse but they were documenting their observations and monitoring it. LPA interviewed 10 Residents and each denied sustaining any pressure injuries and stated they don’t feel staff would neglect a situation like this. Allegation: Staff did not provide resident medical attention in a timely manner It is alleged that R1’s sugar level is high due to the lack of care at the facility. LPA interviewed 5 Staff and each denied the allegation and stated that residents in assisted living that require sugar monitoring are only assisted with the process and must be able to self administer the needle to get their sugar reading or have Nurse come do it for them. S1 and S5 explained that R1’s son would take responsibility for this as R1 has a device on their arm that will alert R1’s son on an app when sugar levels drop or rise and R1’s son is to notify the facility when this occurs. LPA interviewed R1’s son and they confirmed that they help with the device and monitor it on their phone. LPA interviewed 10 Residents and 9 out of 10 residents denied the allegation, with residents stating they get medical attention in a timely manner, R2 and R8 stated they have experienced injuries where they have to call for help, staff arrived immediately and sent them to the hospital right away. Allegation: Staff did not assist resident with bathing needs It is alleged that R1’s clothing smells and is believed that this is because R1 is not receiving their 2x weekly bath/shower. LPA obtained copies of shower log during initial visit on 6/19/26, there were missing log’s for 5/22/26-6/1/26 and during todays subsequent visit Executive Director could not show proof of the logs. LPA interviewed 5 Staff and each denied the allegation stating that R1 was refusing showers. Interviews with S1 and S5 revealed that R1 had been refusing showers, LPA revisited shower logs provided and observed that on 5/21/26, 6/2/26, 6/9/26, 6/11/26 R1 had refused showers which was documented in the logs. LPA interviewed 10 Residents and 8 out of 10 residents denied the allegation and stated they are assisted as needed with showers. Based on statements and interviews conducted with staff, review of staff files & facility file records, there was not enough supportive evidence to concur with the reported 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 allegation is UNSUBSTANTIATED. Exit interview held, a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 28-AS-20260618110714

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 25, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. (4)The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: During medication review and observed 6 PRN medication errors for R11-R16 (the PRN medication is on order but not present at the facility) and 1 routine medication error for R17 (the medication is not at the facility and has missed the medication for today 7/24/26), which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2026

Plan of correction: Administrator/Licensee to ensure all PRN medication that was missing during todays visit is placed on order and show proof by photo that the routine medication for R17 is at the facility by POC due date and email proof to LPA. tena.herrera@dss.ca.gov

Allegation investigated: Staff is not qualified to perform duties as a Wellness Director

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint investigation to investigate the allegations listed above. LPA met with Executive Director Maria Quizon and explained the reason for the visit. The investigation consisted of the following: On 7/9/26 LPA Chan conducted the initial visit and obtained copies of the staff roster, resident roster, the job description for the Wellness Director and reviewed the file of the current Wellness Director. During todays visit LPA Herrera reviewed Staff 4 and Staff 2’s files (S4 &S2), obtained copy of Wellness Coordinator Job Description and conducted interviews with 4 Staff (S1-S4). Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff is not qualified to perform duties as a Wellness Director It is alleged that the current Wellness Director does not meet the qualifications/requirements of the jobs description. LPA reviewed the Wellness Director Job Description and reviewed the previous Wellness Director’s file (S5) and S5 had all the qualifications, requirements and training's within their file. S5 left the facility for another job on 6/26/26 and per Interview with the Executive Director they have not yet filled the position but they have promoted a staff for the Wellness Coordinator position which is a step higher than Medication Technician (Med-Tech) and acts as an assistant to the Wellness Director. Executive Director also stated that they have assistance with their Corporate Office where the Nurses/LVN’s assist the facility daily until a proper fit for the Wellness Director position is found. LPA reviewed S2’s file and all qualifications and requirements listed on the job description were observed in file. LPA interviewed a total of 4 staff and each denied there currently being a Wellness Director and stated that the previous Wellness Director stopped working at the facility in June 26, since then there have been Nurse’s/LVN’s helping along with the Memory Care Director assisting when needed. Based on statements and interviews conducted with staff, review of staff files and facility file records, there was not enough supportive evidence to concur with the reported 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 allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 28-AS-20260706143444

Allegation investigated: The facility has insufficient staffing. The facility mismanages residents' medication while in care.

Licensing Program Analyst (LPA) Tao conducted an unannounced 10-day complaint visit to this facility. Upon arriving at the facility, LPA met with Maria Teresita Capito Quizon, administrator. LPA explained the purpose of today’s visit and discussed the allegations mentioned above to administrator Maria Quizon. The investigation consisted of resident interviews, staff interviews, physical plant tour and facility records reviews. LPA obtained resident roster, staff roster, staff work schedule, clock in and out time log for June 2026, and resident’s medication records. The investigation revealed the following: In regard of the allegation that the facility has insufficient staffing, it is alleged that facility does not have enough med tech, especially during the night shift. Per resident interviews, three (3) out of ten (10) residents could not corroborate with the allegation. (-continued on LIC 9099C-) Substantiated Seven (7) out of ten (10) residents indicated there were not enough staff when they need medication assistance during the nighttime (NOC shift). Per staff interviews, one (1) out of five (5) staff indicated staff was not aware of short of staff. Four (4) out of five (5) staff interviewed were corroborated with the allegation. It revealed that staff were aware that only one (1) night shift med tech to assist residents from both memory care and assisted living units in some days. Per record review, the time log showed there was only one med tech to assist both memory care and assisting living units in some days during evening or night shift. Therefore, facility staff do not have sufficient number of care staff. In regard of the allegation that the facility mismanages residents' medication while in care, it is alleged that facility staff did not provide medication assistance and administer medication properly to residents. Per resident interviews, three (3) out of ten (10) residents could not corroborate with the allegation. Seven (7) out of ten (10) residents indicated they did not get their medication as prescribed. Per staff interviews, one (1) out of five (5) staff indicated staff was not aware of short of staff. Four (4) out of five (5) staff interviewed were corroborated with the allegation. It revealed that staff were aware that some residents’ medication was not administered as prescribed due to staffing issues. Per record and medication review, LPA found multiple residents’ medication mismanagement. Licensee did not have an explanation about medication and record discrepancy. Therefore, facility mismanaged residents’ medication. Based on record review, medication reviews and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Administrator. Copies of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 28-AS-20260629081405

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 3, 2026

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: R1 BM Atorvastatin - did not administer one doze in July; R2 AP- Acetaminophen 325 mg, 500 mg and Mucus Relief 600 mg were missing the med cart; R3 KP- Nubequa 300 mg - did not administer for mulitple days; R4 CR -Dimethyl Fumarat 240mg, Eliquis 2.5 mg and Famotidine 20 mg did not administer to resident for muliple days; R11 PB- Amlodipine Besylate 5mg- short 1 pill and Bisacodyl - missing 1 pill. Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to personsin care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Licensee agreed to (1) review all residents' medication and medication log to ensure residents' medications are current. (2) provide additional medication administration / in service training to all staff and provide proof to the department; (3) review Title 22, Section 87465 and provide a signed statement indicating the review of this section detailing how to prevent future medication errors by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jul 9, 2026

Basic services shall at a minimum include:...Personal assistance and care as needed by the resident ... and assistance with taking prescribed medications. This requirement is not met as evidenced by: Per staff and residents’ interviews, there were not sufficent staff to provide medication assistance to residents to meet residents' needs. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2026

Plan of correction: Licensee agreed to esure enough Med Tech and staff to provide proper medication assistance to residents. Licensee will provide proof of hiring additional med tech to provide assistance to residents. POC by due date.

Allegation investigated: Staff did not administer medication as prescribed.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation on the allegation listed above. LPA met with Executive Director, Maria Quizon, and informed the purpose of the visit. The investigation consisted of the following: LPA obtained copies of the staff and resident rosters, reviewed medication for ten (10) residents, and interviewed six (6) staff and ten (10) residents. The investigation revealed the following: Allegation - Staff did not administer medication as prescribed. It is alleged that staff did not administer the donepezil medication for Resident #1 (R1) on 6/16/26, and that the medication Olanzapine changed from 15mg to 10mg was not administered because staff was not aware of the change. Substantiated LPA conducted a review of the medication for ten (10) residents during the visit today. LPA observed discrepancies for six (6) out of ten (10) medications and their Medication Administration Record (MAR) logs. LPA found that several of the medications were missing from the cart and/or were pending refills from the pharmacy. Other discrepancies included a medication for one resident was already administered for tomorrow, 6/24/26, and staff indicated the open date of 6/1/26. Additionally, the staff initial was not indicated for R1’s morning medications on 6/20/26. Interviews with staff revealed that there are times when medications were not fulfilled timely due to pending physician authorization or that the pharmacy did not receive the on-cycle medications timely. LPA also interviewed ten (10) residents. Four (4) out of the ten (10) had issues with medications not administered due to staff not receiving the medication from the pharmacy. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC9099D. An exit interview was conducted. The Plan of Correction was reviewed and developed with the Executive Director. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 23, 2026 · control 28-AS-20260617114724

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 24, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. (4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication review, there were discrepancies found in six out of ten residents' medications which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 23, 2026

Plan of correction: Licensee shall conduct an inservice on medication training and submit a plan to ensure medications are administered as prescribed. This plan is due on 6/24/26.

Allegation investigated: Staff is mismanaging residents' medications. Facility did not adhere to company policy.

LPA Cota, conducted an unannounced subsequent visit to deliver findings regarding the above-mentioned allegations. LPA met with Maria Quiroz, Executive Director, and the reason for the visit was explained. The investigation revealed the following: During initial investigation visit conducted on 3/26/2026, LPA obtained copies of staff and resident rosters, toured the facility, conducted interviews with Staff 1 (S1), interviewed (10) residents and reviewed medication randomly. During today’s visit, LPA obtained copies of staff and resident rosters, toured the common areas of the facility and conducted interviews with (6) staff. During the course of the investigation, LPA reviewed LPA reviewed email blast message dated 3/19/2026 and attempted to conduct interviews with Staff 2 – Staff 3 (S1-S3). Substantiated The investigation revealed the following: Regarding: Staff is mismanaging residents' medications. It is alleged that staff documented in the system that bedtime medication was given to resident; however, resident was not at the facility to receive their bedtime medication due to being on an outing. It is also alleged that resident’s bubble packs were observed with the bedtime medication popped and that staff did not know where the medication went or if it was thrown away. Interview with S1 revealed that S1 received a report from S3 that R1 did not receive their bedtime medication after returning from a trip outside of the facility on 3/24/2026. S3 who came on shift after S2 ended their day, informed S1 that when R1 and their responsible party returned from an outing on 3/24/2026 at about 11:30 p.m., they approached the med-tech room to have staff provide R1 with their bedtime medication. S3 indicated that the bedtime medication appeared to have been already popped and given to R1 by S2 when cross check was conducted on the Medication Administration Record (MAR) by S3. S1 indicated that S3 informed S1 that when checking the MAR, it was noted that R1 had already been given their medication by S2, even though R1 was not at the facility during the bedtime medication pass was conducted. S1 indicated that they spoke to S2 on 3/25/2026 and was informed that S2 acknowledged “popping” R1’s bedtime medication and documenting on MAR ahead of time thinking that R1 was at the facility. S2 informed S1 that R1’s medication was placed in a medication cup but was unable to recall where the medication went. S1 stated that removing medication from bubble packs ahead of time is not appropriate practice for medication management and conducted on the spot training with S2 during audit of R1’s medication. LPA attempted to interview S2 and S3; however, they did not return LPA's calls. LPA conducted random review of medication and found, R2 has discontinued Rx-Furosemide 40 mg no longer administered but still listed on MAR. Based on interviews, observations and record reviews the allegation that staff mismanaged resident’s medication is corroborated. ***Continues on LIC 9099-C page 2*** Regarding: Facility did not adhere to company policy. It is alleged that the facility does not keep the facility doors locked in the evening and there is no supervision and anyone is able to walk into the building at 11:30pm at night. It is also alleged that facility staff did not inform Person 1 regarding the new concierge. Interview with S1 stated that facility’s doors are locked from the outside starting at 10:00 p.m. to 6:00 a.m., daily and entry can only take place when the facility is alerted of people wanting to come in via call button on the front door. S1 revealed that as of 3/25/2026, the facility no longer has a concierge service 24 hours a day which required a staff member to be posted at the front desk of the main entrance during the night shift. S1 indicated that moving forward, the main entrance to the facility will be inaccessible at 10:00 p.m. which will now require visitors to push the alert button on the front door to alert staff to grant access to into the facility. No one will be posted in the front desk to open and staff on shift working the floors will be assigned to monitor the call button alters coming from the front door to grant visitor access. S1 indicated that the new concierge hours have taken effect and that Information regarding the new policy was sent via email blast to resident families and flyers were provided to residents by hand. Interviews with (16) out of (17) people stated that they feel safe in the facility or and not received reports of people not feeling safe in the facility. However; interviews indicated that they didn't know and were not informed about the changes in the hours of facility’s concierge service and that the facility should have informed them of the changes. People further indicated that resident responsible parties have not received information from the facility regarding the changes. Interviews corroborate the allegation that the facility did not adhere to company policy. Based on interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted with Maria Quiroz, and a copy of this report, 9099-D and Appeal rights was provided. Regarding: Staff speaks to resident in an inappropriate manner. It is alleged that staff speak to residents in a harsh tone of voice. Staff deny the allegation. Interviews with (7) out of (7) staff indicated that staff do not talk to residents in a harsh tone of voice. Staff indicated that they treat residents with dignity and respect and use a calm voice to talk to residents. Staff further indicated that they have not observed other staff talking to residents in harsh tones and if they do, they are mandated to report any type of abuse to proper authorities. Interviews with (6) out of (6) residents indicated that staff talk to them respectfully and do not use harsh tone of voice to talk to them. Interviews do not corroborate the allegation that staff speak to residents in harsh tone of voice. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Maria Quiroz, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 8, 2026 · control 28-AS-20260325094546

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(6) · Plan of correction due date: Jun 9, 2026

Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:..(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained. This requirement is not met as evidenced by Based on interview, R1's bedtime medication was not administered on 3/24/26 due to R1 being away from the facility during scheduled pass. MAR indicated that R1 received their bedtime medication; however, staff indicated that it was prepared and documented ahead of time and that R1 did not receive their medication. Medication review indicated that R2 has discontinued Furosemide 40 mg tablets no longer administered but still listed on MAR.the state’s words, verbatim · CDSS document, Jun 8, 2026

Plan of correction: Licensee will provide LPA with a plan on how to regularly monitor medication and medication logs, ensure medications are current, provide additional medication administration in service training to all staff and provide proof to the department via email by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(10) · Plan of correction due date: Jun 8, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(10) To be informed of the licensee’s policy concerning visits and other communications with residents, according to Health and Safety Code section 1569.313. This requirement is not met as evidenced by Interviews with (16) out of (17) people stated that they feel safe in the facility or and not received reports of people not feeling safe in the facility. However; interviews indicated that they didn't know and were not informed about the changes in the hours of facility’s concierge service and that the facility should have informed them of the changes. People further indicated that resident responsible parties have not received information from the facility regarding the changes.the state’s words, verbatim · CDSS document, Jun 8, 2026

Plan of correction: Licensee will ensure that the concierge hours remain posted in front of the facility on the entrance door for public view. Licensee will monitor the door's posting of the hours. LPA, observed the posting during visit. Citation cleared on 6/8/2026.

Allegation investigated: Resident was not afforded dignity Personal accommodation in bedroom is inadequate Staff did not assist with resident's needs

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced subsequent complaint investigation visit today 5/22/2026. During today’s visit LPA Trueman was greeted by Administrator Maria Quizon and explained the purpose of the visit. The purpose of the visit is to investigate the above additional allegations that were not addressed from the initial complaint issued 11/17/2025. The initial visit was conducted on 11/21/2025 and subsequent complaint visit was conducted on 2/12/2026. On 2/12/2026 Allegations Staff do not answer residents calls for assistance timely (findings Substantiated) and Staff do not ensure facility is free of pests (Unsubstantiated) were investigated. At today's visit Resident and Staff Roster were submitted along with document Assisted Living Waiver (ALW) Agreement. Resident Care Summary was submitted. Interviews were conducted with Administrator Maria Quizon and Staff S1-S4. Resident's R2-R11 were also interviewed. In regards to the allegation Resident was not afforded dignity, based on interviews conducted and Unsubstantiated information gathered it was revealed by Resident's R2-R11 that staff are very kind and helpful. All stated that staff treats everyone with respect and dignity and have never mocked or laughed at any resident. All said staff are very polite and terrific. Resident R8 said that she admires whomever is training staff. Administrator stated that staff would cater to Resident R1 and even give clothes because R1 didn't have alot. Staff S3 said they treated R1 kindly and R1 would say she loves staff and they are angels. Staff S1-S4 all stated that staff treat all residents with respect and dignity. 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, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Personal accommodation in bedroom is inadequate, based on interviews conducted and information gathered Administrator stated that the family tours the bedrooms and they pick and choose the room. It is approved living space by the family and R1 is part of the ALW program in which R1 has a shared room. Residence and Care Agreement was signed by Authorized Representative of R1 on 2/12/2025. Interviews with R2-R11 who all stated that their rooms were spacious and clean. Said housekeeping comes there 1x a week. All stated that the room is still sufficient for those who have wheelchairs or walkers. Staff S1-S4 all stated the rooms were spacious and sufficient. Staff S3 stated that she worked on the admission of R1 and said they work with the ALW Program. Stated that during the assessment they will tell them they will have a roommate. Said they were taken on a tour and shown a room with 2 residents so they will know exactly what they will have. 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, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff did not assist with resident's needs, based on interviews conducted and information gathered Resident's R2-R11 all stated that they get their care needs met. All stated that staff respond promptly when residents ask for help. R2 stated he used the clicker for assistance and staff came within 1 minute.Administrator stated that if a resident requested physical therapy it has to go thru the doctor first. It's applied for because with medical they have to wait for approval. Staff S1 stated that R1 was always showered and was very verbal and would let staff know if she needed assistance.Staff S3 said that staff were always friendly with R1 and that R1 loved staff and called them angels. Stated they took very good care of R1 and they knew R1's daily schedule of what R1 needed and were very on top of what was needed for R1. Staff S4 stated that she helped assist R1 with showering and changing clothes and getting dressed. Said staff would bring R1 clothes because R1 didn't have alot. Stated that she knows her schedule and when R1 wants certain things to be done. Said R1 was very nice and polite. It should be noted that R1's last day residing at the facility was 5/2/2026 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, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and copy provided to Administrator.the state’s words, verbatim · CDSS document, May 22, 2026 · control 28-AS-20251117093224

Allegation investigated: Staff do not ensure residents are safe from harm from other residents.

*** This report supersedes the report dated 03/16/26. The superseded report was created due to additional staff/residents interviews were conducted and clarification of the allegation was made. The finding of the allegation remains unchanged. *** Licensing Program Analyst (LPA) Tao conducted an unannounced subsequent visit today on 05/04/2026 to re-deliver finding. The initial visit was conducted by LPA Tao on 03/16/2026. Today’s visit, LPA Tao met with Administrator Maria Quizon. The purpose of today’s visit was discussed with the Administrator. The investigation consisted of residents/staff interviews, facility tours, and review of facility records. LPA obtained resident roster, staff roster and residents’ facility files. The investigation revealed, in regards of facility staff do not ensure residents are safe from harm from other residents, it was alleged that a resident hit other residents with fists and walker. LPA interviewed eleven (11) residents including resident#1 (R1) who was alleged to hit other residents. (- Continued on LIC 9099C-) Substantiated *** This report supersedes the report dated 03/16/26. The superseded report was created due to additional staff/residents interviews were conducted and clarification of the allegation was made. The finding of the allegation remains unchanged. *** Per the resident interviews, ten (10) out of eleven (11) residents were corroborated with the allegation which resident#1 (R1) was constantly yelling and threatening to hit or had hit other residents. All residents interviewed were residing on the second floor. They stated R1's situation had been going on for a year and they know what R1 did. Residents stated staff may talk to R1 to redirect R1 but it did not work most of the time. No preventive action was taken to ensure residents were safe from R1’s harm. Per staff interviews, all four (4) staff interviewed were corroborated with the allegation. Administrator was aware of R1’s combative behavior. Per record review, the Administrator handled R1 behavior by consulting psychiatrist and changing R1’s medication for three (3) times. Preventive action was minimal. Per the observation during the interview with resident#1 (R1), LPA went to R1’s room and R1 opened the door. R1 raised resident’s voice when talking to LPA at resident’s room door. Then, R1 used resident’s index finger pointing at LPA and raised voice again to shout at LPA continuously. R1 moved closer to LPA with an index finger pointing at LPA’s face. R1 was about to hold a fist to LPA, LPA backed off quickly enough from being harmed and tried to de-escalate the situation. LPA thanked R1 and ended the interview. R1 slammed the door close. During the facility tour later that day, LPA observed R1 walking in the hallway with a walker. R1 was combative and had aggressive behaviors toward other people trying to get other people out of the way in the hallway. LPA did not observe any staff intervention. Therefore, staff failed to ensure residents were safe from harm from other residents. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Administrator Maria. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 4, 2026 · control 28-AS-20260313143559

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(2) · Plan of correction due date: May 5, 2026

(2) Safe and healthful living accommodations and services. This requirement was not met as evidenced by: Per LPA's in person interview with R1, R1 had combative behavior which created an unsafe environment to other residents at the facility. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 4, 2026

Plan of correction: Licensee agreed to work with R1's physician and family member for an updated care plan, change of medication and possible for a new placement for the level of care that R1 needs. Administrator will provide training for all staff in the facility related to handle resident with combative behavior. Licensee will send the updated care plan and/or possible placement of R1 by POC due date. POC had been cleared prior to the subsequent visit. 5/4/26

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tao conducted an unannounced case management visit regarding the incident report submitted to the department on 04/04/2026. LPA met with Administrator Maria and explained the reason for the visit. Administrator submitted a copy of SOC 341 along with an incident report on 04/04/2026. The incident occurred on 04/03/2026 at around 11:30am. Resident #1(R1)’s son reported to the administrator Maria that R1’s leg and knee were hit by the metal part of the Hoyer lift when staff #2 (S2) transferring R1 using the Hoyer lift. R1’s son stated R1’s leg and knee were observed to have bruises, but no injuries were reported. Only one staff, S2, assisted R1 during the transfer of using the Hoyer lift. The Administrator stated only one resident at the facility needs to use Hoyer lift to transfer. LPA interviewed the administrator and two staff. Per the staff interview, Administrator denied that only one caregiver operating the Hoyer lift when assisting that resident. The staff interviews of staff#3 (S3) and staff#4 (S4) revealed the only one staff assisted resident when using Hoyer lift. The suspected abuser, staff#2 (S2), was no longer working at the facility and unable to contact that staff for interview. Per resident interview, only one caregiver assisted the resident during the transfer of resident using the Hoyer lift or mechanical lift. Per the physical plant tour, LPA did not observe a sign indicating two (2) caregivers are required to operate the Hoyer lift. Per record review, the facility’s policy and procedures, dated 06/01/2024, indicated two (2) caregivers are required to assist residents when operating Hoyer lift/mechanical lift. (-continues on LIC 809C-) An in-service training conducted by a professional vendor regarding the proper use of Hoyer lift was provided to staff on 04/07/2026. As mentioned above, the facility’s Human Service investigated and let go the suspected abuser/staff. The reason was violations of company policy using Hoyer lift. The facility is working on training new hires and will hire additional caregivers in May 2026. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Administrator Maria and a copy of this report, LIC 809D and appeal rights were provided.the state’s words, verbatim · CDSS document, May 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: May 5, 2026

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Staff#2 (S2) did not follow the facility's procedures of having the required two (2) staff for proper use of Hoyer lift when transferring Resident#1 (R1) which cause bruises on leg and knee. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 4, 2026

Plan of correction: Administrator agrees to submit (1) a staff list for additional in-service training for proper use of Hoyer lift (2) a written statement of how the facility will compliance with section 87411(a) and ensure staff are following the facility policy of using Hoyer lift by 05/05/26. Follow up with proof of training on Hoyer lift by 05/12/2026.

Allegation investigated: Staff left a resident in a soiled diaper for a long period of time. Staff did not administer medications to a resident in care.

Licensing Program Analyst (LPA) Vaid conducted a subsequential visit to the facility and met with Maria Quizon, Executive Director and discussed the above-mentioned allegations.LPA Vaid collected staff and residents' rosters. On 12/02/2025, Licensing Program Analyst (LPA) Vaid conducted 10-day initial complaint visit and met with Michelle Paradilla-Business Office Manager, the visit was discussed. Wellness Director arrived shortly after. LPA Vaid requested and obtained the following documents- Resident#1 -Resident #5 -ID and face sheet, physicians report, residents’ incontinence care list, medication list. NOC shift staff contact information. Caregiver and medication technicians’ weekly schedules. LPA toured the facility with Michelle Castillo and did not observe any health and safety concerns. LPA Vaid did not interview resident 1(R1) they are at hospital. LPA Vaid need to interview NOC shift staff. Due to insufficient information gathered today, this complaint needs further investigation. LPA may return at future date. The investigation revealed the following: CONTINUED ON 9099C........................... Unsubstantiated Regarding the allegation: Staff left a resident in a soiled diaper for a long period of time. It is alleged that staff are not changing R1’s and R2’s adult briefs for long periods of time during the NOC shift. It is alleged staff takes very long time before responding to residents’ incontinent needs. Eight (8) of Eight (8) staff deny this, according to staff residents are check for incontinent changes upon starting, during and before the end of each shift, staff stated providing Assisted daily Living needs to residents needing incontinent services three times per shift and as needed for a few residents requiring constant incontinent care needs. During NOC shift staff make nighty checks upon incontinent needing residents, staff periodically checks upon residents' needing constant incontinent care due to their medical conditions and avoid residents' developing UTI's and sores on their privates. Staff stated they communicate residents’ issues with the next shift and take appropriate actions when required. Nine (9) of eleven (11) residents could not corroborate this allegation. Residents stated they receive incontinent care throughout the day and night and when needed. Residents' also stated, not being left in soiled adult briefs to develop a sore in their private areas. Six of eleven residents stated staff responds within 10 minutes of call for incontinent care. Based on interviews and records review, 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, therefore the allegation is unsubstantiated. Regarding the allegation: Staff did not administer medications to a resident in care. It is alleged that staff are not administering medications to R1. Eight of eight staff deny this, staff stated administering R1’s medications as prescribed by the physicians’ orders. Medication is administered one hour before or after the medication stated times. Review of medical records for R1 observed medications administered and refused by R1, PRN medication for pain did not exceed prescribed amount. Seven of eleven residents stated being administered their medications within a reasonable time. Based on interviews and records review, 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, therefore the allegation is unsubstantiated. Exit interview was conducted and a copy of this licensing report was provided to Executive Director, Maria Quizon.the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 28-AS-20251125090516

Allegation investigated: Staff do not ensure prescribed medications are properly managed or dispensed.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint investigation visit regarding the above stated allegation. LPA met with Margaret ‘Maggie’ Jay, Business Office Manager and explained the reason for the visit. Shortly after, Maria Quizon Executive Director met with LPA and assisted with the investigation. The investigation consisted of the following: On 12/24/2025, LPA Madyun obtained copies of staff/resident roster and reviewed files for fifteen (15) residents such as Physician reports, admission agreements, appraisal needs and services plans, identification and emergency information, face sheets, and medication sheets for June and December 2025. LPA Madyun also conducted interviews with Staff #1 (S1) - Staff #3 (S3). During today’s visit, LPA Pena conducted a tour of the facility focusing on the medication room, obtained copies of the staff & resident rosters, Resident #1 (R1) and random staff/Med Tech files files pertinent to the investigation and facility's medication policy. LPA re-interviewed S1, interviewed Staff #4 (S4) - Staff #5 (S5), Resident #1 (R1) - Resident #6 (R6) and telephonically interviewed Staff #6 (S6) *****CONTINUED ON LIC9099-C***** Substantiated The investigation revealed the following: Regarding the allegation: "Staff do not ensure prescribed medications are properly managed or dispensed." It was alleged that staff do not dispense all of R1's medications and the pain medication is consistently missing. (2) out of (6) staff interviewed corroborated the allegation. Staff stated that they observed many medication errors on their shifts and many residents are aware that they were not getting all of their medications. (2) staff also stated that they have seen other staff pre-pour all the medication the night before, as directed and postpone giving it to the residents. When it's too late, staff would simply throw away the medication, causing the residents to miss their scheduled medication regimen. (2) of (6) residents interviewed stated that the staff had either forgotten to administer their medications on time or had failed to administer their medications at all. LPA observed a number of medication errors for (4) different residents including R1. Additionally, a review of R1's medication administration records revealed that procedures were not followed and there was insufficient supervision. Therefore, there was sufficient evidence to corroborate with the allegation. Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D. A civil penalty assessment (LIC421M) was also issued for repeat violations. An exit interview was conducted, and a copy of this report provided to Maria Quizon, Executive Director along with the Appeal Rights. The investigation revealed the following: Regarding the allegation: "Staff does not ensure issues of missing medications is being properly addressed." It was alleged that R1 has been consistently missing a prescribed medication and facility's pharmacy has regularly failed to fulfill R1's prescription in a timely manner. Staff interviewed stated that R1 did not have missing medications but has a PRN prescription that cannot be filled early without a doctor's intervention. R1 has a PRN prescription for (120) pills, supposedly good for (4) months. However, the pills only lasted for thirty days because R1 took the medication four times daily. Because it is a controlled substance and not on cycle, it needed doctors authorization. When staff contacted the pharmacy to follow up, the pharmacy claimed they have not received the authorization from R1's doctor yet. Staff stated that their method in requesting refills for medication from PAX pharmacy is either via fax, phone or online and the pharmacy is quick with response time and completing orders. Interviewed residents stated that they have not missed medications and they get refills on time. Documents reviewed showed that staff have followed the method for refilling the medication but there may have been a breakdown in communication between the physician and/or the pharmacy. Therefore, there was insufficient evidence to corroborate with the allegation. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive 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 violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Maria Quizon, Executive Director.the state’s words, verbatim · CDSS document, Mar 26, 2026 · control 28-AS-20251217104411

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 27, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This deficiency was evidenced by the following: Based on interview and record review, staff do not dispense all of R1's medications and R1’s medication Gabapentin 300 mg capsule was marked administered, but the medications were still on the bubble pack and the PRN pain medication was not given as prescribed which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: The licensee shall ensure all medications are administered timely and that residents do not miss any dosage. An in-service training course for medication staff shall be conducted and the log to be submitted to LPA by POC due date.

Allegation investigated: Staff is mismanaging resident's medications.

Licensing Program Analyst (LPA) Tao conducted an unannounced 10-day complaint visit to this facility. Upon arriving at the facility, LPA met with Maria Teresita Capito Quizon, administrator. LPA explained the purpose of today’s visit and discussed the allegation mentioned above to administrator Maria Quizon. The investigation consisted of resident / staff interviews and medication/ facility records reviews. LPA obtained resident roster, staff roster, resident’s medication records and residents’ facility files. The investigation revealed the following: In regards of facility staff is mismanaging resident's medications, it is alleged that staff did not administer medication to residents as prescribed. Per resident interviews, LPA attempted but unable to interview resident#1 (R1) because resident was out in the community with family. (-Continued on LIC 9099-) Substantiated Per resident interview from resident #2 (R2) to resident #4 (R4), two (2) out of three (3) residents interviewed stated that they were not aware of any missing medication. One (1) out of three (3) residents interviewed stated the resident’s medication was missing a pill or two pills occasionally. It revealed most residents were not aware of any missing medication. Per staff interviews with the administrator and med tech, they were aware of mismanagement of residents’ medication in the facility. Administrator and Human Resource were involved to investigate the incident. As a result, a med tech was suspended due to mismanage residents’ medication. LPA reviewed residents’ medication and medical records from resident #5 (R5) to resident #7 (R7) with Med Tech. Medication mismanagement was observed as the following. A medication log of a resident was not updated which a discontinued medication was still on the list. A discontinued medication was still administered to a resident while the medication was discontinued. Med tech immediately removed such medication from the resident’s medication during the review. In addition, a resident’s controlled medication log and the bubble pack showed such controlled medication was administered twice on 03/14/26 but did not administer on 03/18/26. Therefore, facility staff is mismanaging resident's medications. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Administrator. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 26, 2026 · control 28-AS-20260323135810

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(6) · Plan of correction due date: Mar 27, 2026

(h) The following requirements shall apply to medications which are centrally stored:..(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained. This requirement is not met as evidenced by: Per medication review, R5 TK has control Rx Pregabalin 150 mg adminsitered twice on 3/14/26 but did not administer on 3/18/26. R6 AT has discontinued Rx-Midodrine HCL 2.5 MG still given to R6 on 3/26/26. R7 SS, has discontinued Rx-Furosemide 40 mg no longer administered but still listed on MAR. Licensee did not have an explanation about Rx discrepancy/ record.Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: Licensee agreed to (1) review all residents' medication and medication log to ensure residents' medications are current. (2) provide additional medication administration / in service training to all staff and provide proof to the department; (3) review Title 22, Section 87465 and provide a signed statement indicating the review of this section detailing how to prevent future medication errors by the POC date.

Allegation investigated: Facility did not ensure that there is adequate staffing to meet the needs of the residents in care. Facility is falsifying the staffing schedule.

Licensing Program Analyst (LPA) Galarza conducted an unannounced subsequent visit to continue and deliver findings on the above allegations. The purpose of the visit was explained to Executive Director Maria Quizon and new Memory Care Director Zion Brown. The investigation consisted of: On 10/30/2025,a physical plant tour of the facility Assisted Living areas and Memory Care Unit was conducted. Staffing schedules, resident files, Memory Care incident reports [Sep 2025- to present], and Dementia Plan of Operation were reviewed. A total of 10 staff were interviewed. Copies of resident face sheets, Medical Assessments, Service Plans, staffing schedules, 16 MCU incident reports, and LIC 500 Personnel Report were obtained. During today's visit, the new Memory Care Director was interviewed, as well as Memory Care residents (R2- R10) were interviewed. Resident (R1) was not interviewed because they are deceased. A physical plant inspection of the Memory Care Unit was conducted. *Narrative continues next page. Substantiated Allegation: Facility did not ensure that there is adequate staffing to meet the needs of the residents in care. It is alleged that during Fall 2025 there was not enough staffing in the Memory Care Unit, and as a result residents were not receiving dressing and grooming assistance, and were being transported to the dining room in pajamas. According to information obtained, the Memory Care Director was made aware of the aforementioned concerns, but took approximately 2 weeks to respond to emailed concerns and messages. Additionally, it was reported that the facility is alerted at least 1 hour prior to the resident being picked up for medical appointments, and when they arrive to pick up resident (R1), they are not ready and have soiled incontinence briefs. It is alleged that it has occurred between 10 AM - 11 AM. A total of 10 staff and 9 residents were interviewed. Staff interviews revealed that the Memory Care Unit has a census of 50, and is supposed to have 4 caregivers in the morning and afternoon shifts. During the night shift there should be 2 caregivers and 1 medication technician that cover the entire building, which includes the Assisted Living wings. Staff stated that in late October 2025, there were only 3 caregivers working both the day and evening shift, and the Memory Care Unit did not have in place a Task Sheet that states which residents require incontinence care. Staff said that at that time the Memory Care Unit had a census of 50, of which 37 residents required incontinence care, while the Assisted Living wings only had 16 residents that received incontinence assistance. The majority of the staff interviewed confirmed staffing shortages has made it difficult to meet the Memory Care Unit resident's needs, for example sometimes the night shift changes the resident's incontinence briefs at 2:00 AM or earlier, and they do not get changed until the morning shift staff start. NOTE: During the initial complaint visit (10/30/25), there were only three (3) caregivers working during the morning shift. Based on interviews and observations during today's visit, the physical plant condition of the Memory Care Unit and grooming of residents appears improved. However, the staffing shortages that were occurring last Fall 2025 affected resident care in the Memory Care Unit. There is sufficient information to support the allegation. Allegation: Facility is falsifying the staffing schedule. The complaint alleges that in October 2025, the staffing scheduled showed names of staff that were no longer working at the facility, and Administration staff did not remove staff names nor obtained staffing coverage for the Memory Care Unit. A total of 10 staff were interviewed. Staff said that in the month of October 2025, two (2) Memory Care Unit staff were placed on suspension, which resulted in a termination of employment. Additionally, a third Memory Care Unit staff was on leave, but their name still appeared on schedule. Staff stated the Memory Care Unit staff schedule was posted weekly, but was not accurate. Administration staff and the Memory Care Director denied the allegation, but acknowledged the posted staff schedule and documents provided to LPA do not reflect updated staffing changes and/or schedule because the terminated employee and suspended employee are still listed in the schedule, as well as the 3rd staff that was on leave. There is sufficient information to support the allegation. Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Pursuant to Title 22 California Code of Regulations, the following deficiencies were cited (refer to LIC 9099D). Exit Interview was conducted, citations issued, appeal rights discussed, and a copy of the report was issued to Executive Director Maria Quizon.the state’s words, verbatim · CDSS document, Mar 26, 2026 · control 28-AS-20251024162227

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Apr 9, 2026

Managed Incontinence.... the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met evidenced by: Based on interviews and observation during the 10/30/25 physical plant inspection, the findings indicate R1 requires incontinence care at least every 2 hours and feces were observed on the floor, bedding, and mattress of a Memory Care Unit resident room. This posed a potential health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: Executive Director agrees to conduct staff training in incontinence care, responsibilities, and Memory Care Unit facility protocols. Submit proof of staff training.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87413(a)(1) · Plan of correction due date: Apr 9, 2026

Personnel - Operations. In each facility: When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement was not met evidenced by: Based on interviews and record review, it was revealed that in October 2025, 2 Memory Care Unit (MCU) staff were suspended, of which 1 was terminated, but both were listed in the MCU weekly staff schedule and administration staff did not ensure adequate staff coverage. This posed a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Mar 26, 2026

Plan of correction: Executive Director agreed to ensure staff schedules are updated, posted, and in instances of staff shortages shift coverage shall be implemented. Please submit a written plan of correction.

Allegation investigated: Unqualified staff are administering insulin.

Licensing Program Analyst (LPA) Tao conducted an unannounced 10-day complaint visit to this facility. Upon arriving at the facility, LPA met with Maria Teresita Capito Quizon, administrator. LPA explained the purpose of today’s visit and discussed the allegation mentioned above to administrator Maria Quizon. The investigation consisted of resident / staff interviews and facility records reviews. LPA obtained resident roster, staff roster, resident’s medication records and residents’ facility files. The investigation revealed that in regards of unqualified staff are administering insulin, it is alleged that staff administer insulin to residents. Per resident interviews, all six (6) residents, including three (3) residents who were administered insulin, could not corroborate the allegation. It revealed residents would admininster insulin by themselves if needed. Per staff interviews, all four (4) staff could not corroborate the allegation. (- Continued on LIC 9099C-) Unsubstantiated It revealed that staff and med tech would not administer insulin to residents and facility policy did not allow staff to administer insulin to residents since staff were not medical professional. Per observation during medication time, med techs only assisted residents to set up and prepare the medication/insulin. All residents administered insulin by themselves. Therefore, it was not observed that insulin was administered by staff at the facility. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegation mentioned above. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Maria Teresita Capito Quizon, administrator. The findings were discussed and a copy this report was provided.the state’s words, verbatim · CDSS document, Mar 26, 2026 · control 28-AS-20260320100317

Allegation investigated: Staff do not ensure residents are safe from harm from other residents.

Licensing Program Analyst (LPA) Tao conducted an unannounced 10-day complaint visit to this facility. Upon arriving at the facility, LPA met with Maria Teresita Capito Quizon, administrator. LPA explained the purpose of today’s visit and discussed the allegation mentioned above to administrator Maria Quizon. The investigation consisted of resident interviews, staff interviews, facility tours, and review of facility records. LPA obtained resident roster, staff roster and residents’ facility files. The investigation revealed the following: In regards of facility staff do not ensure residents are safe from harm from other residents, it was alleged that a resident was constantly hitting other residents with fists and walker. LPA interviewed four (4) residents including resident#1 (R1) who was alleged to hit other residents. All four (4) residents were using walkers or wheelchairs. (- continued on LIC 9099C-) Substantiated Per the resident interviews, three (3) out of four (4) residents were corroborated with the allegation which resident#1 (R1) was consistently threatening to hit or had hit other residents. This situation had been going on for a year. Residents indicated other residents on the same floor with R1 would know what R1 did. LPA went to R1’s room and R1 opened the door. When LPA interviewed resident#1 (R1), the resident had the voice raised when talking to LPA at resident’s room door. Then, R1 used resident’s index finger pointing at LPA and raised voice to shout at LPA continuously. R1 moved closer to LPA with an index finger pointing at LPA’s face. R1 was about to hold a fist to LPA, LPA backed off quickly enough from being harmed and tried to de-escalate the situation. LPA thanked R1 and ended the interview. R1 slammed the door close. Per staff interviews, Administrator was aware of R1’s combative behavior. Administrator handled R1 behavior by consulting psychiatrist and changing R1’s medication for 3 times. However, no other preventive action was taken. During the facility tour, LPA observed R1 walking in the hallway with a walker. R1 was combative and had aggressive behaviors toward other people on the hallway. Therefore, staff failed to ensure residents were safe from harm from other residents. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Administrator. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 16, 2026 · control 28-AS-20260313143559

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(2) · Plan of correction due date: Apr 3, 2026

(2) Safe and healthful living accommodations and services. This requirement was not met as evidenced by: Per LPA's in person interview with R1, R1 had combative behavior which created an unsafe environment to other residents at the facility. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 16, 2026

Plan of correction: Licensee agreed to work with R1's physician and family member for an updated care plan, change of medication and possible for a new placement for the level of care that R1 needs. Administrator will provide training for all staff in the facility related to handle resident with combative behavior. Licensee will send the updated care plan and/or possible placement of R1 by POC due date.

Allegation investigated: Staff are not meeting residents bathing needs.

Licensing Program Analyst (LPA) Tao conducted an unannounced subsequent visit on 03/16/26, today, to re-deliver the finding for correcting the citation issued on 02/23/26. LPA met with Administrator Maria Teresita Capito Quizon. The purpose of today’s visit and the allegation of the complaint were discussed with the Administrator. The initial complaint visit was conducted on 02/23/26 which included resident / staff interviews, facility tours, and review of facility records. LPA obtained resident roster, staff roster and residents’ facility files. The investigation revealed that the facility staff were not meeting residents’ bathing needs, which staff did not bathe residents. The allegation was found to be SUBSTANTIATED. Deficiencies were being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Administrator and a copy of this report/appeal rights were provided. Substantiatedthe state’s words, verbatim · CDSS document, Mar 16, 2026 · control 28-AS-20260223085558

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Mar 17, 2026

Personal assistance and care as needed by the resident .. such as … bathing… This requirement was not met as evidenced by: Per staff and residents’ interviews, staff were not bathing residents and missed at least once last week for providing their bathing needs. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 16, 2026

Plan of correction: Licensee agreed to provide bathing care to residents who were not provided from last week and keep up with the bathing assistance as scheduled. Showing log will be provided for POC by due date.

Allegation investigated: Staff are not meeting residents bathing needs

Licensing Program Analyst (LPA) Tao conducted an unannounced 10-day complaint visit to this facility. Upon arriving at the facility, LPA met with Maria Teresita Capito Quizon, administrator. LPA explained the purpose of today’s visit and discussed the allegation mentioned above to administrator Maria Quizon. The investigation consisted of resident interviews, staff interviews, facility tours, and review of facility records. LPA obtained resident roster, staff roster and residents’ facility files. The investigation revealed the following: In regards of facility staff are not meeting residents’ bathing needs, it was alleged that staff did not bath residents. LPA interviewed ten (10) residents who need bathing assistance. Per the resident interviews, ten (10) out of ten (10) were corroborated with the allegation which staff did not provide residents with bathing as scheduled. (-continued in LIC 9099C-) Substantiated Per staff interviews, one (1) out of four (4) staff interviewed could not corroborate the allegation which residents were bathed as scheduled. Three (3) out of four (4) staff interviewed could corroborate the allegation which indicated residents were not getting bathed as scheduled. During the facility tour, LPA observed some residents’ clothes looked unclean. Therefore, staff failed to meet residents’ bathing needs. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Administrator. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 28-AS-20260223085558

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.2(c)(4) · Plan of correction due date: Feb 27, 2026

Personal assistance and care as needed by the resident .. such as … bathing… This requirement was not met as evidenced by: Per staff and residents interviews, staff were not bathing residents and missed at least once last week for providing their bathing needs. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: Liscensee agreed to provide bathing care to residents who were not provided from last week and keep up with the bathing assistance as scheduled. Showing log will be provided for POC by due date.

Allegation investigated: Facility staff do not respond to call bell in a timely manner.

Licensing Program Analyst (LPA) Tao conducted an unannounced 10-day complaint visit to this facility. Upon arriving at the facility, LPA met with Maria Teresita Capito Quizon, administrator. LPA explained the purpose of today’s visit and discussed the allegation mentioned above to administrator Maria Quizon. The investigation consisted of resident interviews, staff interviews, facility tours, and review of facility records. LPA obtained resident roster, staff roster and residents’ facility files. The investigation revealed the following: In regards of facility staff do not respond to call bell in a timely manner, it was alleged that the night shift staff failed to respond to resident’s call bell. Per the resident interviews, one (1) out of eleven (11) residents interviewed stated that the resident had never used the call button / pendant to call staff for incontinent assistance at nighttime. (-continued in LIC 9099C-) Substantiated One (1) out of eleven (11) residents interviewed stated staff would come timely to assist the resident when the staff was called. The staff would come to resident’s room in about 10 minutes after the call button was pressed. Nine (9) out of eleven (11) residents stated night shift staff did not come to assist them timely when staff were called. The interviews revealed that the night shift staff either did not show up in residents’ rooms to assist them or staff would come to assist them from 30 minutes to hours after they pressed the call pendants. It was a concern of short of staff at the night shift staff. Per staff interviews, one (1) out of four (4) staff interviewed could not corroborate the allegation. Three (3) out of four (4) staff interviewed corroborate the allegation which some staff failed to respond to the residents’ calls, especially during the night shift. During the facility tour, LPA tested the call pendants in seven (7) random residents’ rooms. LPA pressed the call button every five (5) minutes and waited in the residents’ rooms for 15 minutes to 25 minutes. Three (3) out of seven (7) residents’ rooms got no staff showed up. LPA spoke with staff to see if they received resident’s calls but staff stated they did not receive the calls. LPA and staff tried the call buttons multiple times to send the calls to front desk and finally, some calls were received by staff’s pagers. Based on the call button test, it showed some pendants were not working properly and staff failed to respond to resident’s calls in a timely manner. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Administrator. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 28-AS-20260217152644

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Feb 27, 2026

(a) (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Per interviews of residents and call button test, it showed that staff would take 15 min or did not respond to residents at all due to the call button was not working. This poses a potential health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: Licensee agree to hire more quailified staff to provide adequate assistance and care to residents. Also to ensure staff would respond to calls within 10 minutes. Proof of hiring additional staff will provide to licensing by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 27, 2026

The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Per call button tests, mulitple of call buttons were not working properly at the facility. This poses a potential health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: Licensee agree to fix the call button to ensure it is in good repair at all times. Proof of repair will provide to licensing by the POC due date.

Allegation investigated: Staff do not ensure facility is free of pests

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced subsequent complaint investigation visit today 2/12/2026 regarding the above allegations. During today’s visit LPA Trueman was greeted by Administrator Maria Quizon and explained the purpose of the visit. The purpose of the visit was to investigate the above allegations. The initial visit was conducted on 11/21/2025 and included the following: LPA Trueman requested and obtained copies of Resident/Client Roster, Staff Roster (LIC 500), Interviews with Business Office Director Michelle Castillo, Staff#1 (S1) and Resident#1-16 (R1-R16) interviews, and physical plant tour was conducted which included the following: Resident Rooms 1st Floor #107, #111, #113 #121 2nd Floor #206 #214, # 220 A, #220 B, #232, #235, # 213 A, and #213 B. At today's visit Resident and Staff Roster were submitted, and the Administrator and Staff S1-S5 were Unsubstantiated interviewed. In regards to the allegation Staff do not ensure facility is free of pests, based on physical plant tour which was conducted which included the following: Resident Rooms 1st Floor #107, #111, #113 #121 2nd Floor #206 #214, # 220 A, #220 B, #232, #235, # 213 A, and #213 B. and information gathered there were no pests observed in any resident room and not observed in all common areas of the facility. Interviews with Residents R1-R16 whom all stated they had not observed any pests in their rooms. All staff stated they had not observed any pests in the facility or in the resident's rooms. Administrator stated that the facility is contracted with pest control for routine visits monthly. 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, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 28-AS-20251117093224

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 19, 2026

Personnel Requirements- General 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 requirement was not met as evidenced by: Based on interviews conducted staff stated there is not enough staff and at times residents aren't assisted in a timely manner This poses a potential health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: Licensee will conduct an in-service training regarding timely response to assist residents and also submit a staff schedule which includes additional staffing to meet the needs of over 100 residents and submit POC to LPA by 2/19/2026.

Allegation investigated: Staff did not ensure resident was treated with dignity and respect. Staff did not provide adequate laundry services to resident. Staff did not safeguard resident's personal belongings. Staff did not adequately address a change in resident’s condition.

Licensing Program Analyst (LPA) Tao conducted an unannounced 10-day complaint visit to this facility. Upon arriving at the facility, LPA met with Maria Teresita Capito Quizon, administrator. LPA explained the purpose of today’s visit and discussed the allegations mentioned above to administrator Maria Quizon. The investigation consisted of resident interviews, staff interviews, facility tours, and review of facility records. LPA obtained resident roster, staff roster, staff training records and residents’ facility files. The investigation revealed the following: In regards of facility staff did not ensure resident was treated with dignity and respect, it was alleged that staff failed to show respect to resident when providing care. Per the resident interviews, one (1) out of eleven (11) residents interviewed stated that staff did not treat the resident with respect and dignity. (-continued on LIC 9099C-) Unsubstantiated Ten (10) out of eleven (11) residents interviewed could not corroborate the allegation. It revealed residents were treated with respect and dignity. Per staff interviews, all six (6) out of six (6) staff interviewed could not corroborate the allegation which indicated staff would treat residents with respect and dignity. During the facility tour, LPA observed residents were looking happy when talking to staff. Staff would say hello to residents and have short conversations with them. Therefore, residents are treated with dignity and respect. In regards of facility staff did not provide adequate laundry services to resident, it was alleged that laundry service was not provided regularly and clean clothes were not hung in the closet but folded in resident’s bed. LPA interviewed residents, one (1) out of eleven (11) residents interviewed stated that laundry staff did not wash the resident’s clothes once a week and resident had to remind staff to provide laundry services. Ten (10) out of eleven (11) residents interviewed could not corroborate the allegation. It revealed that laundry services were provided at least once weekly and more if needed. Their clothes were hung in the closets. Per staff interviews, all staff interviewed could not corroborate the allegation which indicated laundry services were provided at least once every week and more if requested. Staff would check on residents when called for laundry services. During the physical plant, all residents’ clothes were observed to be hanging in closets and no clothes were laid in bed. Thus, staff provided adequate laundry services to residents. In regards of facility staff did not safeguard resident's personal belongings, it was alleged that some hangers and money were missing in resident#1 (R1)’s room while in care. LPA interviewed residents, one (1) out of eleven (11) residents interviewed stated that some hangers were missing in the closet and some clothes were taken by the roommate, but the resident was unable to confirm money was missing in the room. During the resident interview, LPA visited R1’s room to interview R1’s roommate, resident#2 (R2). R2 was non-ambulatory and needed assistance to get up/out of bed. R2 also needed assistance to transfer to wheelchair and dressing/grooming. Ten (10) out of eleven (11) residents interviewed could not corroborate the allegation. It revealed that residents were not aware of any missing hangers or personal belongings while in care. Per staff interviews, all staff interviewed could not corroborate the allegation which staff would assist residents to locate the missing personal belongings when reported missing. The facility has extra hangers in the storage and would provide resident with more hangers if requested. As a result, staff did not fail to safeguard resident’s personal belongings. (-continued on LIC 9099C-) In regards of facility staff did not adequately address a change in resident’s condition, it was alleged that resident was noted with increased confusion and staff did not address it properly. LPA interviewed residents, one (1) out of eleven (11) residents interviewed stated that staff did not report resident’s change in condition correctly and the resident insisted that was not change in resident’s mental status. Ten (10) out of eleven (11) residents interviewed could not corroborate the allegation. It revealed that staff would address residents’ changes in condition and notify their families / primary physicians. Per staff interviews, all staff interviewed could not corroborate the allegation which staff would document residents’ changes, notify administrator and report the changes to residents’ primary doctors. Per record review, in-service training was provided to staff related to changes in conditions. Besides, records showed med tech and care coordinator had observed resident's changes. The changes were documented in resident's notes on 01/11/26, 01/16/26, 01/21/26 and 01/28/26. Psych counsel was provided to resident on 02/10/26. Physician assistant visited and evaluated the resident on 02/12/26. Resident's prescription was updated on 02/12/26 today. Additional lab tests and assessments were requested. Therefore, staff had adequately addressed residents’ changes in condition. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. An exit interview was conducted with Maria Teresita Capito Quizon, administrator. The findings were discussed and a copy this report was provided.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 28-AS-20260208123605

Allegation investigated: Staff touched resident in an inappropriate manner. Staff made inappropriate comments to resident.

Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with Karine Tovmasian, admissions coordinator for the facility, and explained the purpose of the visit. LPA met with Maria Quizon, Executive Director, shortly thereafter. The investigation consisted of the following: On the initial visit conducted on 10/8/2025, LPA Zaragoza obtained the physician's report, appriasal, FACE Sheet, and admissions agreement for Resident #1 (R1), and also conducted a tour of the facility. Since the initial visit, Investigations Branch (IB) investigator Douglas Real interviewed Staff #1 - 2 (S1 - S2), Residents #1 - 4 (R1 - R4), Witness #1 (W1), and also obtained a police report from the Pasadena Police Department #2025-77351. During today's visit, LPA Zaragoza interviewed Staff #3 - 6 (S3 - S6), and also interviewed R1, R2, and Residents #5 - 13 (R5 - R13). LPA Zaragoza is also delivering the findings of the investigation. Unsubstantiated The investigation revealed the following: in regards to the allegation that "Staff inappropriately touched resident," it is alleged that S1 inappropriately touched R1 in a sexual manner when providing care to them, including touching their genital area and also forcing R1 to touch them in the groin region. IB investigator Real investigated the above allegation. During interviews with the staff, none of them corroborated the allegation. S1 repeatedly stated in various interviews that they never inappropriately touched R1 in a sexual manner in the past. Other staff interviewed stated that they never witnessed S1 touching R1 or any other resident inappropriately. During interviews with the residents, three (3) out of four (4) denied the allegation. One resident stated that none of the facility caregivers have ever touched them inappropriately anywhere on their body. Another resident interviewed stated that they have received assistance with showering from S1 in the past, and that S1 has always been respectful while assisting them. During an interview with W1, a detective with the Pasadena City Police Department, they stated that based on their investigation, there was insufficient evidence to press charges against S1. In regards to the allegation that "Staff made inappropriate comments to resident," it is alleged that S1 made sexually inappropriate comments to R1 while providing care to them. The above allegation was investigated by LPA Zaragoza. During interviews with the staff, none of them corroborated the allegation. One staff interviewed stated that they have never heard of S1 make inappropriate comments towards R1 or any other resident when they were providing care to them. Another staff similarly stated that they never heard S1 make an inappropriate comments towards any of the residents. During interviews with the residents, ten (10) out of eleven (11) did not corroborate the allegation. One resident stated that they have never heard of any staff members making inappropriate comments towards the residents in the facility. Another resident interviewed also stated they have not heard any staff make inappropriate comments towards residents and that staff treat them respectfully. LPA did not overhear any staff making inappropriate comments towards residents across the two (2) unannounced visits at the facility. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 9, 2026 · control 28-AS-20251007152115

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Erik Zaragoza conducted a case management visit in conjunction with a complaint that has the control #28-AS-20251007152115. During record review of the facility staff associations on the Guardian website at the time the complaint was filed on 10/7/2025, it was revealed that Staff #1 (S1) was not associated to the facility while working as a caregiver. S1's association status in Guardian stated that he was "In Process" of being associated, but was not yet eligible to work. It was revealed that S1 had worked at the facility from February of 2025 - 10/16/2025 while not being fully associated. In a letter sent by Guardian to S1 on 7/22/2024. It reads that S1 had an "Ineligible Fingerprint Submission" due to the fact that S1 is ineligible due to a previous denial of a criminal record exemption or exclusion action, and therefore was not allowed to work with residents or be present in an agency licensed by the department. The related deficiency is cited on the LIC809D page. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 9, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Feb 10, 2026

Criminal Record Clearance. (e) 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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by: Based on record review, S1 had been working at the facility from February of 2025 - 10/16/2025 while not being associated to the facility, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 9, 2026

Plan of correction: Licensee/Administrator is to ensure that all staff are associated to the facility prior to working at all times. Administrator is to submit a written plan explaining how the facility will ensure all staff are associated to the facility prior to beginning work, and submit the place to the licensing agency for review by the POC due date.

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

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced initial 10-day complaint investigation visit regarding the above allegation. LPA Gonzalez was greeted by Administrator Maria Quizon and the purpose of the visit was explained. Care Coordinator Petra Vancini assisted with the visit. The investigation consisted of the following: LPA Gonzalez requested and obtained copies of Personnel Roster, Resident Roster, reviewed facility file for R1, interviewed staff #1-5 (S1- S5) and interviewed residents #1-10 (R1-R10). continued on LIC9099C Unsubstantiated Regarding the allegation "Staff did not ensure residents personal property was safely secured”: it was reported that R1 stated that they had money stolen. The investigation revealed 5 out of 5 staff deny the allegation. S1 stated nothing had been reported to them, especially not money. S2 stated an incident was brought to their attention and attempted to assist R1 in looking for the missing money but R1 stated they were not missing anything. Interviews with residents revealed 7 out of 10 residents deny the allegation. R1 stated they had reported someone had taken their money, but they were mistaken because they had somebody to hold it. R2 stated once, about 10 years ago, money went missing from their room, but not now under the new management. R3 stated cigarettes had gone missing from their room but not any money. R4 stated a sweater set was not returned from laundry but has not had money missing. R3 and R4 admitted to not reporting the missing items to staff. LPA unable to interview the reporting party. LPA made three (3) attempts to contact the reporting party. Based on interviews, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Administrator Maria Quizon.the state’s words, verbatim · CDSS document, Feb 6, 2026 · control 28-AS-20260130091554

Allegation investigated: Staff are not allowing resident to leave facility.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit regarding the above stated allegation. LPA met with Maria Quizon, Executive Director and explained the purpose of the visit. The investigation consisted of the following: On 12/29/2025, LPA obtained copies of the staff & resident rosters, Elopement and Restraints Policies, Staff in-service training logs on elopement, restraints and Residents personal rights, Email correspondence between R1’s family member and Administrator and Resident #1 (R1) – Resident #2 (R2) pertinent files such as: Identification/Emergency Information, Preplacement Appraisal, Phyician's report, Medication list, Service/Care plan and Personal Rights. Prior to today's visit, LPA communicated with Resident #1 (R1). During today's visit, LPA obtained copies of the staff & resident rosters, Incident report and Resident #1 (R1) – Resident #2 (R2)’ s Admission Agreements. LPA also interviewed Staff #2 (S2) - Staff #4 (S4) and Resident #2 (R2) - Resident #15 (R15). *****CONTINUED ON LIC 9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: "Staff are not allowing resident to leave facility." It is alleged that staff did not allow R2 to leave the facility with R1 and staff did not treat them with dignity, comparing the environment to being incarcerated in a state penitentiary. Staff interviewed denied the allegation. Staff stated that they are trained on resident rights and residents are allowed to leave the facility if they choose to. However, some residents, including R2, have restrictions based on doctor's orders and are required to have permission from a family member to leave unassisted. Staff stated that based on the documented care plans that were required for R2's care and due to safety concerns, R2 was not permitted to leave the facility unassisted. Additionally, there was an instruction requiring that a family member (FM) grant authorization before R2 was permitted to leave the community. Staff confirmed that no residents are restrained and that R2 does not have a restraint device. (11) out of (15) residents interviewed stated that they can leave the community whenever they want and none of the staff ever tried to stop them. (3) out of (15) stated that they wanted to leave the facility on their own but their doctor restricted them to leave unassisted. Some interviewed residents also stated that they feel safe leaving and have not been threatened by any staff when leaving the premises. Review of R2's Physician's report indicated that R2 cannot leave unassisted. LPA also confirmed the family member's instruction about getting permission for R2 to leave the community. During the visit, LPA also observed that the reception area maintains a list of residents who are restricted to leave the facility unassisted. Furthermore, the facility maintains a sign in and out logs and residents are free to come and go. Therefore there was insufficient evidence to corroborate with this allegation. Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive 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 violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Maria Quizon, Executive Director.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 28-AS-20251226111803

Allegation investigated: Staff provided unwashed utensils to resident in care Staff did not attend to resident call for assistance Staff did not keep the facility free of pests

On today’s visit, Licensing Program Analyst (LPA) Luis De Leon conducted a subsequent complaint visit and met with Business Office Manager Michelle Castillo. LPA explained the reason for today’s visit was to deliver findings on the above allegations. LPA toured residents’ common areas and observed no health and safety risks. LPA interviewed one resident and obtained staff and resident rosters and Pendant Response Time. During the initial visit on 7/1/2025, LPA toured the facility and obtained copies of the following documents: Staff roster, Resident roster, R1’s physicians reports, resident assessments, admission agreement, face sheet, facility maintenance work orders, pest control invoices, and operation plan for call response and kitchen sanitation. LPA interviewed eleven (10) residents and seven (7) staff. Report continues on page LIC-9099C... Unsubstantiated Regarding allegation: Staff provided unwashed utensils to resident in care. It is alleged that the staff does not follow proper cleaning procedures for utensils used by resident in the dining room area. Investigation consisted of interview with staff, residents, and LPA observations. LPA interview with residents revealed that ten (10) out eleven (11) residents denied the allegation above. Residents stated that residents have not seen or heard of utensils to be dirty or unwashed. Residents stated that facility is clean and staff do a great job. Residents stated that staff wraps utensils in napkins to keep them clean. LPA interview with staff revealed that seven (7) out of seven (7) staff denied the allegation above. Staff stated that staff has not heard of any issues with dishwasher that would fail to clean utensils or dishes. Staff stated that sometimes residents use utensils and place utensils back on the table, but if staff notices it, the staff will remove utensils or dishes that have been used by residents. LPA observed the dish washing station while washing breakfast utensils and dishes. LPA did not observe staff failing to follow cleaning procedure for utensils and dishes. LPA observed serving stations and all utensils and dishes were clean. Based upon the investigation, residents and staff interviews, and LPA observations, there is no evidence to support that the facility staff is failing to wash utensils and dishes. Regarding allegation: Staff did not attend to resident call for assistance. It is alleged that R1 has fallen a couple of times and staff failed to provide assistance. Investigation consisted of interview with staff, residents, and LPA observations. The investigation reveals the following: LPA interview with residents revealed that six (6) out eleven (11) residents denied the allegation above and stated that staff have responded in a timely manner or that residents have not needed to call for assistance. R8 stated that R8 used the call pendant, and the staff response was quick. Residents have observed that staff take longer to respond in the morning when staff prepares residents for grooming, showering, and escorting residents to the dining area. Eight (8) out eleven (11) residents stated that staff treats residents well and with respect. Interviews with staff reveal that seven (7) out of seven (7) staff denied the allegation. Staff denied not responding to residents call for assistance. Staff stated that the average response time is 10-15 minutes. If a caregiver is not able to respond, the med tech team assist with residents calls for assistance. Staff stated that the morning shift is more challenging for the number of residents who request assistance for preparing residents for breakfast, showering, and grooming. LPA tested the call system on four residents rooms. LPA observed that staff responded within the average response time in three (3) out of four (4) calls for assistance. Based upon the investigation, residents and staff interviews, and LPA observations, there is no evidence to support that the facility staff is not attending residents call for assistance. Report continues on page LIC-9099C... Regarding allegation: Staff did not keep the facility free of pests. It is alleged that the facility does not maintain facility clean free of bugs such as fleas. Investigation consisted of interview with staff, residents, facility work order logs for the period of 04/6/2025 thru 07/01/2025, Pest control invoices, and LPA observations. The investigation reveals the following: The facility work order logs records four instances, in three different residents’ room, where residents requested for bug spray in their rooms for flies. Pest control invoices revealed that the pest control treatments are done once a month. LPA interview with residents revealed that eight (8) out eleven (11) residents denied the allegation above and stated that they have not seen or heard of any pest in residents’ rooms including roaches, fleas, or flies. R1 and R5 stated that residents had seen gnats come in through the window, but if reported, staff will spray quickly. Interviews with staff reveal that seven (7) out of seven (7) staff denied the allegation. Staff denied knowing that the facility has issues with pest. Staff described issues with flies in rooms due to residents bringing fruit to residents’ rooms. Staff described water bug or roaches in patio drains but pest control is immediately contacted to treat the area. Staff denied hearing any issues with fleas. LPA did not observe any pests in residents rooms and common areas in the facility. Based upon the investigation, residents and staff interviews, document reviews, and LPA observations, there is no evidence to support that the facility staff is not maintaining the facility free of pests. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held with Executive Director Maria Quizon. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 28-AS-20250626085735

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

Licensing Program Analyst (LPA) Nune Margaryan conducted a complaint visit to investigate the allegation listed above. LPA met with Maria Quizon, Administrator who assisted with the visit. Reason for the visit was explained. The investigation consisted of the following: LPA Margaryan requested Staff and Residents rooster, conducted interviews with Administrator, Staff 1 to Staff 4 (S1 to S4) and Resident 1 to Resident 10 (R1 to R10). LPA reviewed R1's file and obtained relevant documents. Continue 9099C Unsubstantiated Regarding Allegation: Staff did not ensure residents personal property was safely secured. It was alleged that R1's personal belongings stolen. Interviewed Administrator and staff denied the allegation. They stated that all residents personal belongings are safety secure. They indicated that they have never stolen any resident personal belongings, never heard of any residents stealing anyone's personal belongings, and would notify and report it if they did hear of them stealing. They stated sometimes residents’ personal belongings were misplaced in their rooms or being stored in their closets after washed, but never stolen. Interviewed Administrator stated that if there is any report from the residents regarding any missing personal belongings they will talk to the staff immediately to assist the residents to find the item. Administrator stated that they will check the room, laundry, common areas. Interviewed Administrator and staff stated that they didn't hear from the residents that their personal items were stolen. All interviewed residents stated none of their personal belongings have gone missing. They stated they haven't heard of any one stealing someone's personal belongings. Review of R1's file Client/Resident Personal Property and Valuables document dated 2/11/25, has signature of R1's representative which states: "At the present time I decline to track personal property". 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, therefore the allegation is Unsubstantiated. Exit interview was conducted and the copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 28-AS-20251217135910

Allegation investigated: Staff do not prevent a resident from pulling the fire alarm

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced complaint visit to investigate the above allegation. LPA met Maria Quizon, Executive Director and discussed the purpose of the visit. The investigation consisted of the following: LPA obtained and reviewed staff and resident rosters, staff rosters, interviewed four (4) staff, ten (10) residents, took tour of facility including memory care. The investigation revealed regarding: Staff do not prevent a resident from pulling the fire alarm. It is alleged that resident is setting off the fire alarm and staff do not prevent resident from doing it. LPA interviewed five (5) staff and three (3) of five staff confirmed that someone pulled the fire alarm. The three (3) staff stated it only happened once on 12/18/2025. LPA interviewed ten (10) residents and seven (7) of ten (10) residents stated they heard the alarm at least once and several residents stated they heard it more than once. All ten (10) residents could not identify the person or witness the person that set off the fire alarm. (continued on 9099C) Unsubstantiated (Continued from 9099) Facility staff were unable to identify the resident or person setting the alarm. The Executive Director stated that she will be having refresher training for staff to be able to monitor the residents to prevent this from happening again. She also stated that she will hold a meeting with the residents to answer any questions they may have. The person responsible for setting off the fire alarm has not been identified, and facility is addressing the issue. Executive Director stated she will install covers for the alarms in assisted living like they have in memory care to address the issue. There is insufficient evidence to substantiate this allegation. Based on interviews conducted, there is insufficient evidence to support the allegation. 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, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted, technical advisory issued and a copy of this report was provided along with appeal rights.the state’s words, verbatim · CDSS document, Dec 22, 2025 · control 28-AS-20251216142626

Allegation investigated: Staff do not safeguard resident's personal belongings Staff do not respond to calls from resident's representative in a timely manner

Licensing Program Analysts (LPA) Christian Gutierrez conducted an unannounced subsequent complaint visit in response to the above allegations. LPA met with Stasha Provitt who assisted with today’s visit. The investigation consisted of the following: During the initial visit conducted on 12/06/2025, LPA interviewed Executive Director, Staff 1-staff 6 (S1-S6), residents 2- residents 5(R2-R5) and witness 1- witness 3 (W1-W3) by telephone. LPA obtained copies of the following documents: staff roster, resident roster, R1’s physicians reports LIC 602, Residents appraisal LIC 603, wellness group history and physical report, and emails regarding R1’s lost item. During today’s visit LPA delivered findings. SEE LIC 9099C Unsubstantiated In regard to the allegation “Staff do not safeguard resident's personal belongings”, it is alleged that R1 was missing prescription glasses. During interviews with Administrator and staff four (4) out of seven (7) stated that R1 always takes off his/her glasses and puts them down. Staff stated that R1 needs to be remined to put on their glasses and they are always found under the bed or in the pillows. Administrator stated that although R1 may have never took of glasses before this could be a new behavior with someone with dementia. During interviews with residents two (2) out of five (5) residents stated they have never had anything missing from facility. R3 stated that they had a missing item but never reported it to staff. In regard to the allegation “Staff do not respond to calls from resident's representative in a timely Manner”, it is alleged that facility took to long to respond to phone calls and emails about R1’s missing item. During interviews with Administrator and staff seven (7) out of seven (7) stated that they always call back family and friends in a timely manner. Administrator stated that it took three days to call representative of R1 back because that was their first day working at the facility. S4 stated that he/she took the call from the representative on Saturday and informed them that the people they were emailing were no longer with the company. S4 all stated that they personally went to look for the missing item. LPA interviewed three (3) witnesses by telephone and all three stated they have had no issues in regard to callbacks or emails from the facility. Witness #2 two stated that it might take a little longer for a caregiver to call back but that’s because they are busy with residents. LPA obtained emails from S4 to staff explaining glasses were missing and new email contacts were proved to R1’s representative. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. 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 the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided. _the state’s words, verbatim · CDSS document, Dec 20, 2025 · control 28-AS-20251208151137

Allegation investigated: Staff does not ensure facility plumbing is in good repair. Staff do not treat residents with respect.

Licensing Program Analyst (LPA) Elizabeth Irra conducted a visit to investigate the above allegations. LPA met with Maria Quizon and discussed the purpose of today’s visit. During today’s visit, LPA obtained a copy of the resident and staff rosters, interviewed Staff #1 (S-1) through Staff #7 (S-7), interviewed Resident #1 (R-1) through Resident #10 (R-10) and conducted a tour. Refer to LIC 9099C for the continuation of this report. Unsubstantiated Allegation: Staff does not ensure facility plumbing is in good repair. It has been alleged that last Summer (2) hallway bathrooms were out of order for over a month and that this facility lacks proper maintenance, upkeep and does not repair bathroom plumbing in a timely manner. Staff interviews revealed that all hallway bathrooms have been and continue to be operational (including Summer 2025). Interviewed staff indicated that this facility has not had any major plumbing problems. Interviewed staff indicated that the most common plumbing issue is clogged toilets (due to wipes being flushed down the toilet which causes the toilet to be clogged). Per staff interviews, when toilets get clogged, the maintenance staff repair the issue in a timely manner (same day). Staff indicated that they have not received complaints/concerns pertaining to plumbing repairs not being completed in a timely manner. Resident interviews revealed that they do not have any concerns pertaining to the plumbing at this facility. Interviewed residents indicated that they have not had any plumbing issues in their bathrooms nor there has been any issues in the common area bathrooms. Interviewed residents did not have any concerns pertaining to this matter. LPA conducted a tour of the following and did not observe any plumbing issues: restroom near the employee lounge (1st floor), bathroom near the discovery room (1st floor), restroom near room #254 (2nd floor), restroom near the activity room (2nd floor), room #107, room #111, room #113, room #114, room #115, room #213, room #250, room #224 and room #260. Interviews and tour do not corroborate this allegation. Allegation: Staff do not treat residents with respect. It has been alleged that staff come across “as rude and arrogant and unfriendly” and that staff are “gossiping and spreading immature rumors that are untrue of residents”. Staff interviews revealed that staff are not rude, arrogant nor unfriendly. Interviewed staff indicated that they do not gossip and/or spread any rumors nor have they witnessed any staff doing this. Interviewed staff indicated that they are trained in Resident Rights and Mandated Reporting. Interviewed staff indicated that they have not received any complaints pertaining to this matter. Interviewed residents indicated that staff are respectful, helpful and courteous. Interviewed residents have not heard nor witnessed any staff being disrespectful to anyone. Interviewed residents have not heard anyone complaining about this matter. Interviewed residents indicated they do not have any concerns. Interviews do not corroborate this allegation. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report and appeal were provided to Maria Quizon.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 28-AS-20251211093818

Allegation investigated: Staff did not keep facility free of insects. Staff overcharged a resident in care. Staff did not seek timely medical attention for resident in care. Staff refused to assist resident in care with their insurance application. Staff did not provide good quality foods to residents in care. Staff did not provide proper housekeeping services to residents in care. Staff did not treat resident with respect.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to deliever findings on the above allegations. LPA met with Stasha Provitt and discussed the purpose of the visit. The investigation consisted of the following: On 12/12/25 LPA conducted an intital 10day visit and obtained copies of staff/resident rosters, copy of food menu and alternate menu, copies of the following documents from R1's file: admission agreement, insurance information, payment history. LPA toured facility, kitchen, dining, and random rooms were inspected, and LPA conducted interviews with 6 Staff and 11 Residents. During todays visit 12/13/25 LPA typed report with findings and delivered findings for the reported allegations. (Continued on the LIC9099-C page) Unsubstantiated The investigation revealed the following: Allegation: Staff did not keep facility free of insects. It is alleged that the facility has a roach infestation. LPA toured facility, the kitchen/dining, 1st floor and 2nd floor, and a total of 8 resident rooms were inspected and LPA did not observe any insects or roaches throughout the facility. LPA interviewed 6 staff and each denied the allegation, interview with S1 revealed that there is a monthly pest control that inspects and services the facility and there have been no observations of any insects or bugs at the facility. LPA interviewed 11 residents and 9 out of 11 residents denied the allegation and stated that they have not observed roaches anywhere in the facility or their rooms. Allegation: Staff overcharged a resident in care. It is alleged that R1 was accused of not paying rent and forced to pay their rent twice to avoid eviction. LPA reviewed R1’s file and observed that R1 is set up on an auto withdrawal and month of July 2025 was skipped but paid in August 2025, therefore, the month of August had 2 charges. LPA interviewed 6 staff and each denied the allegation, interview with S1 revealed that there was an error in the month of July 2025 where several residents including R1 did not get charged, during an audit in August the error was discovered and residents were informed and each (including R1) agreed to pay in the month of August. S1 stated since that error was found their procedure for auto payments have changed to where now instead of staff manually inputting the information to authorize the withdrawal each month, those on auto pay are now electronically on a payment plan where funds will be withdrawn automatically with no need of staff manually processing payments. LPA interviewed 11 residents and 10 of the 11 residents denied the allegation and stated that they have not had any issues with their rent and have never been over charged. Allegation: Staff did not seek timely medical attention for resident in care. It is alleged that R1 experienced a fall last summer and had to wait hours for medical transport. LPA reviewed R1’s file and did not observe any notes indicating R1 had a fall and file revealed that R1 is independent and fully ambulatory. LPA interviewed 6 staff and each denied the allegation and stated that staff tend to residents immediately, if staff are busy assisting another resident when a call is heard another available staff will assist or that staff will assist as soon as they are done with the resident they are working with. LPA interviewed 11 residents and 10 out of 11 residents denied the allegation and stated that they have never had any issues with getting medical attention in a timely manner. (Continued on the LIC9099-C page) Allegation: Staff refused to assist resident in care with their insurance application. It is alleged that S1 refused to assist R1 with getting their insurance set up. LPA reviewed R1’s file and observed that they have valid insurance, resident is self responsible and schedules their own visits. LPA interviewed 6 staff and each denied the above allegation, interviews with S1, S2 and S4 revealed that upon admission the insurance is set up and residents are assisted with being added to an assisted living waiver program that provides assistance/supplies/funds to their medical needs and without residents having insurance they would not be able to be a part of that program. Interviews with S1 and S4 revealed that although there were issues with the insurance group that R1 was originally with upon admission they did provide assistance in changing the insurance, however, the insurance company did not want to release information to staff and required R1 to be present for any and all changes in which R1’s expectation was for staff to handle all the changes. LPA interviewed 11 residents and 10 out of the 11 residents denied the allegation and stated that they have not had any issues with their insurance or the set up process and stated that the staff have been helpful with their needs. Allegation: Staff did not provide good quality foods to residents in care. It is alleged that the facility has poor food. LPA toured dining/kitchen and observed a sufficient supply of perishable foods and non-perishable foods, during the lunch hour LPA observed resident meal of egg salad sandwich with watermelon, some residents ordered off the alternate menu and meals such as a caeser salad and hamburgers were provided to those residents, residents were also observed to have a dessert with their lunch including Jello, ice cream or fresh fruit. LPA reviewed the food menu and alternate menu and meals match what LPA observed during visit. LPA interviewed 6 staff and each denied the allegation and stated that they think the food is good and nutritious and have not heard complaints about the food. Interview with S1 revealed that there is a resident committee and meetings that are held with the chef and residents where preferences are discussed and chef will make adjustments to accommodate those requests and preferences when possible. LPA interviewed 11 residents and 10 out of the 11 residents denied the allegation, although some stated that some of the meals are not to their liking they did share that the alternative menu is available and they are accommodated with something different than the meal of the day when they ask. (Continued on the LIC9099-C page) Allegation: Staff did not provide proper housekeeping services to residents in care. It is alleged that the facility has poor house cleaning. LPA toured facility a total of 7 resident rooms were inspected as well as dining area and kitchen, LPA did not observe facility to have poor housekeeping. Housekeepers and Caregivers were observed to be cleaning and throwing away trash from residents room during tour. LPA toured R1’s room and although R1’s personal belongings did appear to be scattered the room did not appear to be dirty, beds were made, floor appeared clean and trash was empty. LPA interviewed 6 staff and each denied the above allegation and stated that house keeping is done daily with the routine work such as sweeping, taking out trash and making beds, the deep cleaning is done once weekly where housekeeping will mop, dust, clean bathroom, change linens and do laundry. LPA interviewed 11 residents and 10 of the 11 residents denied the above allegation, residents stated that the minor housekeeping is done daily and a deep cleaning is done once a week, residents also stated they don’t have issues with the housekeeping. Allegation: Staff did not treat resident with respect. It is alleged that S1 yelled, humiliated, embarrassed and accused R1 of kidnapping. Per interview with R1, resident stated they are being wrongly accused of taking another resident (R12) out of the facility without any approval. LPA interviewed S1 and they denied the allegation and stated that R1 went on an outing and lied to front desk staff that they had prior permission to take R12 out of the facility on an outing, when staff left to verify R1 quickly left facility with R12, S1 stated that R12 is not able to leave facility unassisted and R1 is not listed as a responsible party for R12. LPA reviewed R12’s file and did not see R1 listed as a responsible party, R12 has only family listed as a responsible party and POA. LPA also reviewed R12’s physician report dated 2/11/25 and it indicates that resident is not able to leave facility unassisted. LPA interviewed a total of 6 staff and each denied the allegation and stated they have never nor have they ever witnessed any other staff yell, humiliate, embarrass or accuse any of the residents. Interviews with S1-S2 & S5-S4, revealed that R12 is not to leave the facility unassisted and have been advised by POA that only the POA can take R12 out of the facility unless otherwise stated/approved, which they have not yet done so. LPA interviewed a total of 11 residents and each denied the allegation and stated they have never been yelled at, humiliated, embarrassed or accused of anything by staff and say staff treat them with respect. During inspection of R1's room, LPA observed that the toilet in the private bathroom that R1 and their roommate share was not operable, LPA conducted a case management visit and issued a citation during the initial visit. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened are is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 13, 2025 · control 28-AS-20251210121051

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tena Herrera generated this Case Management visit and report as there was a - Deficiency observed during todays complaint investigation for complaint control number 28-AS-20251210121051. The purpose of the report was explained to staff. During complaint investigation, LPA toured facility and observed Room #116's toilet to be completely off and in the shower. It was explained to LPA by Adrian Castillo (Maintenance Director) that there is a plumber arriving to repair toilet today 12/12/25 as the toilet is clogged. LPA toured room once again prior to concluding visit (around 3:20pm) and toilet was still not repaired and taken apart. Based on observation and conversation with Adrian Castillo, the toilet in room #116 is not in operating condition, a citation is being issued during todays visit please see LIC809-D for details. An exit interview was conducted, and a copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Dec 12, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(6) · Plan of correction due date: Dec 19, 2025

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement was not met as evidence by: During facility tour LPA observed Room #116's toilet to be completely off and in the shower. It was explained to LPA by facility's Maintenance Director that there is a plumber arriving to repair toilet today 12/12/25 as the toilet is clogged. LPA toured room once again prior to concluding visit (around 3:20pm) and toilet was still not repaired and taken apart.the state’s words, verbatim · CDSS document, Dec 12, 2025

Plan of correction: Licensee/Administrator to have toilet repaired and submit proof of repair via email to LPA by POC due date. A copy of the invoice/work order and photo of toilet back in its proper area is to be emailed as proof. tena.herrera@dss.ca.gov

Allegation investigated: Staff did not respond to resident's call button in a timely manner. Staff left resident on the floor for an extended period of time.

Licensing Program Analyst (LPA) Alberto Lopez made subsequent unannounced visit to deliver finding for the above-mentioned allegations. LPA met with Stasha Provitt, Community Liason Director and discussed the purpose of the visit. LPA interviewed seven (7) staff total (S#1 – S#7) and Eleven (11) residents (R#1 -R#11) On 11/24/2025 Licensing Program Analyst (LPA) Alberto Lopez made an unannounced complaint visit to investigate the above allegations. LPA met with Karine Tomassian, Admissions Coordinator, and discussed the purpose of the visit. The investigation consisted of LPA taking a tour of facility common area and random rooms, reviewing and obtaining staff and resident roosters, schedule for November 7, 2025, call light log for November 7, 2025, interviews with five (5) staff and Eleven (11) residents. Due to lack of information, requires needs further investigation, LPA will return another day. (Continued on 9099C) Substantiated (continued from 9099) Allegations: Staff did not respond to resident's call button in a timely manner. It is alledged that resident pressed call pendant due to fall and staff did not respond in timely manner. - Staff left resident on the floor for an extended period of time. It is alleged that resident was on the floor for an unreasonable amount of time. On November 7, 2025 at approximately 5:00am, R1 had a fall, hit head on the closet doors and fell to the ground. R1 stated R1 pushed call pendant, and R1 waited for what seemed to be a very long time. Several staff blamed other co-workers for the delay. LPA reviewed the call light log for November 7, 2025, and it showed that R1 pressed the pendant at 4:57:00 AM, at 5:06:11AM, the pendant pressed cleared, 9 minutes and 11 seconds after it was initially pressed. At 5:06:00AM, R2 pressed R2 pendant to get assistance for R1 who remained on the floor. At 5:18:42 it was acknowledged by: desk, front. At 5:30:17 AM, the pendant pressed cleared. Based on records reviewed, the resident spent 9 minutes 11 seconds on the floor or 24 minutes 17 seconds on the floor. Both times are unreasonable for any resident to spend on the floor. One staff member stated it was about 30 minutes that resident spent on the floor. R2 stated it was more like an hour. There is sufficient evidence to substantiate both allegations. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was provided. (continued from 9099A) The investigation revealed: Allegation Facility does not have adequate staffing to meet resident's needs. It is alleged that the facility does to have enough staff to meet resident’s needs. LPA interviewed seven (7) staff and five (5) of seven (7) staff denied the allegation. LPA interviewed eleven (11) residents and nine (9) of eleven (11) residents agreed that facility could use more staff. LPA reviewed the current schedule, and it shows the facility schedules three (3) to five (5) caregivers plus two (2) to four (4) Med-Techs during the day. The schedule shows the facility schedules two (2) caregivers, one (1) front desk and one Med-Tech during the NOC shift which is 10PM – 6:00AM. Facility appears to have sufficient staff scheduled to meet residents needs. There is not enough evidence to substantiate this allegation. 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, therefore the allegation is UNSUBSTANTIATED. A copy of this report was provided to staff.the state’s words, verbatim · CDSS document, Dec 6, 2025 · control 28-AS-20251119194926

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87415(a)(2) · Plan of correction due date: Dec 16, 2025

87415(a)(2) - Night Supervision (a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m....shall be available... to assist in caring for residents. (2) In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake.... This requirement was not met as evidenced by: LPA's interviews with staff, residents and review of facility alarm event report for 11/07/2025 showed that staff did not respond in timely manner and that resulted in R1 spending 9 minutes 11 seconds or 24 minutes 17 seconds on the floor. Both times are unreasonable call light respond times or for any resident to spend on the floor. This poses a potential health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Dec 6, 2025

Plan of correction: Licensee will conduct an in-service training regarding call light response and submit POC to LPA by 12/16/2025

Allegation investigated: Staff are retaliating against resident. Staff are not ensuring that resident is provided meals in a timely manner.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 12/05/2025 regarding the above allegations. During today’s visit LPA Ramirez was greeted by Administrator Maria Quizon and explained the purpose of the visit. On 11/10/2025, LPA Ramirez conducted an initial visit and a needs further investigation was documented. The investigation consisted of the following: LPA Ramirez requested and obtained a copy of Resident/Client Roster, Staff#1 - 6 interviews (S1 – S6), Resident#1-9 (R1-R9) interviews review of Resident#1-9 (R1-R9) facility file, review of staff#4-6 (S4-S6) personnel file, and tour of dining room area. SEE 9099-C for continued report Unsubstantiated The investigation revealed the following: regarding the allegation “Staff are retaliating against resident.” It is alleged that staff are retaliating against a resident. Eight (8) out of the nine (9) residents interviewed did not corroborate this allegation. Interviews with eight (8) residents revealed that staff have never retaliated against them and have always been professional when providing care. Six (6) out of the six (6) staff interviewed denied this allegation. Staff interviewed revealed that any type of mistreatment or retaliation against residents is not allowed and would report retaliation if they observed it. Review of S4-S6 personnel files did not corroborate the allegation that staff are retaliating against a resident. 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, therefore the allegation is UNSUBSTANTIATED. “Staff are not ensuring that resident is provided meals in a timely manner.” It is alleged that staff are not ensuring that a resident is provided with meals in a timely manner. Eight (8) out of the nine (9) residents interviewed did not corroborate this allegation. R5 and R6 revealed they have received their meals late in the past, but it was within reason, and they felt that their meals were late due to their table placement. Six (6) out of the six (6) staff interviewed denied this allegation. Staff interviews revealed that the dining room is set up as a “restaurant” style dining experience and residents’ orders are taken by servers once the resident is seated. Staff interviews revealed that once a server takes a table’s order, servers place the tickets on holder in the kitchen for the cooks but sometimes the kitchen gets backed up by plating the orders or if a resident changes their mind and orders something different, the ticket gets placed in order received. On 11/10/25, LPA Ramirez observed servers taking lunch orders and bringing meals out to resident tables. LPA Ramirez observed most meals were delivered to tables within 4 to 6 minutes of orders being placed. 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, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited for this complaint investigation. A copy of this report was provided via email due to printer out of ink.the state’s words, verbatim · CDSS document, Dec 5, 2025 · control 28-AS-20251105150508

Allegation investigated: Staff neglect resulted in a resident sustaining multiple pressure injuries. Lack of supervision let to multiple falls resulting in injuries Staff did not address a resident's change in medical condition. Staff did not seek timely medical attention for a resident. Staff did not ensure a resident consumed an appropriate amount of liquid while in care.

Licensing Program Analyst (LPA) Alberto Lopez made a subsequent visit to facility to investigate the above allegations. LPA met with Michelle Castillo, Business Office Manager, and discussed the purpose of the visit. 11/25/2024 - Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Stephanie Funderburg, Administrator, and explained the reason for the visit. The investigation consisted of the following: LPA requested a copy of staff/resident roster. LPA conducted a health and safety check tour of the facility and observed commercial kitchen, common areas, and 13 residents’ randomly chosen rooms. There are sufficient food supplies for at least 2 days of perishables, and 7 days of non-perishables. (Continued on 9099C) Substantiated (Continued from 9099) Water temperature was tested in each residents room and tested between 108.0 -109.2 degrees F., which is within the required 105-120 degrees F. LPA reviewed and requested copies of resident #1(R1)'s file. LPA interviewed Administrator. No health and safety hazards were observed during visit. LPA reviewed and obtained resident’s hospital records, home health records, and other pertinent medical information. LPA also reviewed the department’s investigation reports. LPA interviewed five (5) staff and five (5) residents. Allegation: Staff neglect resulted in a resident sustaining multiple pressure injuries. It is alleged that facility staff neglected resident which caused resident to develop pressure injuries. The investigation revealed: LPA interviewed five (5) staff, and three (3) of five (5) staff denied the allegation, stating they were not aware of the allegation. Two (2) staff stated they reported the wound(s) to their supervisor who no longer works at facility. LPA interviewed five (5) residents, and all five (5) residents could not corroborate the allegation. The department investigated this allegation and presented the following. The resident moved into the facility on 9/11/2024 with no pressure injuries. He was identified as needing full assistance with bathing and dressing in the resident assessment dated 09/11/2024. Caregivers did not observe or address the wounds during bathing and dressing tasks. On 11/16/2024 the resident was discovered with an open wound pressure injury on resident’s sacral area that was described as stage 3 wound by an Agency Med Tech who saw the resident’s wound the day of discovery. The resident was admitted to the hospital on 11/19/2024 and was diagnosed with an unstageable pressure injury on his sacral area. In addition to the sacral pressure injury, deep tissue pressure injuries (DTIs) were discovered on the victim’s right hip, as well as on his left and right heels, and feet. Facility caregivers failed to provide an appropriate level of care and supervision resulting in pressure injuries. There is enough evidence to prove that facility staff neglected resident causing resident to sustain pressure injuries. Allegation: Lack of supervision lead to multiple falls resulting in injuries. It is alleged that resident had multiple falls that led to injuries. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. LPA interviewed five (5) residents, and all five (5) residents could not corroborate the allegation. Resident had been residing in the Baldwin Gardens Skilled Nursing facility from 12/24/2023 until 9/11/2024. The resident was sent to Arcadia USC Hospital on 7/15/2024 and a CT of the victim’s head was done. The CT scan revealed no injuries, and no subdural hematomas were found on the CT scan. After returning to the SNF the resident was placed onto one-on one supervision for the remainder of his time there and resident had no further falls. Records revealed the resident had two falls while residing at the facility, the first fall occurred on 9/14/2024. (CONTINUED) (Continued from (9099C) The date for the second fall is not clear but possibly around 10/20/2024. Resident was not taken to hospital during those falls despite residing in the memory care section. On 11/19/2024 Resident was diagnosed with hematoma; however, there is no evidence that the Injury/hematoma developed due to fall(s) on 09/14/2024 and 10/20/2024. A review of the records indicated that during a home health nursing visit on 10/30/2024 nurse learned that the victim had a fall on 10/23/2024 while walking to the bathroom. Home Health notes for 11/8/2024 indicated the victim had a laceration on his shin due to the fall. On 11/15/2024 the victim was seen by a home health nurse and the wound was healed There is enough evidence to support this allegation. Allegation: Staff did not address a resident's change in medical condition. It is alleged that resident had a change of condition and staff did not address it. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. LPA interviewed five (5) residents, and all five (5) residents could not corroborate the allegation. It is documented by hospital admission records that resident arrived at emergency room on 11/19/2025 with a sacral wound that was diagnosed as unstageable and resident had developed eight (8) deep tissue pressure injuries (right elbow, right hip, right lateral ankle, right lateral foot, left medial foot, left lateral ankle, and left heel. Resident had a change of condition days before been sent to hospital and staff did not address the change of condition. There is enough evidence to substantiate this allegation. Staff did not seek timely medical attention for a resident. It is alleged that staff did not provide timely medical attention to resident after resident suffered two falls. LPA interviewed five (5) staff, and five (5) staff denied the allegation. LPA interviewed five (5) residents, and all five (5) residents could not corroborate with the allegation. Facility records revealed the resident had two falls while residing at the facility, the first fall occurred on 9/14/2024. The date for the second fall is not clear but possibly around 10/20/2024. and resident was not taken to the hospital for medical assessment despite residing in the memory care section of the facility. No other falls were listed in the obtained notes. The facility did not obtain timely wound care/medical attention to address the developing pressure injuries resulting in the multiple pressure injuries identified in the first allegation. There is sufficient evidence to substantiate this allegation. Allegation: Staff did not ensure a resident consumed an appropriate amount of liquid while in care. It is alleged that staff did not ensure resident was provided with an appropriate amount of liquids that lead to resident being diagnosed with dehydration when admitted to hospital on 11/19/2024. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. Several staff stated resident refused food and liquids. LPA interviewed five (5) residents, and all five (5) residents could not corroborate the allegation. Resident was admitted to hospital on 11/19/2024 and hospital records show that resident was dehydrated on arrival. Facility records show that resident suffered from diarrhea and staff did not ensure resident consumed enough liquids. There is sufficient evidence to substantiate this allegation. (CONTINUED) (Continued from 9099C) Based on the department's interviews which were conducted, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Deficiencies noted on LIC 9099D. Exit interview was conducted with Maria Quizon, Administrator and Michelle Castillo, Business Office Manger, and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 28-AS-20241122160546

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Dec 3, 2025

(a) Persons who require health services for or have a health condition...shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Record review shows that R1 developed stage 3 and 4 pressure injuries while at the facility and was retained by facility.the state’s words, verbatim · CDSS document, Dec 2, 2025

Plan of correction: The licensee shall review the prohibited health conditions regulation 87615 and shall not retain a resident with stage 3 and 4 pressure injuries. Licensee will send written notice that section 87615 has been reviewed and understood. $500 immediate civil penalty

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Dec 16, 2025

87468.1(a)(16) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This requirement is not met evidenced by: R1 was not provided timely medical care for pressure injuries.the state’s words, verbatim · CDSS document, Dec 2, 2025

Plan of correction: Licensee will read section 87468 and write a statement indicating that licensee read and understand the section. Also, Licensee will provide personal rights training to all staff and have all staff sign the roster as proof that training was provided.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 10, 2025

87411(a) Personnel requirements general. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: After R1 was admitted to the hospital and was diagnosed with dehydration. Medical documents showed the resident was lacking fluid intake. Medical records show the resident was suffering from diarrhea at facility and interviews with staff indicated that resident was refusing liquids.the state’s words, verbatim · CDSS document, Dec 2, 2025

Plan of correction: The facility will provide training to staff on the observation and needs of all the residents and send proof to LPA by POC date.

Allegation investigated: Staff are not administering residents' medications as prescribed

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Community Director Stasha Provitt who assisted with today’s visit. The investigation consisted of the following: During the initial visit conducted on 11/06/2025, LPA interviewed Executive Director, Staff 1-staff 3 (s1-S3) and residents 2- residents 10 (R2-R10). LPA obtained copies of the following documents: Staff roster, resident roster, R1’s physicians reports, identification information (LIC 601), orders for medication, hospital discharge paperwork with updated medication, and Medication distribution log. LPA also did random medication checks and obtained documents for residents’ medication distribution. During today’s visit LPA Gutierrez delivered findings. SEE LIC 9099C Substantiated In regard to the allegation” Staff are not administering residents' medications as prescribed”, It is alleged that R1 did not receive medication despite documentation stating that he/she did. R1 was not present at the facility for the time medication was marked given. Its is also alleged that R1 was given medication that had been discontinued by physicians During interview with Administrator, and staff two (2) out of four (4) stated that there was a medication error and R1 did not receive medication due to them being away with family for the day even though it was signed off as given. S4 stated that R1 was given discontinued medication because it was put in the medication cart even though it was discontinued. During interviews with residents eight (8) out of ten (10) residents stated that they have had no problems with medication to their knowledge. LPA conducted random medication check on residents’ medication and found errors and discrepancies in all five residents checked. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 22, 2025 · control 28-AS-20251104120932

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 23, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. Based on observations and interviews licensee did not ensure, R1 received the medication prescribed due to R1 not being in the facility also R1 was given discontinued medication by staff which poses an immediate risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Nov 22, 2025

Plan of correction: Administrator will conduct training with staff on 87465(a)(4) and the importance of medication given to residents correctly and on prescribed time.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christian Gutierrez generated this Case Management - Deficiencies report in conjunction with complaint control 28-AS-20251104120932 pertaining to observations during record review. The purpose of the report was explained to staff. During complaint investigation, LPA Gutierrez observed R1 medication log being marked by staff as given for the date of 11/01/2025 even though R1 was not present in the facility. Based on observation, a citation is being issued. See LIC 809D. An exit interview was conducted, and a copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Nov 22, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Nov 28, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff Based on interviews conducted with other agencies licensee did not ensure staff were following complete and correct record log for medication infection which poses a potential risk to the persons safety, health, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Nov 22, 2025

Plan of correction: Administrator will conduct training with staff on section 87506 and ensure staff does not sign for medication that is not given to residents. Administrator will send training to LPA by POC due date.

Allegation investigated: Staff handled resident in a rough manner

The purpose of this report is to conduct additional staff interviews regarding the above allegation from the initial complaint dated 10/15/2025. LPA met with Administrator Stephanie Funderburg and discussed the purpose of the visit. At today's visit 11/06/2025 Staff S1- S4 were interviewed. The initial visit was conducted on 10/20/2025 and included the following: Licensing Program Analyst (LPA) Glenn Trueman made an unannounced initial visit to investigate the above allegation. LPA met with Stephanie Funderburg and discussed the purpose of the visit. The investigation consisted of LPA reviewing and obtaining copies of staff and resident rosters, R1's file was reviewed and Admission Agreement. Physician's Report and Emergency ID Face sheet were submitted. Interviews were conducted with (2) staff (S1-S2), eleven (11) residents (R#1-R#11) Administrator was also interviewed. The investigation revealed regarding Allegation Staff handled resident in a rough manner, based on interviews conducted and information gathered Resident's R3- R11 all stated that they never observed Unsubstantiated staff doing anything verbally or physically abusive. R3 and R11 stated they live over the courtyard and have not seen staff mishandling residents in a rough manner. R3- R11 also stated that staff treat them well and will help them if they ask for assistance. Administrator stated that Staff S1 said that the alleged incident never happened. Said there has not been any complaints regarding S1 previously. Staff S1 stated that the incident didn't occur. Said the alleged incident doesn't reflect on S1 as a person. Said that will comb residents hair and maybe that was misinterpreted. Also stated that residents are treated with respect and has no idea why the allegation was made. Staff S2 stated that was working PM shift and didn't see any incident. Said R1 sometimes hits staff or other residents. Stated S1 never complains and has worked 8 months with Staff S1 and has never seen anything occur with S1. Interviews conducted today 11/06/25 with Staff S1-S4 revealed that there is no additional evidence to support the allegation having occurred. Therefore the findings remain the same. 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, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Administrator Stephanie Funderburg and copies issued.the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 28-AS-20251015113838

Allegation investigated: Staff did not prevent a physical altercation between residents in care

Licensing Program Analyst (LPA) Daniel Konishi conducted an initial 10-day complaint visit at the facility and met with the Executive Director, Stephanie Funderburg to discuss the purpose for today's visit. The purpose of the visit is to investigate the above allegation. Investigation consisted of the following: LPA requested a copy of staff and resident rosters. LPA also requested copies from Resident#1 (R1’s) file such as: Face Sheet, Physician’s Report, House Rules, Resident Handbook, SOC341, and Incident Reports. LPA also obtained Staff training documents. LPA also requested copies of Resident #2 (R2’s) file such as: Face Sheet and Physician’s Report. LPA interviewed R1 to Resident #6 (R6), the Executive Director, and Staff #1 (S1) to Staff #6 (S6). The investigation revealed the following: In regards to the allegation, “Staff did not prevent a physical altercation between residents in care.” It is alleged on 10/25/2025 at 4:29pm, Resident #1 (R1) yelled at Resident #2 (R2) and R1 slapped the left side of R2’s face at the hallway on the way to the dining hall and staff separated the two residents. Unsubstantiated It is also alleged that R1 was unprovoked. LPA interviewed two (2) staff that denied the allegation stating on witnessing the incident and immediately de-escalating and separating both R1 and R2. LPA interviewed an additional five (5) out of five (5) staff that all denied the allegation and stated the staff immediately intervene, separate, and re-direct residents whenever they are involved in a physical altercation. LPA interviewed R1 that denied the allegation by stating that R1 did not hurt R2 or anyone by the hallway near the dining hall. LPA interviewed R2 that denied the allegation by stating not being yelled or slapped by R2 by the hallway near the dining hall. LPA interviewed an additional four (4) out of four (4) residents denied the allegation by stating not witnessing the physical altercation between both R1 and R2. However, the four (4) out of (4) residents stated that staff immediately intervene to de-escalate verbal or physical altercations by separating the residents. LPA reviewed ongoing staff training on De-Escalating Dementia Behavior and Residents’ Rights in file. There was insufficient evidence to corroborate with the allegations. Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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, therefore the allegations are UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided to the Executive Director, Stephanie Funderburg.the state’s words, verbatim · CDSS document, Nov 4, 2025 · control 28-AS-20251027173421

Allegation investigated: Staff mismanaged resident's medication.

Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent visit to investigate the reported allgeation, met with Administrator Stephanie Funderberg and explained the purpose for todays visit. On 6/30/25 LPA Wesely conducted the inital 10 day visit and obtained copies of staff/resident rosters, reviewed medication log, interviewed 3 staff and retrieved specific items regarding the complaint investigation allegation. During todays visit LPA Herrera obtained copies of staff/resident rosters, copies of Resident #1's (R1) MAR (Medication Administration Record) from March-May 2025, LPA reviewed 15 residents medications and conducted interviews with 3 Staff (S1-S3) and 11 Residents. (Continued on LIC9099-C page) Substantiated The investigation revealed the following: Allegation: Staff mismanaged resident's medication. It is alleged that R1 was out of a routine medication in the month of May 2025 as facility failed to confirm if the medication was discontinued by the doctor. LPA reviewed R1’s MAR for the months of April-May 2025 and observed that on 5/18/25 R1 was not administered 1 of their routine medications with notes stating that a refill was ordered 5/19/25. LPA conducted interviews with 4 staff and 3 of the 4 staff confirmed that there was a glitch in the MAR that is used through the pharmacy where it documented the medication as discontinued and resident did not receive their medication but could not confirm for how many days R1 was without the medication. Per the MAR it appears that R1 was without medication for one day (5/18/25) as the MAR was not signed by staff and notes on MAR indicate that on 5/19/25 the medication was refilled. Additionally, LPA reviewed 15 residents medications during todays visit with no errors observed. Interviews were conducted with 11 residents and 10 out of the 11 residents denied the allegation. Based on LPAs observations, interviews which were conducted and medication review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 20, 2025 · control 28-AS-20250625144015

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 21, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This standard was not met as evidence by: Based review of R1's MAR on 5/18/25 R1 missed a dose of thier routine Riboflavin medication, when LPA interviewed staff 3 staff confirmed that their was a glitch in the MAR during that time where the medication was listed as discontinued and was reordered the following day.the state’s words, verbatim · CDSS document, Oct 20, 2025

Plan of correction: *medication was all accounted for during visit* Administrator confirmed that there has been an in-service training on medication and provided LPA a copy of the training participant log that was on 10/7/25, and a copy of the training materials. POC is cleared

Allegation investigated: Staff handled resident in a rough manner

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced initial visit to investigate the above allegation. LPA met with Stephanie Funderburg , and discussed the purpose of the visit. The investigation consisted of LPA reviewing and obtaining copies of staff and resident rosters, R1's file was reviewed and Admission Agreement. Physician's Report and Emergency ID Face sheet were submitted. Interviews were conducted with (2) staff (S1-S2), ten (11) residents (R#1-R#11) Administrator was also interviewed. The investigation revealed regarding Allegation Staff handled resident in a rough manner, based on interviews conducted and information gathered Resident's R3- R11 all stated that they never observed staff doing anything verbally or physically abusive. R3 and R11 stated they live over the courtyard and have not seen staff mishandling residents in a rough manner. R3- R11 also stated that staff treat them well and will help them if they ask for assistance. Unsubstantiated Administrator stated that Staff S1 said that the alleged incident never happened. Said there has not been any complaints regarding S1 previously. Staff S1 stated that the incident didn't occur. Said the alleged incident doesn't reflect on S1 as a person. Said that will comb residents hair and maybe that was misinterpreted. Also stated that residents are treated with respect and has no idea why the allegation was made. Staff S2 stated that was working PM shift and didn't see any incident. Said R1 sometimes hits staff or other residents. Stated S1 never complains and has worked 8 months with Staff S1 and has never seen anything occur with S1. 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, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Administrator Stephanie Funderburgthe state’s words, verbatim · CDSS document, Oct 20, 2025 · control 28-AS-20251015113838

Allegation investigated: Staff are not following proper eviction procedures.

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced initial visit to investigate the above allegation. LPA met with Michelle Castillo, Business Office Manager, and discussed the purpose of the visit. Administrator Stephanie Funderburg arrived a short time later and assisted with the visit. The investigation consisted of LPA reviewing and obtaining copies of staff and resident rosters, R1 admission agreement. R1 Physicians report dated 02/27/2025, R1overdue rent notices provided to resident, Interviewing four (4) staff (S#1-S#4), ten (10) residents (R#1-R#10) The investigation revealed regarding Allegation: Staff are not following proper eviction procedures. It is alleged that facility administrator verbally gave resident a 3 day notice to quit. (Continued on 9099C) Unsubstantiated (continued on 9099C) LPA interviewed four (4) staff, and all four (4) staff denied the allegation. S2 denied giving resident any kind of eviction including verbal. S1 stated she never witnessed S2 giving verbal eviction to R1. LPA interviewed Ten (10) residents and ten (10) of ten (10) residents could not corroborate the allegation. LPA reviewed R1 admission agreement, and it showed that R1 was admitted to facility on 02/27/2025 and showed rent amount of $1420.07. The only notices that facility has provided for R1 are overdue rent notices. R1 physician’s report dated 02/27/2025 showed that R1 can make own decisions and does not have cognitive impairment. R1 stated that R1 was not told R1 had to leave facility, but that facility may evict R1 for nonpayment. R1 said R1 offered $1000.00 but administrator refused it. Administrator denied that she refused the $1000.00. Administrator stated R1 asked for copy of R1 admission agreement and that R1 would like time to review it before paying. Administrator stated she will work with R1. R1 stated R1 would be willing to work out an arrangement. R1 stated has only paid $500 since arriving on 02/27/2025. There is insufficient evidence to support this allegation. 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, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 28-AS-20250930161850

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to Business Office Manager Michelle Castillo. The Residential Care for Elderly (RCFE) facility serves residents ages 60 and over. There is a Memory Care Unit for cognitively impaired residents. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed. The facility has sufficient supply of Personal Protective Equipment (PPEs). Operational Requirements: The facility has an approved fire clearance for 104 ambulatory and 116 non-ambulatory residents, of which 104 residents may be bedridden. A hospice waiver for 25 residents is approved. Facility does not handle resident monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 2/1/2026. Physical Plant/Environment Safety: The facility is a 2-story building consisting of 119 resident rooms, Memory Care Unit, 2 activity rooms with fireplaces, library, game room, beauty salon, private dining room, dining room, shower rooms on the 1st and 2nd floors, outdoor courtyards with shaded areas, employee lounge, and offices. Resident rooms have required furniture, bedding, linens, and lighting. The majority of the resident rooms inspected had beds without mattress pads. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. Cleaning supplies and toxic substances are inaccessible to residents. The signal system was tested and is operational. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. The facility is equipped with sprinklers, smoke detectors, carbon monoxide detectors, and has charged fire extinguishers. Rooms 130 & 133 do not have No Smoking/Oxygen-In Use signs. The Memory Care Unit had cleanliness issues and deferred maintenance. The last fire inspection was conducted on 4/30/25 by Pasadena Fire Department. Staffing: A total of 90 staff members provides care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 1/25/26. Staff have criminal background clearance.10 staff files were reviewed. They contained 1st Aid/CPR training, criminal background clearance, health/TB screenings, 1st Aid/CPR training, and training records. Staff (S3, S5, S7, S8) do not have 1st/Aid CPR cards on file and/or had expired cards. Resident Records/Incident Reports: 10 resident files were reviewed. They contained Admission Agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, and centrally stored medication records. RCFE & Ombudsman complaint posters are posted. A technical advisory was issued due to size requirements. Planned Activities: Facility activity calendar was posted in the. Sufficient space to accommodate both indoor and outdoor activities was observed. Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Executive Chef has a current Food Handling Certificate. Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family or facility van. Four of R1's medications have not been filled. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed and is updated. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 8/8/25. Residents with Special Health Needs: There are currently 12 residents receiving hospice services, 59 receive home health services, and no residents have prohibited health conditions. Individual Service Plans, Appraisals, and postural support physician orders are on file. Pursuant to California Code of Regulations, Title 22, deficiencies were cited. Exit interview, copy of report/appeal rights was conducted with Michelle Castillo.the state’s words, verbatim · CDSS document, Oct 6, 2025

Allegation investigated: Staff are not properly supervising resident who may be a fall risk Staff were not meeting residents personal hygiene needs Staff do not provide adequate food service to residents Staff did not seek timely medical attention for resident

****This report supersedes the complaint investigation report dated 09/23/2025. The purpose of the visit is to add additional information not included in the report; the findings remain the same. ***** Today 11/13/25, Met with Ruth Villa and conducted tour of the facility and did not observe any healthyand safety concerns. On 09/23/25, Licensing Program Analyst (LPA) Sanjay Vaid conducted a subsequent unannounced complaint investigation visit regarding the above allegations. LPA met with Wellness Director Ruth Villa and explained the reason for the visit, Administrator Stephanie Funderburg arrived shortly after and assisted with the tour. LPA Vaid did not observe any health and safety concerns. On 04/17/2025, LPA Vaid met with Mena Marrisa-Wellness Director. LPA requested and obtained resident and staff rosters. LPA requested copies of residents’ files for 5 random residents -face sheet, physicians reports. #1(R1) identification and emergency sheet, physician’s report, last incident report, last needs/service assessment, memory care progress notes. LPA Vaid conducted a tour of the facility and observed 10 random resident rooms. LPA interviewed ten (10) residents and eight (8) staff. CONTINUED ON 9099C................................... Unsubstantiated ****This report supersedes the complaint investigation report dated 09/23/2025. The purpose of the visit is to add additional information not included in the report; the findings remain the same. ***** Regarding the allegation: Staff are not properly supervising a resident who may be a fall risk. It is alleged staff did not provide adequate supervision, resulting in a resident sustaining multiple hospitalization. It is alleged that R1 has had multiple falls in the facility due to lack of supervision. (8) of (8) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Interviews with staff showed knowledge of one fall where R1 slipped due to loss of balance related to R1’s medical condition. Staff were present and able to assess R1. 911 was also called and R1 was transported to the hospital. File review shows SIR dated 2/17/25, 3/4/25 (family was present) and 4/6/25 for the fall incident provided to licensing. There were no other recordings of falls R1 may have had in the facility. Staff stated they check on fall risk residents more frequently, every 30 minutes. During activities residents with fall risk are assisted and observed much more frequently. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. 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, therefore the allegation is unsubstantiated. Regarding the allegation: Staff were not meeting residents’ personal hygiene needs. It is alleged that the staff is not meeting and providing residents with personal hygiene needs and not assisting residents to change their clothing regularly. (8) of (8) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. According to staff interviewed, caregivers provide daily assistance services and needs to the residents in memory care (MC). Memory care staff stated they assist the residents with grooming, scheduled showers, a few residents in MC residents required assistance while other residents required full care. Residents who refuse daily living services are reproached at later time in the day. Notes are communicated to next shift staff. LPA Vaid observed MC staff assisting residents with daily living needs. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. 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, therefore the allegation is unsubstantiated. CONTINUED ON 9099C.................. ****This report supersedes the complaint investigation report dated 09/23/2025. The purpose of the visit is to add additional information not included in the report; the findings remain the same. ***** Regarding the allegation: Staff are not providing adequate food service to residents. It is alleged that staff are on their phones during mealtimes and not assisting residents with feeding and thus residents have lost a lot of weight since moving to the Memory Care Unit. Eight (8) of eight (8) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Staff interviewed stated that each resident in the memory care unit has meals prepared according to their dietary orders by the physician. R1's diet plan, and care plan require eating own food and encouragement but not to be fed directly. Staff have stated they however do make sure R1 finishes their meals and will assist if R1 needs it. LPA observed residents eating in the facility on their own, a few residents were observed to be semi-assisted (hand over hand) and fully assisted (residents are fed by staff) by staff. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. 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, therefore the allegation is unsubstantiated. Regarding the allegation: Staff did not seek timely medical attention for resident. It is alleged that the staff did not seek timely medical attention for the resident after resident falls. Per complaint, the resident has lost a lot of weight since being at the facility. (8) of (8) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Staff interviews reveal that R1 care plan was created and finalized in January of 2025. This plan was communicated with R1's responsible party. File review showed last service plan on file for R1 was created on 1/26/24. According to SIR dated 2/17/25, 3/4/25 and 4/6/25 R1 was assessed by the med-techs before going to the hospital, and R1’s family and physician were notified same day. Staff stated R1 had lost weight due to the medications R1 was prescribed, staff communicated observations to family and physician. Medication dose was lowered and administered as prescribed. Based on observations, file reviews, and interviews conducted there was not enough supportive evidence to concur with the reported allegation. 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, therefore the allegation is unsubstantiated. Exit interview was held and copy of this report was provided to Wellness Director Ruth Villa..the state’s words, verbatim · CDSS document, Sep 23, 2025 · control 28-AS-20250411114444

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit to follow up on observations during a complaint investigation visit conducted on 9/2/25. LPA met with Stephanie Funderburg and explained the reason for the visit. On 9/2/25 LPA Flores conducted a medication review during the review LPA reviewed medication list for the following residents and did not observed the medications available at the time of the visit: Resident #1(R1) On 9/2/25 LPA did not observed Hydrocodone listed as needed. On 9/19/25 a physician's order dated: 8/21/25 notes the medication was prescribed for 7 days only. Resident #2(R2) On 9/2/25 LPA did not observed Senna 8.6mg routine medication, Acetaminophen 325mg, and Oxycodone 5mg as needed medications. On 9/19/25 there are no discontinued orders. Resident #3(R3) On 9/2/25 LPA did not observed Acetaminophen 325mg prescribed as needed. On 9/12/25 LPA Flores received a picture of the bubble pack medication with original Rx date: 12/18/24. LPA interviewed R1-R3, residents stated they have not needed to ask for the medication. One resident refused to talk to LPA. A deficiency is being cited today under Title 22 Regulations. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(6) · Plan of correction due date: Sep 20, 2025

87464 Basic Services: (f) Basic services shall at a minimum include:v(6) Arrangements to meet health needs, including arranging transportation... This requirement is not met as evidence by: Based on medication review, and document review licensee did not ensure that R2 had routine and as needed medication which poses an immediate risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Sep 19, 2025

Plan of correction: Administrator will provided a picture of as needed medications and or a discontinued order for the medication for R2 by POC due date 9/20/25.

Allegation investigated: Facility staff did not provide medications as prescribed Facility staff failed to provide assistance with activities of daily living Facility staff retaliated against a resident

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Michelle Castillo and explained the reason for the visit. Administrator arrived shortly after. The investigation consisted of the following: LPA requested a copy of staff/resident roster. LPA conducted a medication check for 8 residents, interviewed 8 residents and 6 staff, and requested copies of medication sheets for 8 residents, physician’s report, needs and care plan, and notes for resident #3 and #8(R3 and R8). The investigation revealed the following: Regarding allegation: Facility staff did not provide medications as prescribed. It is alleged staff have not provided resident with routine medication for several occasions. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with residents revealed 8 out of 8 residents stated they are being provided with their medications by Medication Technicians. 1 out of the 8 residents stated to have refused the medication in the evening but has been asked by med techs to take. Interviews with staff revealed medication is provided to the residents by the med-techs and it is only not provided when the resident refuses which is noted in their notes. Also the only other time a resident does not received medication is if the medication is not available due to the pharmacy not providing it. Medication review revealed medications are available for the residents, med-techs check mark their data system after providing the medication and are able to note if the resident refuses medication in the data system. Resident’s notes revealed the resident in question refused medication on two occasions. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility staff failed to provide assistance with activities of daily living. It is alleged staff did not provided resident with showers as schedule. Interviews with residents revealed 4 out of 8 residents do not need assistance with showers. However, staff assist them with other activities of daily living as needed. 4 out of 8 residents who require assistance with showers said they have received their showers as scheduled. However, 1 of the 4 residents, stated that they have requested a bed bath instead to an agency employee and not a facility staff, and was deny the request. Interviews with staff revealed residents are assisted with showers twice a week. Some residents are provided showers three times a week. Per staff, if a resident refuses a shower they are asked at least 3 times during that shift. If they continue to refuse, it is noted with the med-tech that they refused. If the residents request a shower on a different day, staff will provide the shower if they are available. Per documents reviewed resident in question needs full assistance with showers and are noted twice a week, no notes of shower refusal were observed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Facility staff retaliated against a resident. It is alleged staff retaliated against the resident by not assisting with showers due to resident not wanting to use the Hoyer lift. Interviews conducted with residents revealed 8 out of 8 residents stated staff have not responded in a retaliated manner in any situation. Per residents, staff are nice and assist as needed. Interviews with staff revealed, upon a resident refusing to shower. The staff communicate to the residents that if they are not showered the day of the scheduled shower, they may need to wait until the next schedule shower. However, they do make an effort to provide a shower if the resident had previously refused upon the residents’ request and staff have the availability during their shift. Per staff they will not respond to the resident in a retaliated manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. The staff communicate to the residents that if they are not showered the day of the scheduled shower, they may need to wait until the next schedule shower. However, they do make an effort to provide a shower if the resident had previously refused upon the residents’ request and staff have the availability during their shift. Per staff they will not respond to the resident in a retaliated manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 2, 2025 · control 28-AS-20250826094641

Allegation investigated: Staff prohibit resident from leaving the facility.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/08/2025, regarding the above allegation. LPA Ramirez identified herself and was greeted by the Wellness Director- Ruth Villa and explained the purpose of the visit. Administrator Stephanie Funderburg arrived shortly after to assist with tour. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff roster, Staff#1 – 4, 6, interviews (S1 – S4, S6), Attempted Interview of Staff#5 (S5), Resident#1 – 6 interview (R1- R6), copies of Resident#1 (R1): physician report dated 2/10/2025, Face sheet, Service plan, Admissions Agreement, Facility Activities Schedule for the month of August 2025 & July 2025, and physical plant tour. See 9099-C for continued narrative. Unsubstantiated The investigation revealed the following: regarding the allegation “Staff prohibit resident from leaving the facility.” It is alleged staff prohibit resident#1 (R1) from leaving the facility. LPA Ramirez reviewed and obtained a copy of R1’s physician’s report, which revealed that R1 may not leave the facility unassisted. Interview with resident#1 (R1) revealed that R1 enjoys going on outings when R1 chooses to sign up for an outing. Five (5) out of the five (5) staff interviewed denied the allegation. Five (5) out of the six (6) residents interviewed denied the allegation. Interview with Staff#1 (S1) revealed that R1 may not leave the facility unassisted however, the facility offers in-house activities and community outings. S1 revealed residents can sign up for community outings if they choose to do so. LPA Ramirez reviewed and obtained a copy of the facility posted Activities Schedule for the months of August 2025 and July 2025. LPA Ramirez observed several community outings listed including, mornings walks, outings to museums, local ice cream parlors, local restaurants, local retail stores and local movie theaters. 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, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited. Exit interview was conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Aug 8, 2025 · control 28-AS-20250803223816

Allegation investigated: Staff retained resident that requires a higher level of care Staff do not ensure that resident is transported to medical appointments Staff do not ensure that resident's hygiene needs are met Staff do not accord resident dignity in their relationship with staff Staff handle resident in a rough manner

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Administrator Stephanie Funderburg and explained the purpose of the visit. The investigation consisted of the following: During the initial visit conducted on 06/19/2025, LPA toured the facility and obtained copies of the following documents: staff roster, resident roster, R1’s preplacement appraisal information, physicians reports, admission/record admission, identification information (LIC 601), orders for medication and facility assessment. During visit on 07/10/2025 LPA’s interviewed Administrator, staff 1-staff 5 (S1-S5), resident one (R1) by telephone and residents 2-9 (R2-R9). During todays visit LPA delivered findings. See 9099C Unsubstantiated In regard to the allegation “Staff retained resident that requires a higher level of care “, it is alleged that staff did not adequately meet R1’s needs. During interviews with Administrator and staff six (6) out of six (6) staff stated that facility meets all the needs of all residents. Administrator stated that facility provides end of life services for residents and are more than qualified to handle non ambulatory residents and residents who require a high level of care. It was also stated that R1 did go from a level 1 care to a level 5 care therefore more services were provided but at no time did a physician state that he needed a higher level of care than what the facility could provide. During interviews with residents eight (8) out of nine (9) residents felt they received good quality of care by staff. R4 stated that overall, all needs have been met and staff is cordial to residents. In regard to the allegation “Staff do not ensure that resident is transported to medical appointments “, It is alleged staff did not provide transportation to resident due to nonpayment of rent. During interviews with Administrator and staff six (6) out of six (6) staff stated that transportation is arranged with front desk and residents are never denied service regardless of nonpayment of rent. Administrator stated there are many residents that don’t pay, and facility has never stopped rendering services because of that. During interviews with residents three (3) residents stated that they have never needed transportation, two (2) residents stated that they need to make arrangement a week in advance, and four (4) residents stated they have had no problems with transportation. In regard to the allegation “Staff do not ensure that resident's hygiene needs are met “, it is alleged that R1 smelled strongly of urine as well as wheelchair. During interviews with Administrator and staff four (4) out of six (6) stated that residents are always changed and showered. Two (2) staff stated that there has been a couple of incidents that they have found residents soiled in the morning shift and that gets reported right away. During interviews with residents seven (7) out of nine (9) stated that they have never had any problems with being left soiled nor ever witnessed residents being left soiled. R2 stated that they had witnessed R1 being changed 2 or 3 times a day by staff. SEE 9099C In regard to the allegation “Staff do not accord resident dignity in their relationship with staff “, it is alleged staff can be mean and rude to residents. During interviews with Administrator and staff six (6) out of six (6) stated that they have never witnessed staff treat residents rude. Administrator stated there has been no write ups or disciplinary actions for this type of behavior. During interviews with residents eight (8) out of nine (9) residents stated that staff has not been rude or disrespectful to them. R3 stated that staff shows him/her the “most respect”. In regard to the allegation “Staff handle resident in a rough manner”, it is alleged that staff jerks’ residents around. During interviews with Administrator and staff six (6) out of six (6) stated that no residents has ever told them that staff jerks them around. All staff stated that if they had heard staff was mistreating residents that it would be reported. During interviews with residents eight (8) out of nine (9) residents stated that staff has never handled them in a rough manner nor have they witnessed other residents being handled rough. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. 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 the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Administrator.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 28-AS-20250616114202

Allegation investigated: Resident was physically/mentally abused while in care.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation regarding the allegation listed above. LPA met with Administrator, Stephanie Funderburg, and explained the purpose of the visit. On 4/22/25, LPA toured the facility and obtained copies of the resident roster, staff roster, and documents for Resident #1. Interviews were held with the administrator, Staff #1 - #6, and 4 Residents. During today’s visit, LPA interviewed a Staff and 6 Residents. The investigation revealed the following: Allegation – Resident was physically/mentally abused while in care. It is alleged that the incident occurred on 3/20/25 at approximately 7 pm. Resident #1 (R1) was being physically and mentally abused by two employees. Unsubstantiated LPA interviewed R1 during the visit today. R1 recalled 2 staff being rough while trying to get the resident to the showers. R1 stated that one of the staff was frustrated and said to “get in the shower.” R1 did not recall the staff names and stated that it was the only time R1 had seen them working. LPA interviewed the administrator and 7 staff, which included the agency staff who worked during the time of the incident. Staff interviewed stated they have not observed any staff physically or mentally abusing residents in care. They will report it if they see any staff being abusive or aggressive. They stated that they receive annual training on how to properly transfer residents to prevent injuries. Regarding Resident #1, they stated they did not notice any bruises on the resident’s hands or arms until the police came to investigate. R1 did not mention any abuse or roughness prior to the police visit on 4/15/25. It was reported that R1 obtained bruises to the left and right arms during a shower transfer in March 2025. Staff interviewed denied being rough with R1 during transfers and stated they would ask other staff to assist with transferring R1. According to the administrator, there were no reports of staff being rough or injuring R1 during transfers. An additional nine residents interviewed have not been hurt or injured by staff. They stated the staff are respectful and careful. They have not seen any staff abusing residents in any way. 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, therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with the administrator. A copy of this report, along with the appeal rights, was provided.the state’s words, verbatim · CDSS document, May 20, 2025 · control 28-AS-20250414163448

Allegation investigated: Facility staff do not ensure resident eats an adequate amount of food

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Stephanie Funderburg and explained the reason for the visit. The investigation consisted of the following: LPA requested copies of staff/resident roster. LPA reviewed file for resident #1 (R1) and request copies of physician’s report, identification and emergency information sheet, needs and care plan, pre-placement appraisal, chart notes, physician’s visit records, medical discharge records. LPA interviewed 10 residents and 8 staff. The investigation revealed the following: Regarding allegation: Facility staff do not ensure resident eats an adequate amount of food. It is alleged R1 is malnourished with muscle waste due to neglect. Interviews with residents revealed 9 out of 10 residents stated meals with plenty of food is provided to them daily. Per residents, they receive three meals a day and they are given options if they don’t like the food. (CONTINUED ON LIC 9099C) Unsubstantiated One out of ten (1 out of 10) residents was unable to answer interview due to cognitive skills. Interviews with staff revealed residents are encouraged to eat their meals and assisted when needed. Per staff, if changes in condition are noticed they are noted in the resident chart notes. Medication Technician then follow up with physician and/or family members. Administrator stated staff did observed R1’s food intake decreased. However, R1’s physician was conducting visit. On 5/2/25, R1’s physician recommended nutritional shake to be increase. Documents reviewed revealed R1’s physician’s report dated: 1/2/25 notes, R1 has a special diet due to health condition. R1’s service plan dated: 3/5/25 notes R1 will obtain assistance with cutting and preparing food or prompting throughout the meal. Medical evaluation conducted on 2/24/25 notes R1 is consuming three meals a day. Facility’s notes from 4/7/25 – 5/12/25 note R1 refused to eat on 4/7/25, 4/18/25, 5/3/25. Physician visited R1 on 3/20/25, 4/23/25,5/2/25. Physician’s order dated: 5/2/25 note an increase from 1 to 3 nutrition shakes a day for R1. Although R1 did seem to have had a change in condition. Per interviews conducted facility staff have assisted R1 with food intake and physician’s follow ups/visits. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 13, 2025 · control 28-AS-20250505162357

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mary Flores and Gabriela Castro conducted an unannounced case management visit regarding deficiency observed on 4/3/25 during a complaint investigation visit. LPAs met Stephanie Funderburg with and explained the reason for the visit. On 4/3/25 LPA Flores conducted a complaint investigation visit and conducted a medication review. During the medication review observed that three (3) residents, resident #1-#3(R1-R3) did not have between 1 to 4 routine medications missing. R1 was missing one routine medication. R2 was missing 4 routine medications. R3 was missing 1 routine medication. Each have not been refilled for at least 4 days per Medication technicians interviewed. A deficiency is noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Stephanie Funderburg administrator and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 29, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 2, 2025

87465 Incidental Medical and Dental Care:(a) A plan for incidental medical and dental care shall be developed by each facility... by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by: Based on observations and review licensee did not ensure that routine medications were available for R1-R3 which poses a potential risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Apr 29, 2025

Plan of correction: Administrator implemented weekly audit since 4/3/25 and training was provided on 3/27/25 deficiency clear as of 4/29/25.

Allegation investigated: Staff administered another resident’s medication to resident resulting resident being admitted to the hospital.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met Stephanie Funderburg with and explained the reason for the visit. The investigation consisted of the following: LPA requested a copy of staff/resident roster. LPA conducted a medication review of 5 residents. LPA conducted interviews with 7 residents and 6 staff. LPA requested a copy of resident #1(R1)’s physician’s report, admission agreement, identification and emergency information sheet, needs and care plan, medication sheet for the last three months, and Resident #2(R2)’s March medication sheet, and Staff #1(S1)’s initial medication training, corrective action, and in-service training. The investigation revealed the following: Regarding allegation: Staff administered another resident’s medication to resident resulting resident being admitted to the hospital. It is alleged R1 was admitted to the hospital on 3/27/25 due to staff administering another resident’s medication. (CONTINUED ON LIC 9099C) Substantiated Interviews with residents revealed 2 out of 7 residents interview stated to have been given the wrong medication and 1 out of the 2 had to go to the hospital for an evaluation. 5 out of 7 residents stated to not have had medication errors. However, 1 out of the 7 stated to have not have medication available for over a week. Interviews conducted with staff revealed S1 had made a mistake by providing R1 the medication of another resident. Per S1 the other resident realized it was not their medication and let S1 know. It was then when S1 communicated with Wellness Director and they follow up with physician and responsible party, who advice R1 be taken to the hospital. Per Administrator, S1 received a corrective action and an in-service training was provided to the medication technicians on 3/27/25. Per documents reviewed R1’s medical assessment dated:4/14/24 notes, R1 is able to manage own medications. Needs and care plan dated: 4/2/25 notes R1 requires assistance with medication, and medication is provided by the medication technician. Medication error was not noted on the medication sheet. However, on 4/2/25 facility staff submitted an incident report in which it was reported that on 3/27/25 S1 provided R1 with the wrong medication and R1 was send out to the hospital. Per R1’s hospital discharge, R1 was seen for a medication problem. S1 was provided initial medication training on December of 2024, and training was retaken on 3/28/25 and 4/3/25. In-Service training was provided by wellness director on 3/27/25 to all medication technicians. Medication review revealed 3 out of 5 residents were missing at least one of their routine medication. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 28-AS-20250327151357

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 4, 2025

87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... staff shall... ensure provision of personal assistance and care... This requirement is not met as evidence by: Based on observations and interviews licensee did not ensure, R1 received the correct medication provided by S1 which poses an immediate risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: Administrator provided in-service training to S1 on 3/28/25. Administrator will create a plan to have all medications audit and will submit the plan to the department by POC due date 4/4/25.

Allegation investigated: Staff do not respond to resident's call for assistance Staff did not notify resident's responsible party of fall Staff do not ensure facility is free of bad odors Staff are not safeguarding resident's belongings Staff do not ensure resident has privacy in their room Staff did not assist resident after a fall Staff did not notify responsible party of resident’s room change Staff’s negligence let to resident’s fall

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Michelle Castillo and explained the reason for the visit. The investigation consisted of the following: On 1/7/25 LPA conducted an initial investigation visit, conducted a tour of the facility, observed 10 random resident rooms, and common areas. LPA interviewed 10 residents and 9 staff. LPA requested copies of incident reports for resident #1(R1) between November 2024 and January 2025, identification and emergency sheet, admission agreement, physician’s agreement, resident personal property and valuables sheet, service plan for resident #1(R1). On 1/13/25 Administrator emailed pendant call log for January for R1. (CONTINUED ON LIC 9099C) Unsubstantiated The investigation revealed the following: Regarding allegation: Staff do not respond to resident’s call for assistance, and Staff did not assist resident after a fall. It is alleged R1 fell between 12/30/24 and 1/1/25, and pressed the call button for assistance, and staff did not come to assist. Interviews conducted with residents revealed staff have responded to resident’s pendant call and assisted them when needed. Interviews with staff revealed staff respond to the pendant call as soon as possible. Per staff, it may take staff longer to respond if they are assisting other residents with something they cannot leave unattended. Documents review revealed pendant call was pressed for R1 on 1/1/25 at 5:19pm, front desk acknowledges R1 at 5:30pm, and a staff responded and clear pendant call at 5:52pm. Between 12/30/24-12/31/24, R1 pressed the pendant call button 7 times and each was cleared by a staff. There are no incident reports or notes to note R1 fell on/or before 1/1/25 and requested assistance. Although R1 pressed the pendant button on 1/1/25 it is uncertain the reason of the call as residents use the pendant call for assistance with different things as well as for emergencies. Desk acknowledges the call to the residents to ensure the immediate need and proper response. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not notify resident’s responsible party of fall. It is alleged responsible party was not notified by staff of the fall. Interviews conducted with residents revealed staff either notifies or are certain staff will notify responsible parties if an incident occurs. Interviews with staff revealed when a fall occurs the Med-Tech notifies the responsible party/family of the incident. Documents review revealed R1 is self-responsible, per Emergency Information Sheet signed and dated on 9/28/24. Per incident report dated 1/3/25, R1’s family member was contacted and notify of incident. Per incident report dated 1/5/25, R1’s family member was contacted. Notes on internal incident report dated 1/5/25 note staff was unable to contact family member or leave a voice message after three attempts. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff do not ensure facility is free of bad odors. It is alleged that the hallway smelled of feces and urine. Interviews with residents revealed the facility does not have bad odors throughout. (CONTINUED ON LIC 9099C) Interviews with staff revealed odors are only noticed when a resident with incontinence has had a bowel movement or urinated. Caregivers stated to clean residents timely and ensure that items are properly disposed, and contact housekeepers if additional cleaning is necessary. On 1/7/24 LPA conducted a tour of the facility and did not notice any bad odors throughout the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff are not safeguarding resident’s belongings. It is alleged a blood pressure machine purchase by R1’s representative was missing. Interviews conducted with residents revealed residents have not lost any items. One resident stated to have misplace items and staff assisted to find them. Interviews with staff revealed residents usually report to staff when they lose something, and residents have not reported any lost items within the last two months. LPA reviewed R1’s Resident Personal Property and Valuables sheet dated and signed on 9/27/24 and notes R1 “decline to track personal property”. Although the item may have gotten lost, there are no documents that record the missing item and there were no reports to staff of the item getting lost per interviews conducted. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff do not ensure resident has privacy in their room. It is alleged that staff do not knock before entering the room. Interviews with residents revealed staff knock at the door before entering their room. Interviews with staff revealed staff knock at the door before entering the room and let the residents know they are coming in. On 1/7/25 during the tour of the facility, LPA observed staff knock before entering each room visited. LPA also observed other staff knock at the door before entering the rooms to check on residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. (CONTINUED ON LIC 9099C) Regarding allegation: Staff did not notify responsible party of resident’s room change. It is alleged staff did not notify responsible party of R1’s room change. Interviews conducted with residents revealed residents believe their family members will be notify of any incidents or changes regarding their care. Interviews with staff revealed Med-Tech or administrative staff are the ones who notify family members of incidents or changes in the residents’ care. Per administrator R1 was aware that a room change will take place and R1’s family member was present during the notification of the last room change. Document review revealed Emergency Information Sheet signed and dated on 9/28/24, notes R1 is self-responsible. There were no emergency contacts listed other than R1’s physician. Due to records noting R1 is self-responsible the facility is not responsible for notifying additional parties. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff’s negligence let to resident’s fall. It is alleged R1 fell on 1/5/25 due to staff not locking the brakes on the wheelchair. Interviews conducted with residents revealed staff ensure residents safety. Residents have observed staff locking wheelchair when assisting residents to the dining room or other places. Interviews conducted with staff revealed staff are familiar with safety precautions for residents using a wheelchair and ensure that the wheelchair brakes are lock when they come to a full stop. Documents review revealed, incident report dated 1/5/25 notes R1 fell while attempting to scoot self in the wheelchair while staff were assisting to push R1’s wheelchair in their apartment. Facility staff called emergency personnel and R1 refused to go to the hospital. Although, R1 did suffer a fall on 1/5/25 there is no evidence to support R1 fell due to wheelchair brakes being unlock due to staff neglect. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 15, 2025 · control 28-AS-20250106121829

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management - health and safety check visit regarding reported incident on relocation of 2 residents from Foothill Heights Care Center due to mandatory evacuation orders from the Fire Advisory. LPA met with Michelle Castillo and explained the reason for the visit. During the visit today, LPA Flores conducted a health and safety check by touring the facility. No immediate health and safety concerns were observed. LPA obtained a copy of the resident and staff roster. Per interview with the administrator, there are 2 residents that have been relocated from Foothill Heights Care Center. Facility is fully staff and nurses have been visiting the 2 residents daily. Administrator has been in contact with Pasadena Public Health Nurse and Ombudsman, who have visited the residents. Food and hygiene supplies are available to accommodate all the residents. LPA reviewed medications and MAR logs for the 2 residents that were transferred to the facility and are centrally stored and inaccessible to the residents. The last fire drill was conducted on 12/17/24. LPA discussed with administrator proper relocation of resident #1 who has a prohibited health condition and there is no enrollment in hospice care. Per administrator they are currently working on it. Due to the situation most skill nursing facilities are full at this time. However, will continue to seek proper placement. An exit interview was held and a copy of this report was given to the Stephanie Funderburg Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 16, 2025

Allegation investigated: Staff are not properly storing a resident's personal belongings Staff do not ensure the residents hygiene needs are being met

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Michelle Castillo and explained the reason for the visit. The investigation consisted of the following: LPA requested resident and staff rosters. LPA conducted a tour of the facility and observed 10 random resident rooms. LPA interviewed 10 residents and 9 staff. LPA requested staff assignment chart and service plan for resident #1 - #2(R1-R2). The investigation revealed the following: Regarding allegation: Staff are not properly storing a resident’s personal belongings. It is alleged boxes are being stored in resident’s shower. Per interviews conducted residents stated they have sufficient space to store their belongings. Per staff, residents’ personal belongings are stored in their closet and/or drawers. Administrator stated, R2 had boxes in the shower prior to getting a roommate. R2 was requested to move the boxes as a roommate would be moving in. (CONTINUED ON LIC 9099C) Unsubstantiated Administrator attempted to resolve the situation by providing staff to assist R2 to store the items in the boxes and offered to purchase additional storing space for R2. However, R2 refused. During the tour of the facility LPA did not observe any personal belongings or boxes stored in the showers of each residents’ room. A closet and drawers were observed in each room assigned to each resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff do not ensure the resident’s hygiene needs are being met. It is alleged residents have not been assisted with showers in almost a month and their bedding is not maintain clean and free of feces. Interviews with residents revealed residents are assisted with showers and are provided a shower at least twice a week. Some residents stated that they are independent and are able to take a shower on their own and had no concerns regarding access to their personal shower. A few residents stated they rather use the common shower when necessary. Interviews with staff revealed residents are schedule to be assisted with showers twice a week. However, if a resident chooses to shower more often, they assist them as needed or if the if the staff determine the resident needs a shower for any reason, they are provided a shower more frequent. Per staff there is a large communal shower that is accessible to the residents for easiest access. Per staff schedule residents are assisted with showers. Per Service plans reviewed residents are receiving assistance with bathing “2x per week”. Per staff assignment chart residents are assisted R1 is assisted with showers on Sundays and Wednesdays and R2 is assisted with showers on Tuesdays and Thursdays. During LPAs toured beds were observed clean, free of debris, and feces. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 7, 2025 · control 28-AS-20241230155252

Allegation investigated: Staff do not prevent inappropriate interactions between residents

Licensing Program Analyst conducted a subsequent complaint investigation visit at the facility regarding the above allegation. LPA met with Stephanie Funderburg and explained the reason for the visit. The investigation consisted of the following: On 11/19/24 LPA Flores conducted an initial complaint investigation visit, requested a copy of staff/resident roster. LPA interviewed administrator, 1 resident, and 5 staff. LPA requested copies of resident’s #1-2(R1-R2) physician’s report, admission agreement, identification and emergency information sheet, needs and care plan, individual service plan. On 11/26/24 LPA Flores interviewed 7 residents. On 12/9/24 LPA interviewed residents’ representatives. On 12/10/24 LPA Flores delivered findings. The investigation revealed the following: Regarding allegation: Staff do not prevent inappropriate interactions between residents. It is alleged a resident has assault another resident and stalk another resident. Unsubstantiated Interviews conducted with staff revealed there have been no reports of physical abuse or stalking been made to the staff by R1 or other residents. Staff stated they were aware of friendship established between R1 and R2. Per staff, both residents have spent time with each other in the facility common areas and each other’s rooms. Per administrator, there was an incident with R1’s roommate and R2, since then there have been concerns express by R1’s family that R2 may have become possessive of R1. Medication technicians have noticed that R2 had become involved in R1’s care and reminded R2 that R1 is independent, and staff are aware of the care R1 needs. Staff have observed R2 calling and requesting R2’s assistance, after it was communicated to R2 to keep distance from R1 per family’s request. Facility staff communicate with family representatives regarding the concerns. It was discussed with the families that staff will attempt to keep them separated in the dining room or when R1 expresses it. As well as, to not go into each other’s rooms. Interviews with residents revealed some residents have noticed the friendship between the two residents and agree that now the friendship is not the same. Based on additional interviews conducted allegedly R1 was struck by R2. However, there was no bruise, after the alleged struck. It was discovered the bruising was cause by a vaccine given in R1’s arm. Per interviews, there were statements that R2 is unable to physically hurt R1. R1’s family does not consider R2 as a threat to R1, and stated facility has been providing supervision and reminding R2 to maintain distance from R1. Documents reviewed revealed R1 and R2 do not have a history of aggressive behaviors or behavioral concerns. Both residents do not have cognitive impairment per physician's reports. Per needs and care plans both residents required minimal care. Although the situation may have presented there is no evidence physical abuse occurred. Facility staff have provided supervision and will continue to record interactions between residents. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 28-AS-20241113151512

Allegation investigated: Staff are not preventing the spread of a communicable disease. Staff are not following infection control requirements

*This is a corrected version of report dated 11/26/24 to reflect unsubstantiated finding correctly on LIC 9099A* Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Stephanie Funderburg and explained the reason for the visit. The investigation consisted of the following: On 11/22/24 LPA contacted Department of Public Health (PDPH). On 11/26/24 LPA requested a copy of staff/resident roster. LPA requested copies of incident reports of recent incident reports, copies of health department reports, and trainings provided to staff. LPA interviewed 6 staff and 6 residents. LPA conducted tour of facility and observed rooms in isolation. The investigation revealed the following: Regarding allegation: Staff are not preventing the spread of a communicable disease. It is alleged staff provided care, meals, to residents in isolation and did not perform hand hygiene/glove change procedures. (CONTINUED ON LIC 9099C) Substantiated Interviews conducted with residents revealed 3 out of 6 residents stated staff have been seen wearing gloves and mask while providing care. 2 out of 6 residents stated staff were sometimes not wearing proper PPE when providing care. 1 out of 6 residents stated to not be aware of breakout. Interviews with staff revealed staff were informed of symptomatic residents on 11/18/24 and staff implemented wearing PPE, resident isolation, and were provided training. On 11/20/24 a server was observed providing meals in residents rooms without changing gloves in between residents during a visit provided by PDPH. On 11/22/24 staff was observed not implementing proper hand hygiene procedures per PDPH. Training was provided to staff on 11/17/24 on Infection control, and on 11/22/24 training was provided on disinfecting, PPE proper use, and hand hygiene. Although the residents and staff stated to have been following guidance to prevent the spread. Visits conducted by PDPH revealed staff did not follow hand washing and glove changing guidance. Therefore, allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Regarding allegation: Staff are not following infection control requirements. It is alleged facility staff enter a resident’s room with infections disease symptoms and did not use proper Personal Protective Equipment (PPE). On 11/19/24 emergency personnel responded to a call upon entering a resident’s room with symptoms of infectious disease facility staff assisting did not put on proper PPE prior entering the room. Interviews conducted with residents revealed the following 3 out of 6 residents stated staff used proper PPE when entering the rooms to provide care. 3 out of 6 residents either did not observe or remembered whether staff used proper PPE supplies. Interviews with staff revealed staff were provided PPE supplies which were placed outside residents’ rooms that were in isolation. However, staff admitted that during the visit of emergency responder, staff was not wearing PPE when assisting resident with infectious disease symptoms going out to the hospital. During facility’s tour, LPA observed PPE supplies in 3 rooms who are currently in isolation. One staff was observed going into a resident’s room to provide care with face mask under the chin as staff walked to provide care into resident’s room. Although facility has implemented guidelines and provided training to staff, staff did not follow infection control guidance. Therefore, this allegation is substantiated. (CONTINUED ON LIC 9099C) Based on LPAs observations, interviews which were conducted, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Deficiency was noted on LIC 9099D on report dated 11/26/24. Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 9099D, and appeal rights were provided. Facility reported outbreak to Community Care Licensing (CCLD) on 11/17/24 and to PDPH on 11/18/24. Families, residents, and staff were notified of outbreak on 11/18/24 via letter. On 11/19/24 facility personnel responded to a call at the facility. Staff in charge did not notify personnel of outbreak. Although the facility staff did not informed emergency personnel regarding outbreak at the facility. Facility administration notified CCLD and PDPH within 24 hours of the third resident with symptoms. Regulation stated an outbreak must be notify to CCLD and PDPH. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 28-AS-20241120082237

Allegation investigated: Staff are not preventing the spread of a communicable disease. Staff are not following infection control requirements

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Stephanie Funderburg and explained the reason for the visit. The investigation consisted of the following: On 11/22/24 LPA contacted Department of Public Health (PDPH). On 11/26/24 LPA requested a copy of staff/resident roster. LPA requested copies of incident reports of recent incident reports, copies of health department reports, and trainings provided to staff. LPA interviewed 6 staff and 6 residents. LPA conducted tour of facility and observed rooms in isolation. The investigation revealed the following: Regarding allegation: Staff are not preventing the spread of a communicable disease. It is alleged staff provided care, meals, to residents in isolation and did not perform hand hygiene/glove change procedures. (CONTINUED ON LIC 9099C) Substantiated Interviews conducted with residents revealed 3 out of 6 residents stated staff have been seen wearing gloves and mask while providing care. 2 out of 6 residents stated staff were sometimes not wearing proper PPE when providing care. 1 out of 6 residents stated to not be aware of breakout. Interviews with staff revealed staff were informed of symptomatic residents on 11/18/24 and staff implemented wearing PPE, resident isolation, and were provided training. On 11/20/24 a server was observed providing meals in residents rooms without changing gloves in between residents during a visit provided by PDPH. On 11/22/24 staff was observed not implementing proper hand hygiene procedures per PDPH. Training was provided to staff on 11/17/24 on Infection control, and on 11/22/24 training was provided on disinfecting, PPE proper use, and hand hygiene. Although the residents and staff stated to have been following guidance to prevent the spread. Visits conducted by PDPH revealed staff did not follow hand washing and glove changing guidance. Therefore, allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Regarding allegation: Staff are not following infection control requirements. It is alleged facility staff enter a resident’s room with infections disease symptoms and did not use proper Personal Protective Equipment (PPE). On 11/19/24 emergency personnel responded to a call upon entering a resident’s room with symptoms of infectious disease facility staff assisting did not put on proper PPE prior entering the room. Interviews conducted with residents revealed the following 3 out of 6 residents stated staff used proper PPE when entering the rooms to provide care. 3 out of 6 residents either did not observe or remembered whether staff used proper PPE supplies. Interviews with staff revealed staff were provided PPE supplies which were placed outside residents’ rooms that were in isolation. However, staff admitted that during the visit of emergency responder, staff was not wearing PPE when assisting resident with infectious disease symptoms going out to the hospital. During facility’s tour, LPA observed PPE supplies in 3 rooms who are currently in isolation. One staff was observed going into a resident’s room to provide care with face mask under the chin as staff walked to provide care into resident’s room. Although facility has implemented guidelines and provided training to staff, staff did not follow infection control guidance. Therefore, this allegation is substantiated. (CONTINUED ON LIC 9099C) Based on LPAs observations, interviews which were conducted, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 9099D, and appeal rights were provided. Facility reported outbreak to Community Care Licensing (CCLD) on 11/17/24 and to PDPH on 11/18/24. Families, residents, and staff were notified of outbreak on 11/18/24 via letter. On 11/19/24 facility personnel responded to a call at the facility. Staff in charge did not notify personnel of outbreak. Although the facility staff did not informed emergency personnel regarding outbreak at the facility. Facility administration notified CCLD and PDPH within 24 hours of the third resident with symptoms. Regulation stated an outbreak must be notify to CCLD and PDPH. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 26, 2024 · control 28-AS-20241120082237

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(b)(2) · Plan of correction due date: Nov 27, 2024

87470 Infection Control Requirements: (b) In addition... the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE),,, This requirement is not met as evidence by: Based on observation and interviews licensee failed to ensure staff are wearing PPE supplies when providing care to symptomatic residents and proper use of PPE which poses an immediate risk to the health, safety, or personal rights to the persons in care.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: Administrator will schedule training to staff regarding proper use of PPE supplies while providing care to residents by POC due date 11/27/24. Will submit all training provided by 12/2/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(a)(1) · Plan of correction due date: Dec 3, 2024

87470 Infection Control Requirements: (a) A licensee shall ensure that infection control practices are maintained as follows: (1) All staff and volunteers shall perform hand hygiene. This requirement is not met as evidence by: Based on interviews conducted with other agencies licensee did not ensure staff were following infection procedures to prevent the spread of the infectious disease which poses a potential risk to the persons safety, health, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Nov 26, 2024

Plan of correction: Administrator provided training on hand hygiene to all staff on 11/22/24. Deficiency cleared as of 11/26/24.

Allegation investigated: Staff did not seek medical attention for resident in a timely manner

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Stephanie Funderburg and explained the reason for the visit. The investigation consisted of the following: On 8/27/24 LPA conducted an initial complaint investigation visit, conducted a health and safety check visit, requested copies of recent death reports, physician’s reports, and other pertaining documents to the complaint for resident #1(R1). LPA interviewed 5 residents. On 9/26/24 LPA interview 1 staff and observed facility's van during another visit at the facility. On 10/3/24 LPA conducted a subsequent visit, interviews 5 additional residents, 6 staff and requested copies of physician’s report, hospital discharge documents for resident #2 (R2) and #3(R3), and facility’s menu. On 10/7/24 LPA requested Pasadena’s Fire Department service log. On 9/26/24 LPA observed facility’s van. On 10/25/24 LPA Flores conducted a visit and deliver findings for the above allegation. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: Regarding allegation: Staff did not seek medical attention for resident in a timely manner. It is alleged R1 waited 20 minutes before paramedics arrived. On 8/1/24, while getting into the facility’s van to go on an outing, R1 injured the knee while lifting self into the van. Due to this incident R1 needed medical attention to be requested. Interviews conducted with residents revealed they have received medical assistance in a timely manner or are certain that they will get assistance with obtaining medical care in a timely manner. Interviews with staff revealed staff was with R1 during the incident. R1 stated to be hurt and Wellness coordinator attempted to assess R1 but R1 did not wanted to be touch. Staff brought a chair to have R1 seat while waiting for paramedics. However, R1 refused. Per staff paramedics were called right away and arrived within 15 minutes of the incident. At the time of the incident there were two residents that witnessed the incident. The residents stated R1 waited less than 15 minutes and no more than 30 minutes. Document review revealed, an incident report dated: 8/6/24 notes that on 8/1/24 R1 “was not able to bare weight on leg while getting into facility’s van” at approximately around 11:30am and 911 was called by staff. Pasadena’s Fire Department service log notes the service call was received at 12:29pm. Fire department responded and service with transport to the hospital within 15 minutes of the call. Per documents review facility staff had a delay of an hour to obtain emergency services/medical attention for R1, who sustained a fracture while getting into the facility’s van. Therefore, the allegation is substantiated. Based on LPAs interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Staff did not ensure facility van was accessible for residents to get in. It is alleged R1 couldn’t get into the van due to it not having any steps to use to climb into, and instead using a kitchen stool to get into the van. Interviews conducted with residents revealed the facility uses a step to assist residents into the van's step. However, residents on wheelchairs or walkers are assisted into the van through the wheelchair lift. Residents that witness the incident stated the step was placed in the cement and had no issues getting into the van while using it. Interviews with staff revealed the step is a commercial stepping stool which is used to assist the residents get into the van. Driver present at the time of the incident stated to have place the stool in the pavement next to the facility’s van step, across from the curve of the sidewalk. Driver stated to have offer to use the lift to assist R1. However, R1 had chosen to use the step to get into the van. On 9/26/24 LPA observed facility’s van. The following observations of the van were noted, the van is in good repair, with a build-in step inside the van by the side door. Step is in good repair. The van has a wheelchair lift in the back, also in good repair. Stepping stool is a commercial grade step which measures approximately 16 in. by 12 in. Although R1 was injured while stepping on the stepping stool, the facility provided the stepping stool as additional support for the residents, the van and step were in good repair, stepping stool was placed in a flat surface when the incident occurred. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 25, 2024 · control 28-AS-20240827104328

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 26, 2024

87468.2 Additional Personal Rights of Residents...:(a) ... facilities for the elderly shall have ... personal rights: (4) To care, supervision, ... meet their individual needs ... by staff that are sufficient in...qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure R1 was provided with timely medical care during the incident by delaying the care by an hour which poses an immediate personal right, health, or safety risk to the persons in care.the state’s words, verbatim · CDSS document, Oct 25, 2024

Plan of correction: Administrator will provide training to facility's staff in timely medical attention, will provide a copy of staff log, description, duration of training, and will submit to the department by POC due date 9/26/24.

Allegation investigated: Questionable deaths Staff are not providing adequate food service to resident Staff are not meeting residents needs

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Stephanie Funderburg and explained the reason for the visit. The investigation consisted of the following: On 8/27/24 LPA conducted an initial complaint investigation visit, conducted a health and safety check visit, requested copies of recent death reports, physician’s reports, and other pertaining documents to the complaint for resident #1(R1). LPA interviewed 5 residents. On 9/26/24 LPA interview 1 staff during another visit at the facility. On 10/3/24 LPA conducted a subsequent visit, interviews 5 additional residents, 6 staff and requested copies of physician’s report, hospital discharge documents for resident #2 (R2) and #3(R3), and facility’s menu. The investigation revealed the following: Regarding allegation: Questionable deaths. It is alleged one resident sustained a fall, fractured hip, and a week later passed away and another resident passed away suddenly after leaving the dining room. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews conducted with staff revealed, R2 had trip and fallen in the dining room on 4/18/24. Staff assisted R2, who was send out to the hospital via emergency services. Interview conducted with R2’s family member who was present during the fall revealed R2 made a sudden turn and fell, sustaining a hip fracture. Per family member facility staff assisted right away, paramedics were called, and R2 was send out to the hospital. While at the hospital R2 was not able to obtain surgery for the hip fracture due to other health conditions and passed away on 4/25/24 at the hospital. Documents reviewed revealed, Incident report dated 4/22/24, notes R2 suffered a mechanical fall in the dining room on 4/18/24 at 5:30pm. Paramedics were called and was transferred to the hospital. Service Plan dated 12/28/23 notes R2 is independent, self-care, with occasionally needing verbal cues. Per physician’s report dated 5/1/23 R2 did not have any motor impairments. Regarding R3, interview conducted with administrator revealed R3 had been at the facility for about 4 weeks and did not show any changes in condition or other signs of distress. On 7/10/24, staff conducting checks found R3 in the room unresponsive. Paramedics were called and R3 was declared death. Documents reviewed revealed the following: Per incident report dated 7/9/24, R3 was found in the room on 7/3/24 at approximately 12pm by a caregiver not responding to verbal commands. R3 was assessed by medication technician, who observed R3 was weak, vomiting, and unresponsive to verbal commands. Emergency services were called and R3 was transfer to the hospital. R3 was hospitalize, received treatment, and return to the facility on 7/8/24. R3’s physician’s report dated: 5/16/24 notes R3 had a history of congestive heart failure. Death report dated 7/10/24 notes, on 7/9/24 R3 was found in their room by a medication technician during check rounds. Paramedics were contacted, arrived at the facility, after evaluating R3 declared time of death at 7:42pm. Death report notes cause of death as cardiopulmonary arrest. Although both deaths were sudden there were no changes in condition, prevention, or lack of staff care that could have prevented the deaths of R2 and R3. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff are not providing adequate food service to resident. It is alleged R1 was on a vegan food program. However, R1 was forced to buy own vegan food for the chef to cook and was not provided vegan meals by the facility. Interviews conducted with residents revealed facility facilitates meals to residents’ dietary needs or preferences and are satisfied with the meals provided. (CONTINUED ON LIC 9099C) Interviews with staff revealed facility staff are able to identify residents with special diets, allergies, or meal preferences which they follow to provide the meals to the residents in care. Kitchen staff are aware of R1’s vegan meals preference and arrange for R1 to received vegan meals daily. Interview with Culinary Director revealed R1 had shown a desired for certain products that the facility was not able to accommodate as food produce vendor did not carry does specific items. However, culinary director had accommodated other brands or substitutes to provide the meals for R1. Document review revealed R1’s facility’s nutritional profile dated 3/22/24 notes vegetarian meals. Physician’s report dated 3/21/24 notes R1 has a vegetarian diet with regular textures. Although R1 may have had preferences in vegan items or produce, interviews conducted revealed the facility provided vegan meals for R1 with accommodations of produce they were able to obtain with food company they vendor with. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff are not meeting residents needs. It is alleged facility staff are not assisting residents with dementia to seat at the dining room table and wheels of residents in wheelchairs are getting stuck in the elevators’ gaps. Interviews conducted with residents revealed residents feel satisfied with the care and assistance the staff are providing to them. Residents that need assistance with wheelchairs stated to be able to get into the elevator without difficulties and wheels have not gotten stuck in the gaps of the elevator. Interviews with staff revealed, at mealtimes staff remind residents to their usual chair when they seem confused and are not left unattended. Also, staff assisting residents in wheelchairs have not have incidents in which wheels get stuck in between the gaps or the elevators’ doorway. During facility’s tour on 8/27/24 LPA observed facility’s elevators in working condition and no large gaps were observed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 28-AS-20240827104328

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not prevent resident from sustaining a fracture while in care. Staff did not prevent the facility from being hazardous resulting in residents sustaining injuries. Staff did not prevent the facility from being in disrepair. Staff did not follow physician's order. Staff did not prevent resident's sleep from being interfered.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Stephanie Funderburg and explained the reason for the visit. The investigation consisted of the following: On 8/27/24 LPA requested a copy of staff and resident roster. LPA toured the facility with Mario Henriquez – Maintenance Director and observed 12 randomly chosen residents rooms and common areas. LPA interviewed 10 residents and 6 staff and requested the following documents for resident #1(R1) physician’s report, resident assessment, pre-placement, identification and emergency information sheet, order summary report dated 1/31/24, admission agreement, and nutritional information sheet. On 9/26/24 LPA interview (1) staff and delivered findings for this complaint. Regarding allegation: Staff did not prevent resident from sustaining a fracture while in care. It is alleged R1 injured self and now has a fractured femur due to facility not being safe. Interviews with residents revealed the facility is safe there are no hazardous around and have not witness residents fall or harm. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with staff revealed R1 was leaving the facility on an outing, facility’s driver assisted R1 standing near R1 and providing hand for support. R1 place her hand on driver and used her left hand on the van’s handle to pull self-up. As R1 was lifting self-up to get into the van, R1 cried out in pain and stated to have “pop my knee”. Staff called emergency services for R1 who arrived right away and was taken to the hospital by paramedics. Documents reviewed revealed, per physician’s report dated 3/21/24, R1 is ambulatory and does not have any physical impairments. Incident report dated 8/6/24 notes R1 was going in an outing and was “stepping into the community bus assisted by facility’s driver. Upon R1 stepping into the bus, R1 stated to have heard a snap in the knee and was unable to bear weight”. A medication technician assessed R1 and 911 was called to send R1 to the hospital. Per preplacement appraisal information dated 3/29/24 R1 had a “prior broken left femur”, hip and knee. Resident Assessment dated 3/20/24 notes R1 is “independent, self care”. Although R1 may have sustained a fracture, the fracture was not due to hazardous or the facility not being safe. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not prevent the facility from being hazardous resulting in residents sustaining injuries. It is alleged the facility is not safe and they are having "things" in places where they shouldn't be causing residents to fall many times and have gotten injured. Interviews with residents revealed they have not observed hazardous materials or construction materials left in hallways or common areas. Interviews conducted with staff revealed there has been some remodeling done at the facility. However, the tools and materials are kept inside the rooms being remodel and not in common areas or corridors. During the tour of the facility LPA observed the remodel rooms. No hazardous materials or tools were observed in the hallways or common areas. Incident reports submitted within the last month to the department note falls due to other reasons. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not prevent facility from being in disrepair. It is alleged shower stopped working and the A/C unit also stopped working. Interviews conducted with residents revealed shower and A/C has been in working condition and had no concerns. (CONTINUED ON LIC 9099C) Interviews with staff revealed facility’s A/C has been in working condition and no reports of clogged showers had been made. During facility tour a total of 12 resident rooms were observed and each shower/bathroom was in working condition. Temperature in each room was felt comfortable and A/C was working. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not follow physician’s order. It is alleged resident did not receive physical therapy for eight weeks due to facility lying agency about whereabouts of resident. Interviews with residents revealed residents are assisted as needed with all their needs. Interview with administrator revealed R1 was not receiving physical therapy or had orders for physical therapy. Documents reviewed revealed Skill Nursing order summary report dated 1/31/24 notes R1 was to received physical therapy, “one time only” until 2/25/24. No other physician orders were observed in R1’s file pertaining most recent physician’s order for physical therapy. Resident Assessment dated 3/20/24 notes R1 is independent to coordinate own healthcare and home care appointments. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not prevent resident’s sleep from being interfered. It is alleged resident’s roommate snored loudly and resident could never sleep. Interviews conducted with residents revealed staff responds to residents’ concerns when necessary and have not experience issues with roommates. Interview with administrator revealed, R1 reported the situation. R1’s roommate was moved from room due to residents not getting alone. R1’s roommate was interview and was not able to recall any incidents with roommates. Although the situation may have happened there is not enough evidence to say that the facility did not take action in assisting R1 after reporting R1’s concerns. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 28-AS-20240822094827

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit regarding incident report submitted to the department on 9/11/24. LPA met with Stephanie Funderburg and explained the reason for the visit. On 9/7/24 LPA Flores received incident report to notify the department of incident occurred on 8/31/24. Per incident report, on 8/31/24 at around 2:10pm resident #1(R1) left the memory care unit, had a conversation with lobby staff and left the facility unattended. Upon memory care staff conducting rounds they noticed R1 was not found. Staff contacted police department to request assistance. Police department notify facility staff R1 was found on the street and will be return to the facility. R1 was returned to the facility at around 5:10pm. LPA conducted interviews with 2 staff, per interviews conducted Lobby staff was not aware of R1 being a memory care resident. Per wellness director, upon checking the egress doors in memory care they were working, it is unknown why the staff were not aware R1 had exit the memory care, lobby staff is provided a binder with pictures of the residents that are not to leave the facility unattended to assist with identifying them. On 9/7/24 Lobby staff was given a final warning notice regarding the incident. On 9/10/24 Wellness Director provided training to staff regarding "Memory Care Secure doors, door checks", and place other measurements in place. Per physician's report R1 dementia is other treated condition and is not to leave the facility unattended. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 809D and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Sep 26, 2024

87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... additional staff whenever... the needs of the particular residents... This requirement is not met as evidence by: Based on documents reviewed and interviews conducted the licensee did not ensure R1 did not elopped from the facility which poses an immediate risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Administrator provided in-service training to staff on 9/10/24 regarding securing doors, conducting door checks. Facilty has put in place a log to ensure egress system is working each day in the memory care unit, and staff was given a warning. Deficiency cleared as of 9/26/24.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual continuation inspection visit at the facility. LPA met with an explained the reason for the visit. During this visit LPA completed the following domains during today's visit: Infection Control, Operational Requirements, Staffing, Personnel Records/Staff Training, Incidental Medical and Dental, Disaster Preparedness, Residents with Special Health Needs. LPA reviewed Infection Control plan and Emergency Disaster plan both were last reviewed on 7/24/24. A total of (8) staff files were reviewed. Training for staff was reviewed. A hospice file was reviewed. LPA reviewed medication for 7 residents. During medication review LPA observed medication for resident #3(R3) did not have labels on the prescribed medication. Liability insurance was reviewed. The following domains were completed and/or observed during the initial annual inspection visit of 8/27/24: Physical Plant/Environmental Safety, Resident Rights/Information, Food Service, Planned Activities, Resident Records/Incident Reports. Deficiency noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 26, 2024

Allegation investigated: Staff are not preventing the spread of COVID-19.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Stephanie Funderburg - Executive Director and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of Staff and Resident Rosters, Correspondence emails beteween the Executive Director and Department of Public Health, Letters informing Residnets and Responsible/Parties of the Covid Positive results, and exposure. LPA toured facility both 1st and 2nd floors along with the memory care wing. LPA interviewed 5 Staff and 12 Residents. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff are not preventing the spread of COVID-19. LPA toured facility alongside of Stephanie Funderburg (Executive Director) and Ann-Marie Boersma (Wellness Director) and observed hand sanitizing stations throughout facility, LPA tested the sanitizing stations in common areas and they were operable. There is one resident that was recently on isolation (last day was yesterday), signage of corona virus was at the door and there was a sanitizing station with masks, gloves, gowns, and hand sanitizer outside of their room. LPA observed a storage room in memory care that had sufficient PPE supplies, such as masks, gloves, gowns and hand sanitizer. LPA obtained copies of letters informing Residents and Family/Responsible parties that were sent out, informing them that there have been Covid Positive cases and encouraging all to wear masks, as well as staff. Throughout the tour LPA observed multiple staff and residents without masks, however, given the recent Rescission of Health Officer Order for the City of Pasadena as of March 5,2024, the order requiring masks by personnel, patients, clients and visitors in health care settings issued March 29.2023 by the health officer of the City of Pasadena is rescinded in its entirety, this information was provided to LPA by the Department of Public Health. LPA interviewed 12 Residents and 10 out of 12 Residents denied the above allegation. 10 residents stated that have observed staff wearing masks and have masks and hand sanitizer readily available for them, they also stated that they were informed of the outbreak and encouraged to wear masks. LPA interviewed 5 staff and 5 out of staff denied the above allegation and stated that they have been encouraging masks, sanitizing and have notified residents of the outbreak. LPA special incident reports that were submitted to licensing, and noticed that the Covid outbreak was not reported per the 24 hour reporting requirement. This will be detailed in a separate case management report. Based on statements and interviews conducted with staff and residents, review of documents/records, there was not enough supportive evidence to concur with the reported allegation. 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, therefore the allegation is UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 28-AS-20240905092935

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Tena Herrera conducted a case management visit in relation to complaint control #28-AS-20240905092935, LPA met with Executive Director Stephanie Funderburg and explained the purpose for visit. During the complaint investigation for the above referenced complaint number, LPA reviewed documents regarding the recent Covid out break and observed that the facility failed to inform the Department of the Covid outbreak within the 24 hour reporting requirement. LPA reviewed the Daily Covid-19 Report that indicated that 2 residents tested positive on 8/20/24, 1 resident tested positive on 8/23/24, and 1 resident tested positive on 8/24/24, and 2 residents tested positive on 8/25/24. LPA reviewed Special Incident Reports (SIR's) that were sent to the Department for those individuals and observed that the fax transmittal dates were from 8/30/24. Therefore, there were multiple Covid cases that were not reported within the 24 hour reporting requirement for epidemic outbreaks, this will be cited on the LIC809-D. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Sep 13, 2024

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidence by: Based on documents reviewed licensee did not report the epidemic outbreak to licensing within the 24 hour reporting requirement, as multiple residents tested positive for Covid-19 (5) days prior to reporting to licensing, which poses a potential risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: Licensee/Executive Director will review the cited regulation in its entirety and confirm that moving forward the facility will report occurences such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. A copy of the signed Proof of Correction Form LIC9098 must be emailed to LPA by POC due date. This form will serve as an agreement that the regulation has been reviewed and understood. (tena.herrera@dss.ca.gov)

Allegation investigated: Staff handled resident in a rough manner.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Stephanie Funderburg and explained the reason for the visit. The investigation consisted of the following: On 8/22/24 LPA Flores conducted a case management visit at the facility regarding the above allegation. During that visit LPA requested copies of the following documents; incident report dated: 8/6/24, report of suspected dependent elder abuse (SOC 341) dated: 8/2/24, Pasadena police department business card with report number, identification and emergency information sheet, physician’s report, pre-placement assessment, needs and care plan for residents’#1-2(R1-R2), notice of employee separation, suspension notice, notice to employee as to change in relationship, personnel record for staff #1(S1), email, and other supporting documents. LPA interviewed 5 staff and 2 residents. On 9/4/24 LPA Flores interview S1 over the phone and delivered findings for this complaint. (CONTINUED ON LIC 9099C) Substantiated The investigation revealed the following: Regarding allegation: Staff handled resident in a rough manner. It is alleged S1 assisted R2 aggressively causing R2 to scream in pain. On 7/26/24, staff witness S1 using force while providing assistance to R2 per incident report submitted to the department on 8/6/24. Interviews conducted with staff revealed there were corroborative statements that S1 had pulled R2’s left in a rough manner, while R2 was seating on a wheelchair. The leg was lifted up and then placed in the wheelchair’s footrest causing R2 to scream due to pain. Documents reviewed revealed, S1 had provided assistance to R2 by lifting the leg with force to put it in the wheelchair's footrest, resulting on R2 screaming. LPA was unable to interview residents due to cognitive skills. Facility reported the incident to all pertaining agencies on 8/2/24 and conducted an internal investigation for which there was enough evidence against S1. On 8/2/24, S1 was verbally notified of a suspension and investigation of the incident. An officer from the Pasadena Police Department conducted a visit and left report #PA24-61517 regarding the reported incident. On 8/6/24 a Notice of Employee Separation was created, and S1 was terminated from the facility after the suspension for suspected abuse. On 8/6/24 an incident report was submitted to the department after obtaining all the pertaining information to the facility's internal investigation. No physical injuries were caused to the residents by S1. Interview conducted with S1 did not provide additional information and stated to not have treated the residents in a rough manner. On 8/22/24 LPA Flores conducted a case management visit regarding the above allegation, during the case management visit LPA provided a deficiency on personal rights due to the suspected abused occurred to the residents in care at the facility. Therefore, no additional deficiencies will be cited on a LIC 9099D during this visit. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 were cited on 8/22/24. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 28-AS-20240827213252

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Stephanie Funderburg and explained the reason for the visit. The facility is licensed to serve 116 non-ambulatory and 104 bedridden residents over the age of 60 years old. Facility is a two story building with a lobby, a memory care unit, several common areas indoor and outdoor such as: a library, activity rooms, game room, private dining room, large dining room, 88 resident bedrooms with private bathrooms, shower rooms in the first floor and second floor, and a commercial kitchen. LPA Flores conducted a tour of the facility with Mario Henriquez - Maintenance Director and observed the following: Facility is in good repair indoor and outdoor. Commercial Kitchen was observed and sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. All common areas have furniture that are in good repair. Fireplaces in common areas are covered. Memory care unit(MCU) was observed common areas are clean, an enclosed shaded area was observed, activities room available, egress doors throughout the unit tested and in working condition. Two resident rooms were observed in the MCU a cleaning solution in room #150 bathroom's sink was observed. Ten assisted living resident rooms were observed. All twelve rooms have the required bedding, furniture, sufficient lighting. Water temperature was tested in each resident's bathroom and tested between 108.0 - 117.0 degrees F., which is within the required temperature of 105-120 degrees F. Facility has a sprinkler fire system throughout Fire extinguishers were lasted checked on 9/7/23. Assisted living has multiple courtyards with shaded seating areas. Elevators are in working condition. Stairways have an evacuation chair at the bottom of each stairway. Medication room is inaccessible to the residents. LPA reviewed medical records for 7 residents, and conducted interviews with 7 residents and 6 staff. (CONTINUED ON LIC 809C) LPA concluded Physical Plant domain during this visit and will return at a different time to conclude annual visit and the remaining domains. Deficiency has been noted on LIC 809D per Title 22 Regulations. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 27, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit regarding incident report submitted to the department on 8/6/24 and 8/8/24. LPA met with Stephanie Funderburg and explained the reason for the visit. On 8/6/24 an incident report was submitted to the department regarding a notification of physically abused by a staff towards two residents in the memory care unit. On 8/1/24, two staff stated to have witness, staff #1(S1) hitting resident #1(R1) firmly in the hand on 7/26/24 and using force to provide assistance to resident #2(R2) on 7/29/24. Interviews conducted and documents reviewed by LPA revealed staff had observed S1 slapped/snatched R1's hand as R1 requested for assistance as S1 walked by. As well as on 7/29/24, S1 had provided assistance to R2 by bending down the leg and using force to lift it up resulting on R2 screaming. LPA was unable to interview residents due to cognitive skills. No injuries were caused to the residents due to staff's behavior. Facility reported it to all pertaining agencies and conducted an internal investigation and substantiated the allegation against S1. S1 was notified of a suspension and investigation verbally and via email on 8/2/24. On 8/6/24 a Notice of Employee Separation and staff was terminated from the facility after suspension of suspected abuse. Police department conducted a visit and left report #PA24-61517. Due to physical abuse observed by staff towards two residents, Deficiency is noted on LIC 809D regarding this incident. On 8/8/24 an incident report was submitted to the department regarding resident #3(R3) provided Heimlich maneuver assistance after staff noticed R3 was chocking during breakfast in the memory care unit dining room on 8/4/24. LPA interviewed the staff who witness and assisted during the incident. Per staff R3 was on a finely chopped diet and was having breakfast at around 10:00am. Dining server noticed R3 was not breathing and went to call Med-tech for assistance. (CONTINUED ON LIC 809C) Med-tech checked on R3 and asked dining server to stay with R3 while staff called 911. Kitchen director went to provided assistance with the incident and attempted to clear the airway by removing food observed in R3's mouth and perform Heimlich maneuver. Med-Tech returned and took over. First responders arrived within 3-4 minutes and took over assisting R3. R3 was transferred to the hospital. LPA reviewed R3's file, per physician's report dated 7/15/24, R3 was on a finely chopped diet. LPA observed observed kitchen staff prepare a finely chopped diet, which consist of dicing all food items served to the residents. After interviews and documents reviewed facility staff provided assistance to R3 as soon as the incident was observed. No deficiencies noted regarding incident occurred on 8/4/24. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 22, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Aug 23, 2024

Additional Personal Rights of Residents ...(a)... shall have all of the following personal rights:(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure S1 treated R1 and R2 with dignity and respect which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: Administrator provided in service training to staff regarding resident personal rights, elder abuse, dignity and respect a copy was provided of training during this visit. Deficiency cleared as of 8/22/24.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) conducted an unannounced case management visit at the facility regarding incident report submitted to the department on 3/7/24. LPA met wtih Stephanie Funderburg and explained the reason for the visit. On 3/7/24 facility submitted an incident report to report that on 3/4/24 at 5:30pm staff noticed resident #1 (R1) was not in the community and an exit door was open. R1 was last seen at 5:10pm after finishing dinner. Interview conducted with administrator and staff revealed after video footage review, R1 used the emergency exit by room #129 in the memory care unit to exit to the parking lot, walked through the parking lot, and jumped over the parking gate to the street. Delay egress system was working, however staff did not hear the device as staff were at the dining room with other residents. Administrator and managers began to search in the area as soon as it was reported R1 was missing and were not able to find R1. Administrator notified Pasadena Police Department and R1's responsible party. Pasadena police department officers found R1 at around 5:48pm and return R1 to the facility. Upon facility's staff physical evaluation, staff noticed a laceration of about 1cm in diameter on the back of R1's head and was send via paramedics to the hospital for further evaluation. Hospital Discharge dated 3/4/24 notes R1 was seen for an abrasion of scalp and no other head injuries were observed. It is unknown how R1 obtained the abrasion. R1 returned to the facility on the same day. Needs and Care plan dated 3/19/24 was updated with notes of resident has been placed on 24/7 supervision by additional care staff. LPA observed emergency exit doors with delay egress system in working condition and tested door by #129 which was observed working but with a faint sound. During this visit administrator notified to have communicated the need of a different environment to the family, facility is assisting with seeking better placement for R1. R1 currently has a one-on-one staff to prevent further incidents. (CONTINUED ON LIC 809C) On 3/4/24 LPA Flores conducted a case management regarding R1, for incident report submitted to the department on 2/21/24 regarding an incident in which R1 had exit the memory care unit by climbing over the fenced courtyard emergency exit door. Deficiencies were noted per Title 22 Regulations on LIC 809D. Exit interview was conducted with Stephanie Funderburg and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 19, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Mar 20, 2024

87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... additional staff whenever... the needs of the particular residents... This requirement is not met as evidence by: Based on documents reviewed and interviews conducted the licensee did not ensure R1 did not prevent R1 from eloping the facility after first incident which poses an immediate risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2024

Plan of correction: Administrator has placed a one-on-one staff to provide care for R1, is activily assisting with placement in a smaller setting, and has provided training to staff on delay egress and memory care on 3/5/24 and 3/19/24. Deficiency cleared as of 3/19/24.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit at the facility regarding an incident report submitted to the department on 2/21/24. LPA met with Stephanie Funderburg and explained the reason of the visit. On 2/21/24 incident report was submitted to the department reporting that on 2/21/24 resident #1(R1) was witnessed outside the memory care unit(MCU) on the parking through a window in the parking lot around 9:45am. During today's visit LPA Flores reviewed the following documents; incident report dated 2/21/24, physician's report dated 12/12/23, resident assessment dated 2/21/24, service appraisal for R1 and activity plan for MCU. R1 was admitted to the memory care unit of the facility on 1/20/24. Physician's report notes R1 under dementia. Resident assessment was updated to note elopement on 2/21/24 and enhanced needs to provide ongoing redirection for exit seeking behavior and assistance with wandering device, which is the same as the initial service appraisal. Per activity calendar residents had fitness at 9:30am and Musical performance at 10:00am. LPA conducted a tour of the MCU and observed all emergency exits to have egress system in working condition, passageway leading from the fenced door of the courtyard was observed with pile wood planks against the side of each wall leaving about a foot and a half space of passageway. Video surveillance was reviewed, R1 is observed going into the courtyard at 10:16am, reaches the courtyard emergency exit door at 10:17am and pauses. At 10:18am R1 places the walker against the wall and fenced door, uses the walker to step in it and climbs over to the side wall and over the 7ft fenced door over to the other side, climbs down and walks towards the parking lot by 10:22am staff observed R1 and redirected R1 to the MCU. Interviews with staff revealed there are 3 staff on each shift and 29 residents in the MCU. At the time of the incident one staff was assisting a resident in the wing by the family lounge, the other staff was on break, and the third staff was assisting another resident in the shower room, other residents were with the activity staff in the activity room. (CONTINUED ON LIC 809C) Per administrator the staff were asked to provide supervision for R1, medications were adjusted by physician after notifying physician of incident, and is currently in the process of hiring an additional staff for the MCU. The facility has created a plan of care for R1 and there are no previous records of R1 elopement. However, during this visit LPA noted wood planks in the back passageway leading to the parking lot of the exit door from the MCU courtyard. Therefore, deficiencies are noted on LIC 809D per Title 22 Regulations Division 6 Chapter 8. Exit interview was conducted with Stephanie Funderburg and a copy of this report and LIC 809D was provided.the state’s words, verbatim · CDSS document, Mar 4, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Mar 11, 2024

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidence by: Based on observation licensee did not ensure that all passageways were free of obstruction which poses a potential risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Mar 4, 2024

Plan of correction: Administrator will remove wood planks and will submit a picture to the department by POC due date 3/11/24.

Allegation investigated: Staff unlawfully evicted resident

Licensing Program Analyst (LPA) Angelica Rea conducted an initial complaint visit in response to the allegation listed above. LPA met with Administrator, Stephanie Funderburg, who assisted with today's visit. Regarding the allegation that : Staff unlawfully evicted resident #1. The investigation consisted of review of resident #1's file, and interview(s) with Administrator, and Staff #1. The investigation revealed that resident #1 moved into the facility on 11/21/23. Administrator stated that resident #1 left the faciilty on 12/4/23, was picked up by the police and taken to the hospital. Administrator stated that the facility wellness director went to the hospital to reassess resident #1. Administrator stated that it was determined that resident #1 required a higher level of care, that they were not initially aware of when resident #1 was admitted. Administrator stated that they did not provide resident #1 with an eviction notice, but they did not feel that resident #1 should return to the facility upon discharge from the hospital. Substantiated Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Ms. Funderburg. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 21, 2023 · control 28-AS-20231214170530

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87224(a) · Plan of correction due date: Dec 28, 2023

Eviction Procedures. The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously identified, and/or a change of use of the facility. This requirement was not met as evidenced by: Interviews with Administrator and Staff #1 indicate that resident #1 was not given 30 days written eviction notice as required.the state’s words, verbatim · CDSS document, Dec 21, 2023

Plan of correction: Administrator will ensure that the facility follows Title 22 eviction procedures, (87224) as required. Administrator will conduct an in service training with staff regarding eviction procedures and will send proof of training to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(LPA) Mary Flores conducted an unannounced case management visit at the facility to follow up on incident report submitted to the department on 12/7/23. LPA met with Stephanie Funderburg and explained the reason for the visit. On 12/7/23 incident report was submitted to the department notifying the following: On 12/4/23 Resident #1(R1) stated, "needed to leave and walked out the front door of the community." On 12/5/23 R1's family representative contacted the facility to notify them that Pasadena Police Department had taken R1 to the hospital after a verbal altercation outside the community. On 12/7/23 LPA followed up and requested a copy of physician's report and needs and care plan. Upon review of Physician's report dated 11/2/23 it was discovered R1 was check under applicable with dementia and notes R1 can leave the facility unassisted. Physician's report was signed by legal representative (POA). During today's visit LPA requested a copy of admission agreement, medication sheet, and identification and emergency information. A copy of Power of Attorney is not on file but the facility will obtain a copy from the legal representative. During interviews with assigned administrator and staff, it was noted that R1 had left the facility unattended twice before as was allowed as the physician's report notes R1 is able to do so. Facility has notified R1's representative each time and R1 has return to the facility within 24 hours. Due to the physician' report being noted that R1 has dementia facility and is able to leave the facility unassisted and has a power of attorney it is unclear whether R1 is able to make this decision and remain safe outside the facility. The facility will obtain a reassessment of the physician's report to note the diagnosis correctly and resident's capabilities. The facility will submit a copy of reassess physician's report and power of attorney to the department by 12/18/23. No deficiencies were noted during this visit. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 8, 2023

Allegation investigated: Staff did not prevent a resident from being sexually abused while in care.

Licensing Program Analyst (LPA) Mary Flores conducted a subsequent compliant investigation visit regarding the above allegation. LPA met with Stephanie Funderburg and explained the reason for the visit. The investigation consisted of the following: On 8/1/23 LPA Flores conducted a Health and Safety check visit at the facility and requested copies of the following documents staff/resident roster, admission agreement, physician's report, identification and emergency information sheet, needs and care plan, medication sheet for July 2023, incident reports, notes on resident #1 and #2 (R1-R2), staff schedules for the month of July 2023. On 8/22/23 and 8/25/23 IB investigator Sonia Sandoval from the department’s Investigation Bureau conducted interviews with R1, and 3 staff(S1-S3). On 10/18/23 LPA Flores contacted Pasadena’s Police Department. On 10/18/23 and 11/8/23 LPA Flores left a voice for Detective at Special Victim Unit. On 12/4/23 LPA Flores conducted interviews with 5 additional residents. (CONTINUED ON LIC 9099C) Unsubstantiated The investigation revealed the following: Regarding allegation: Staff did not prevent a resident from being sexually abused while in care. It is alleged a male resident inappropriately touched a female resident. Per administrator at the time of the incident, On 7/22/23 staff #2(S2) observed R1 exit the elevator and was startled, upon S2 asking R1 what was going on. R1 reported that R2 had touched R1 inappropriately while in the elevator. S2 reported it to management and management reviewed the video surveillance footage in the elevator. On 7/24/23 after reviewing surveillance video administrator reported it to the proper agencies. On 7/27/23 Officer Tucker from Pasadena Police Department assisted with the call regarding the alleged abuse at the facility. Officer Tucker reviewed the video surveillance, in which it was observed both residents entering the elevator in the second floor. Then R2 holds R1 hand once inside the elevator and turns in an attempt to hug R1 by placing hands around R1’s waist. R2 grabs R1’s hand and attempts to place it in R2’s hip, then R2 places R2's head over R1’s left shoulder with R2's face facing R1’s shoulder. R2 is seen speaking to R1, in response R1 pushes R2 away saying “No” twice and “stopped it”. R1 attempted to pull away, but R2 would not let go. Residents are observed exiting the elevator in the first floor holding hands. However, R1 stays back and is able to let go of R2’s hand. It is then that S2 observed R1 agitated and reported to have heard R1 saying “No. Stop” from inside the elevator. Officer Tucker attempted to interview R1 and due to cognitive skills R1 was not able to remember the incident. On 8/22/23 a second attempt to interview R1 was attempted by IB investigator, who was not able to obtain information due to R1’s cognitive skills. On 10/18/23 LPA spoke with intake officer from Pasadena Police Department who stated the report was forward to Special Victim Unti (SVU). On 10/18/23 and 11/1/23 LPA attempted to speak to the detective reviewing the case but was not able to obtain information. Documents reviewed do not revealed any history of related behaviors for R2. R1 and R2 were either on minimal assistance or independent care. R2 moved out of the facility on 8/27/23 and the department was unable to interview R2. Interviews with additional residents revealed residents are respectful with each other and staff are available and responsive to any situations. Although, the incident may have occurred there is not enough evidence to support that R2 had a history of behaviors or notes in change of condition, allowing the facility to have an action plan to prevent the incident from happening. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Stephanie Funderburg and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 5, 2023 · control 28-AS-20230801093641

Allegation investigated: Staff did not provide adequate care and supervision to the residents while in care Staff are blocking the doorway to prevent the residents from coming out

Licensing Program Analyst (LPA) Mary Flores conducted a subsequent visit regarding the above allegations. LPA met with Tasha Thompson Front Desk Concierge and explained the reason for the visit. Administrator arrived 10 minutes later. The investigation consisted of the following: On 4/3/23 LPA Flores conducted a tour of the dementia unit, interviewed staff #1-9(S1 - S9), and residents #1-7(R1-R7), and requested copies of staff/resident roster, and of physician's report, face sheet, and needs and care plan for R1-R6. On 10/19/23 LPA Flores requested physician’s report, needs and care plan, for resident #8(R8) and delivered findings. The investigation revealed the following: Regarding allegation: Staff did not provide adequate care and supervision to the residents while in care. (CONTINUED ON LIC (9099C) Substantiated It is alleged a resident in memory care unit went outside the facility while the staff at the desk where on the phone calling for help. Interviews conducted with residents revealed, 6 out of 7 residents did not know if other residents have exited the memory care unit and gone out to the street or lobby. 1 out of 7 residents was unable to answer due to cognitive skills. Interviews conducted with staff revealed, 6 out of 9 staff interviewed stated that residents have exit the memory care unit unattended either reached the lobby or gone outside. 2 out of 9 staff stated residents have not exit the memory care unit and 1 out of 9 staff was not aware of the situation. Administrator and Wellness Director stated that R8 was found in the corner of Lake and Villa by a staff that was leaving her shift for the day on 3/24/23 and brought back into the facility. On 5/13/23 LPA conducted a complaint visit, during that visit LPA observed a resident exit the memory care unit unassisted into the lobby. Receptionist at that time called for assistance. Documents reviewed note the following: Physician’s report dated 8/17/21, note R8 has wandering behaviors and is unable to leave the facility unassisted. Needs and care plan does not note R8’s wandering behaviors and/or a plan to prevent R8 from leaving the memory care or the facility. Based on LPAs interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Regarding allegation: Staff are blocking the doorway to prevent the residents from coming out. It is alleged there is always a large wood board that staff put to block the door, so the residents don’t come out of memory care unit. Interviews conducted with residents revealed 3 out of 7 residents stated the doors are not block with any items. 2 out of 7 residents stated the doors are block with a wood board, 2 out of 7 residents were either not sure or unable to answer due to cognitive skills. Interviews with staff revealed 5 out of 9 staff stated the doors are not blocked with a wood board. 2 out of 9 staff stated the doors have been blocked with a wood board to prevent residents from leaving memory care unit. 2 out of 9 staff stated either the doors in the memory care unit are not closed correctly to ensure the egress system works or were not sure about if doors were blocked to prevent residents from leaving. During the tour conducted on 4/3/23 LPA Flores observed exit door by room #129 which exits to the parking lot blocked with a sliding wood board, egress system was observed not working for that door, and door was unlock during the visit. Per administrator there was a leak in the wall adjacent to the door and plumbers had to cut the electricity in the door to work on the door. No plumbers were observed working during the visit or staff around the area supervising. (CONTINUED ON LIC 9099C) Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Erin Mahoney and a copy of this report, LIC 9099D, and appeal rights was provided. Interviews with residents revealed, 3 out of 7 residents stated residents are clean and timely changed. 3 out of 7 residents stated they do not require incontinence assistance and 1 out of 7 residents was unable to answer due to cognitive skills. Interviews with staff revealed 9 out of 9 staff stated residents are clean and assisted with incontinence care provided timely. 5 out of the 9 staff stated incontinence care is provided at least between every 2-4 hours or as needed to the residents. Documents reviewed revealed 5 out of 7 residents did not require incontinence care and 2 out of 7 residents need assistance with incontinence care. Needs and care plan noted the residents that need assistance with incontinence care. Other needs and care plan noted reminders needed to be provided to residents that do not required assistance with incontinence care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff are using inappropriate language towards the residents. It is alleged the caregivers yell in the hallways “saying the f word” at residents. Interviews conducted with residents revealed, 4 out of 7 residents stated staff are respectful and have not use foul language while providing care. 2 out of 7 residents were unable to provide an answer due to cognitive skills and 1out of 7 residents stated it was hard to tell what staff were communicating. Interviews with staff revealed, 8 out of 9 staff stated staff do not use foul language while providing care and 1 out of 9 staff was not sure if other staff use foul language while providing care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff behavior poses as a risk to the resident. It is alleged caregivers just sit in the tables on their phone and the residents do whatever they want, even fight. Interviews conducted with residents revealed, 2 out of 7 residents stated staff have been observed in their phones while working. 2 out of 7 residents stated staff are not on their phones while working. 2 out of 7 residents did not know if staff are on their phones while working and 1 out of 7 residents was unable to answer due to cognitive skills. Interviews with staff revealed, 5 out of 9 staff stated staff are not on their phones while providing care and supervision. 4 out of 9 staff stated staff have been observed in their phones during working hours. (CONTINUED ON LIC 9099C) Administrator stated staff communicate with each other with work related stuff via text throughout the day. Therefore, staff will be observe in their phone during working hours. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Erin Mahoney and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 19, 2023 · control 28-AS-20230328095738

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(k)(5) · Plan of correction due date: Oct 20, 2023

87705 Care of Persons with Dementia: (k) The following... requirements must be met ...(5) Residents who continue to indicate a desire to leave the facility following redirection shall be permitted to do so with staff supervision. This requirement is not met as evidence by: Based on observation, interviews, and documents reviewed licensee did not ensure there is a plan, staff, or assessments for residents in the memory care unit that continued to exit the memory care unit which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Administrator is to create and provide a plan, review needs and care plans for residents in memory, and/or ensure there is sufficient staff provided in the memory care unit to assist residents that will potentially attempt to exit by POC due date 10/20/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 26, 2023

87303 Maintenance and Operation: (a) The facility shall be..., safe,... and in good repair at all times... maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Based on observation licensee did not ensure that exit door by room #129 egress system was working at all times which poses a potential risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Administrator fixed the door. LPA observed the door and egress system working, there are no boards blocking the door. Deficiency cleared as of 10/18/23.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit during a complaint investigation visit. LPA met with Erin Mahoney and explained the reason for the visit. On 10/19/23 LPA Flores delivered findings for a complaint #28-AS-20230328095738. During the investigation the following deficiencies were noted: 87211 Reporting Requirements: On 3/24/23, a resident was found on the corner of Lake and Villa St., by facility's staff who was going home after her shift, and brought the resident back to the facility. Resident #1(R1) was a memory care unit resident, who left the facility unattended. Community Care Licensing did not received an unusual incident report regarding the incident. A copy of incident report or transmission sheet was not provided during the visits conducted of 4/3/23 or 10/19/23. Per regulations incidents are to be reported to the department within 7 days of occurrence. 87705 Care of Persons with Dementia: During document review of the complaint investigation, LPA reviewed physician's report for R1 dates 8/17/21. A copy of transmission sheet for a request of physician's report made to the primary physician was provided dated 3/23/23. Per regulation any dementia resident is to obtain an annual medical assessment. Needs and care plan printed on 10/19/23 notes none for special needs, none for wandering and elopement. R1 had left the facility unattended and per interviews conducted will attempt to exit the memory care unit and no plan was developed to address the situation. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Erin Mahoney and a copy of this report, LIC 809D, and appeal rights was provided.the state’s words, verbatim · CDSS document, Oct 19, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 26, 2023

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports...: (1)A written report shall be submitted...within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidence by: Based on document review licensee did not ensure incident occured on 3/24/23 with R1 was reported to the department within 7 days which poses a potential risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Administrator will certify that any incident or occurence will be reported to the department within 7 days of it's occurence and will submit a report for the incident on 3/24/23 by POC due date 10/26/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(5) · Plan of correction due date: Oct 26, 2023

87705 Care of Persons with Dementia; (c) Licensees who accept and retain residents with dementia shall...: (5) Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually. This requirement is not met as evidence by:the state’s words, verbatim · CDSS document, Oct 19, 2023

Plan of correction: Administrator will create a plan to ensure physician's reports are obtained at least annually and needs and care plans are updated at least annually or upon a change in condition occurs, plan is to be submitted to the department by POC due date 10/26/23.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit regarding incident report submitted to the department on 10/2/23. LPA met with Brianna Goodlet and explained the reason for the visit. On 10/2/23 an incident report was submitted to the department, reporting Resident #1(R1) was asking for help on the memory care unit (MCU) courtyard and stated to have jumped from R1's bedroom window. On 10/3/23 LPA Flores contacted Erin Mahoney Executive Director who provided additional information over the phone and requested the following documents: Physician's Report, Needs and Care Plan, Identification and Emergency Information sheet, and medication sheets for the last three months. During this visit LPA Flores interviewed 3 staff, observed the physical plant of the incident, and reviewed R1's file. Interviews conducted revealed, On 10/1/23 R1 who resides in the second floor as an assisted living resident, was heard calling for help in the alleyway outside to the MCU dining room. R1 was observed engaged in activities earlier on the day and right before the incident had spoken to other residents right before dinner. R1 jumped off the window in the physical therapy room located across the second floor the elevator, closest to activity room. Per staff R1's personal belongings were found in the room and the screen of the window was removed and placed inside the room. At around 6:00pm staff in the MCU dining room heard R1 calling for help. Staff called Med-Tech in charge, who observed R1 on the floor and R1 stated to have jumped off the window in an attempt to hurt self. Med Tech called paramedics, who arrived shortly after and transported R1 to the hospital. R1 stated to staff that R1 had jumped from the window. Family representative, and Brianna Goodlet were contact to informed of the incident. Documents reviewed revealed; physician's report dated: 7/7/23 R1 does not note R1 to have a history of confusion, inappropriate behaviors, depression, or suicidal tendencies. Pre-placement assessment and skill nursing discharge notes do note depression. There are no notes of history or attempts of suicide. Medication sheet notes R1 has been taking medication as prescribed. No indications/suicidal thoughts were noted or observed within the last two weeks. R1 is currently hospitalized. No Deficiencies are being noted during this visit. Exit interview was conducted with Brianna Goodlet and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 5, 2023