Balance Assisted Living and Memory Care

Allegation investigated: Refund not provided

On 08/24/26. Licensing Program Analyst (LPA) Kesha Lewis made an unannounced visit to this facility to open a complaint investigation into the above allegation. LPA identified themselves upon arrival, stated the purpose of their visit, and asked to meet with the Designated Facility Administrator. LPA met with Executive Director (ED) MONIQUE CHIB. LPA requested the following documentation accounts receivable for resident 1 (R1) Any proof of a refund issued to R1 or their responsible party. The facility provided a statement showing that the pro-rated payment that was attempted to be collected had been declined, also the reporting party could only provide proof that a stop payment charge was taken from her account. The reporting party verified with their bank that there were no funds withdrawn. Therefore, the above allegation is UNFOUNDED. As a result of this investigation, the preponderance of evidence standard is not met, therefore, this allegation is UNFOUNDED. The allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview and copy of the report given. Unfoundedthe state’s words, verbatim · CDSS document, Aug 24, 2026 · control 27-AS-20260824111324

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

Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a quarterly visit. LPA met with Administrator Monique Chib and explained the purpose of the visit. LPA reviewed and copies provided. Continued presence of the administrator at least 40 hours per week, (2) Continued documented plan to ensure all incidents are reported as appropriate and timely and available for review by the department, (3) Continued checklist to ensure proper maintenance of facility. (4) Continued Incidental Medical Care witch includes an on-going plan on how medications are handled which includes ensuring medication count and insuring medication is being accounted for at the beginning and end of shifts. Based on records review. All the above requirements are being met and training's are being kept up to date and have been completed. Exit interview conducted. Copy of report given.the state’s words, verbatim · CDSS document, Aug 24, 2026

Allegation investigated: Staff are not providing supervision of residents. Facility is not safeguarding residents’ personal property. Reporting Requirements. Facility is not providing hygiene care for resident.

On 07/16/2026 LPA Lewis arrived at facility unannounced to deliver findings on the above allegations. LPA explained the reason for the visit to staff. The department investagated the above allegations and based on the information gathared through interviews and records review, the allegations are UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with resident service specalist, and a copy of this report and LIC 811 provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 16, 2026 · control 27-AS-20260327112911

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655 · Plan of correction due date: Jul 19, 2026

(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident. This subdivision shall not apply to optional services that are provided by individuals, professionals, or organizations under a separate fee-for-service arrangement with residents. This requirement was not met as evicenced by: records review the facility provided a unsinged, undated paper that started a rate increase for 1-1-2026. R1's admissions agreament stats they are to give a 60 day notice R1 moved into the facility min December of 2025.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: Licensee will read the regulation and provide a statemnt of understanding to LPA Lewis by COB on 07/18/2026.

Allegation investigated: Staff drugged resident Staff stole resident’s money and personal belongings

LPA Lewis arrived at facility unannounced to deliver findings on the above allegations. LPA explained the reason for the visit to the executive director Monique Prarthana Chib. The department investagated the above allegations and based on the information gathared at that time executive director Rachelle Reyes of Balance Assisted Living and Memory Care (Balance) assisted R1 with getting a new bank account and getting a higher payment from Social Security through the Assisted Living Waiver Program. R1 owed Balance backpay since her initial Social Security payments did not cover her admission rate. When Social Security approved a higher payment rate, they gave R1 a check and the check was deposited to R1'S account and then it was paid to Balance. R1'S bank records were obtained and the withdrawals from her account match her ledger from Balance. Unsubstantiated There is no evidence indicating R1 was financially abused. Therefore the above allegations are UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 13, 2026 · control 27-AS-20260220094045

Allegation investigated: Facility is not financially solvent

LPA Lewis arrived at facility unannounced to deliver findings on the above allegations. LPA explained the reason for the visit to the executive director Monique Prarthana Chib. The department conducted a solvency audit. Overall, based on the records provided and reviewed, it appears the licensee does not have an adequate financial plan that complies with Section 87213 Finances. Based on the information gathered. As a result of this investigation, the department found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. Substantiated The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. An exit interview was conducted and a copy of this report and appeals rights was provided to the facility at the end of this visit. POC Licensee agrees to quarterly Financial Monitoring for a period of six months or until it is evident that the licensee has an adequate financial plan in place. The first due date being 05/25/2026 (January 2026, February 2026, and March 2026) documents are to include bank statements, profit & loss statements, balance sheets, utility bills, gas bills, worker’s compensation insurance.the state’s words, verbatim · CDSS document, May 13, 2026 · control 27-AS-20251016123647

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405 · Plan of correction due date: May 25, 2026

Administrator Qualifications and Duties. The department conducted a solvency audit. The October 2025 sample month Profit & Loss statement provided shows that the facility did not generate enough revenues to cover expenses and had a net loss of $104,693.85. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: Licensee agrees to quarterly Financial Monitoring for a period of six months or until it is evident that the licensee has an adequate financial plan in place. The first due date being 05/25/2026 (January 2026, February 2026, and March 2026) documents are to include bank statements, profit & loss statements, balance sheets, utility bills, gas bills, worker’s compensation insurance.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87205 · Plan of correction due date: May 25, 2026

Accountability of Licensee The department conducted a solvency audit. The October 2025 sample month Profit & Loss statement provided shows that the facility did not generate enough revenues to cover expenses and had a net loss of $104,693.85. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: Licensee agrees to quarterly Financial Monitoring for a period of six months or until it is evident that the licensee has an adequate financial plan in place. The first due date being 05/25/2026 (January 2026, February 2026, and March 2026) documents are to include bank statements, profit & loss statements, balance sheets, utility bills, gas bills, worker’s compensation insurance.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: May 25, 2026

Finance; Records The department conducted a solvency audit. The October 2025 sample month Profit & Loss statement provided shows that the facility did not generate enough revenues to cover expenses and had a net loss of $104,693.85. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: Licensee agrees to quarterly Financial Monitoring for a period of six months or until it is evident that the licensee has an adequate financial plan in place. The first due date being 05/25/2026 (January 2026, February 2026, and March 2026) documents are to include bank statements, profit & loss statements, balance sheets, utility bills, gas bills, worker’s compensation insurance.

Type of visit: Office

An office meeting was held today to discuss the findings to complaint number # 27-AS-20250925104337 resulting from a solvency audit. Present in today's meeting are: Community Care Licensing (CCL) Licensing Program Manager (LPM) Liza King acting on behalf of Regional Manager (RM) Stephenie Doub CCL Licensing Program Manager (LPM) Stephen Richardson and Liza King CCL Licensing Program Analyst (LPA) Christina Valerio, Kesha Lewis Licensee Shelly Cha and Christine Soriano, and Legal Counsel Jake Reinhardt The solvency audit was conducted by Audit Investigator Benjamin Banahene. During today's meeting LPA Lewis and LPM King reviewed the audit report finding summary. Questions from Licensee Shelly Cha regarding the findings will be sent to auditor Benjamin Benahene for further clarification. The department conducted a solvency audit. The October 2025 sample month Profit & Loss statement provided shows that the facility did not generate enough revenues to cover expenses and had a net loss of $104,693.85. provided only utility statement from the City of Lodi covering Water, electricity, Wastewater & solid waste. The City of Lodi’s statements show unpaid carried balance month after month, and two months of late fees. Additionally, the statement shows three months whereby the licensee did not make payments. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. An exit interview was conducted and a copy of this report and appeals rights was provided to the facility at the end of this visit. POC Licensee agrees to quarterly Financial Monitoring for a period of six months or until it is evident that the licensee has an adequate financial plan in place. The first due date being 05/25/2026 (January 2026, February 2026, and March 2026) documents are to include bank statements, profit & loss statements, balance sheets, utility bills, gas bills, worker’s compensation insurance.the state’s words, verbatim · CDSS document, May 11, 2026

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

A Non-Compliance Conference (NCC) was conducted on this day, 04/23/2026, by the Sacramento South Regional Office via Teams meeting. This Noncompliance Conference was called to discuss the following issues or deficiencies: Care and Supervision, Incidental Medical Care, Personal Rights, Maintenance and Operation, Managed Incontinence Present in the meeting was Regional Manager (RM), Stephenie Doub, Licensing Program Manager (LPM), Liza King, Licensing Program Analyst (LPA) Kesha Lewis, Carolyn Appeal Administrator, Shelly Cha and Christine Soriano facility representative Maryjo Tobola and Andy Sam department of health care services and Kathryn Thomas ombudsmen and Jake Reinahardt Legal Counsel. Items discussed during the Non-Compliance Conference were: 19 Type A 13 Type B Repeat citations Toxins accessible either medications, cleaning supplies or memory care area - current complaint resident drank soap not reported Medications Oxygen no sign or no stand Buildings and Grounds - water temp, heating, air, washing machine, flooring, bugs, cleanliness Personal rights - r:r, furnishings, unable to leave with visitor Licensee agreed to do the following in order to bring the facility into compliance no later than the following date 05/07/2026. · Provide a copy of any changes to the operation of the facility. · Provide copies of the staff checklists for care staff, management, housekeeping and maintenance. · Provide the duty statement for any new positions that are created. · Provide NOC shift scheduling for management. · Participate in TSP. In addition, at this meeting the notified Licensee/Administrator was advised future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and further potential administrative action. The Facility was advised the Department can take action pursuant to regulation 87764 and put a ban on admission's if there is continued Non compliance. Community Care Licensing Department (CCLD) will do the following: · Increase Monitoring to quarterly visits. · The facility will have TSP (Technical Support Program) give technical advice to the facility. Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager. Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited during this visit. An exit interview was conducted with, a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents. In addition, a copy of this report will be sent out certified mail.the state’s words, verbatim · CDSS document, Apr 23, 2026

Allegation investigated: Staff neglect resulted in resident sustaining a knee laceration Staff did not keep resident's authorized person informed about the resident's care

On 03/27/26. Licensing Program Analyst (LPA) Kesha Lewis and Licensing program manager (LPM) Liza King made an unannounced visit to this facility to deliver findings for the above allegations. LPA and LPM identified themselves upon arrival, stated the purpose of their visit, and asked to meet with the Designated Facility Administrator. Based on interviews and documents reviewed including the residents death certificate there was no mention of a laceration on the residents’ knee. Nor did the facility have pictures of any such laceration. All interviewed stated they resident would scratch herself and based on medical records reviewed the resident was proscribed an anti-tech medication. Therefore, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator, and a copy of this report was provided. Appeal rights and LIC 811 provided Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 27, 2026 · control 27-AS-20251109215223

Allegation investigated: Facility staff are not assisting resident with getting dressed. Facility staff are not following admission agreement.

On 03/27/26. Licensing Program Analyst (LPA) Kesha Lewis and Licensing program manager (LPM) Liza King made an unannounced visit to this facility to deliver findings for the above allegations. LPA and LPM identified themselves upon arrival, stated the purpose of their visit, and asked to meet with the Designated Facility Administrator. Based on LPM'S observation of the resident 1 and their room The resident was clean and hair their hair was done. R1'S room was clean and sanitary. The facility provided the admissions agreement and transportation procedures which state the facility will help arrange transportation. Therefore, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator, and a copy of this report was provided. Appeal rights and LIC 811 provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 27, 2026 · control 27-AS-20260108144201

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303 · Plan of correction due date: Apr 3, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observations, the licensee did not comply with the section cited above when Based on LPA'S observation the mashing machine was not working during the annual inspection on 01/15/2026 and as of today’s visit both washing machines are not working.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: Designee stated that they will supply an action plan with dates for completion for all of the above repairs. This will be submitted to CCL by the close of business on 04/03/26.

Allegation investigated: Resident sustained an unexplained injury while in care. Staff did not ensure that resident's room is cleaned. Staff did not notify resident's responsible party of an injury. Staff are not meeting resident's hygiene needs.

On 03/27/26. Licensing Program Analyst (LPA) Kesha Lewis and Licensing program manager (LPM) Liza King made an unannounced visit to this facility to deliver findings for the above allegations. LPA and LPM identified themselves upon arrival, stated the purpose of their visit, and asked to meet with the Designated Facility Administrator. Based on LPA'S observation of the resident 1 and their room The resident was clean and hair their hair was done. R1'S room was clean and sanitary. . Therefore, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator, and a copy of this report was provided. Appeal rights and LIC 811 provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 27, 2026 · control 27-AS-20260114165215

Allegation investigated: Staff forced resident to relocate to another facility.

On 03/27/26. LIcensing Program Analyst (LPA) Kesha Lewis and Licensing program manager (LPM) Liza King made an unannounced visit to this facility to deliver findings for the above allegations. LPA and LPM identified themselves upon arrival, stated the purpose of their visit, and asked to meet with the Designated Facility Administrator. Based on interviews with the executive director Carolyn Appeal the residents insurance was not taken by this facility and the resident was moved to a sister facility that accepted their insurance that is in another city. The resident was not given a choice in where to be placed and would like to return to the Balance facility. Based on observation and interviews it was determined the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations is being cited on the attached LIC 9099D. Appeal Rights have been provided and an exit interview with designee Appeal was conducted to discuss these finding. Substantiatedthe state’s words, verbatim · CDSS document, Mar 27, 2026 · control 27-AS-20260320091447

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Apr 3, 2026

87224(d) Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidence by: Based on interview, R1 was not served a lawful eviction notice, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: The administrator agrees to review the eviction regulations by POC date 04/03/2026. The administrator agrees to provide a written statement to LPA that states the review of eviction regulations has been completed by EOD on POC due date.

Type of visit: Case Management - Incident

Today Licensing Program Manager Liza King and Licensing Program Analyst (LPA) Kesha Lewis made an unannounced visit to this facility to follow up on incident reports received from the facility and documentation requested by the Department. LPA and LPM met with the Administrator Carolyn Appeal. The purpose of the visit was explained. Current census is 67 in hospital 5 on hospice 5 The Regional Office (RO) received an LIC624 on 03/17/26 re an incident that occurred on 3/16/26 for R1 and R2 in which an altercation between the two had occurred. The following documents were reviewed. Admissions Agreement, Emergency Contact Sheet, LIC602, Preplacement appraisal and any reappraisal, Needs and Services Plans, MAR for Jan 2026 to current , Any incident reports Jan 2026 to current , Any Service Notes for Jan 2026 to current, Any discharge summaries for Jan 2026 to current , Resident Roster, Staff Roster with telephone numbers. The incident resulted in R1 being injured. A review of the records revealed there was no update to the care plan. R1 had not been administered any pain medication, since return from the hospital more than a week ago. When LPM asked R1 how they were doing they expressed pain and were able to identify where. Additionally the RO conducted a follow up visit re LIC 624 received for R3, R4, R5, R6, R8 in which falls occurred and residients were hospitalized. Similar documentation was requested from the licensee to be submitted to the RO by 03/26/26, proof of email was observed and documents were printed and provided during visit. The RO will review the documentation, conduct interviews and return at a later date to address any concerns. Documented on several LIC624 was that the caregiver contacted another staff, hospice or a family member prior to calling emergency services (R7, R8). During todays visit three caregivers were interviewed and the all reported that if a resident falls and hits their head on the wall they are to call for a med tech to assess the individual. The caregivers reported they are not to call for emergency services that is the duty of the med tech. A request for the fall policy and emergency protocols was requested which documents any staff may call 911. A tour of the facility was conducted of Memory Care (MC) the door to the laundry room and fire room were unlocked, as well as AL leaving the area with toxins accessible to residents. Additionally several rooms in Memory Care had personal care supplies accessible to residents in care. A review of the LIC602s revealed one or more of the residents were not allowed access to these items. A discussion with the Administrator confirmed that these areas should not have accessibility to personal care supplies, best practices were discussed. Staff were prompted to remove the items. Three doors were tested in MC one released with no alarm after the 15 second delayed egress standard. 2 rooms in MC were observed to have O2 with no warning sign and 1of2 were were improperly stored. More than 10 resident rooms in Al and MC were observed to not have hand soap for residents to wash their hands. A tour of the outside was conducted the water heater closet smelled of gas the Administrator was prompted to call gas service, however Maintenance Director reported that a new water heater is being installed on Monday 03/30/26. Several screen doors were tested, some were unable to move freely. A screen was missing from a window. Hot water was tested ranging from 77 degrees to 125 degrees outside of the acceptable range. Various theromostats were observed at 66 degrees prior to 8am which is outside of the acceptable range. A tour of the AL revealed the floor coming up in room 67, and in the med tech room, in MC with tape over the carpet. In AL a resident was observed with full bedrails. Broken washers and dryers were observed and being cited on a complaint 20260108144201. A tour of the kitchen, adequate food present, breakfast and lunch service were observed with no concern. One broken freezer observed. Currently food is orders twice per week. Citations and civil penalties are being issued today as a result of the visit. A review of the report is being provided and reviewed with Administrator Carolyn Appeal. Appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 27, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 31, 2026

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage... This was not met as evidenced by bleach and laundry supplies asscessible in both memory care and assisted living; all doors were open and accessible to resdients in care. This poses an immediate threat to the health and safety of resients in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: Doors were locked immediately. Administrator will look into a mechanism that locks automatically and send a plan to Kesha.Lewis@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(b) · Plan of correction due date: Mar 31, 2026

(b) Residents may have access to items specified in subsection (a) for personal use unless there is documentation, as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access. This was not met as evidenced by several resident rooms in memory care had personal care supplies such as soap, shampoo, body wash, toothpaste. 2 of 6 files reviewed showed the residents were not allowed access based on physician documentation. This poses an immediate threat to the health and safety of resients in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: The Administrator had staff remove all personal care Supplies immediately. Additionally the Administrator will audit the LIC602s to determine which residents can have access to supplies and place a identifying marker on their room. photos will be sent to Kesha.Lewis @dss.ca.gov by 03/30/26

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(g) · Plan of correction due date: Mar 31, 2026

(g) The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident. This poses an immediate threat to the health and safety of resients in care. This was not met as evidenced by R1 was discharged with a fracture and prn pain medication. A review of the records revealed there was no update to the care plan. This poses an immediate threat to the health and safety of resients in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: The Administrator documents changes in Alice on the daily tracker a random review of care plans will be implemented to ensure staff are adhereing to the needs.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(4) · Plan of correction due date: Mar 31, 2026

(4) The licensee shall assist residents with self-administered medications as needed. This was not met as evidenced by R1 sustained a fracture. A review of records showed no Pain mangement medication provied for over 7 days. Interview with the resdietn revealed pain when asked how they were doing today. This poses an immediate threat to the health and safety of resients in care. This poses an immediate threat to the health and safety of resients in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: The Admnistrator will implement a check in having the Med Tech ask residetns at med adminitration how they are feeling today. A copy of the new procedure and MT signoff of understanding will be provided to Kesha.Lewis

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303 · Plan of correction due date: Mar 27, 2026

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met as evidenced by: 2of2 resdient rooms water tested at 77 and 76 degrees, kitchen sink water temperature tested at 125 degress. Flooring in the AL med Tech office, carpet in MC and flooring in AL rm 49 were all in need of repair. This poses an immediate threat to the health and safety of resients in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: A sign in the kitchen was hung warning of hot water. Hot Water heater will be replaced on Monday. A plan to address flloring will be submitted to Kesha.Lewis@dss.ca.gov completion is estimated at 30 days.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87618(b) · Plan of correction due date: Mar 27, 2026

(3) Ensuring that the use of oxygen equipment meets the following requirements:...(B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas... (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. This regulation was not met as evidenced by O2 canisters were not stored poperly in a stand and oxygen signs were not posted on the bedroom doors. This poses an immediate threat to the health and safety of resients in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: The Administrator agreed to safely secure all Oxygen canisters. Additionally signs will be posted on the exterior of any room which contains oxygen. Photos of proof of correction will be sent to Kesha.Lewis@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Mar 31, 2026

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not as evidenced by R1 being forcefully grabbed by R2 resulting in a fracture. This poses an immediate health and safety rsik.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: The Administrator will provide training to staff on redirecting residents who are exhibiting behavioral expressions

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(5)(B) · Plan of correction due date: Mar 31, 2026

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This was not met as evidenced by a resdient being observed by the LPM and Admin with full bedrails and no physicans order, exception or hospice services.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: The Administrator will have an review of all hospital beds conducted to ensure no other residents have full rails. The Administartor will obtain a physicians order and provide a copy to Kesha.Lewis@dss,ca,gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(a)(3)(D) · Plan of correction due date: Mar 31, 2026

(D) Hygiene items of general use such as soap and toilet paper. This was not met as evidenced by the absense of a hand soap in resdietn rooms. This poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: The Administrator agreed to purchase hand soap (nontoxic) and provide proof to Kesha>Lewis@dss.ca.gov

Type of visit: Office

Office meeting conducted on 03/02/2026 via Teams meeting with the following individuals at this time: Stephenie Doub, Regional Manager Liza King, Licensing Program Manager Lisa Rios, Licensing Program Manager Charlie Yang, Licensing Program Analyst Christine Soriano, LLC Board Member Shelly Cha, LLC Board Member The purpose of this meeting was to discuss the current issues surrounding this facility at this time. It was recently learned by this licensing office that the Chief Executive Officer, CEO, Christine Soriano was removed from the board and no longer a part of operations at this time. This meeting was held to determine the course of action that the Licensee was taking in order to maintain operational stability within the governing board for this facility so as to remain in compliance at all times. The following items will need to be updated and submitted into CCL for further review: Updated LIC 500 for staff coverage and indicated days/hours for the facility designated Administrator to be present in the facility LIC 501 for the facility designated Administrator Copies of the facility utility bills for electric, water, sanitation since 01/01/2026 Letter from the Board appointing the facility designated Administrator Copy of current facility designated Administrator certificate Forms and documents for the facility designated Administrator to show that he/she does meet all educational and experience requirements Documentation that the facility designated Administrator is fingerprint cleared and properly associated to this facility Updated LIC 200 signed by the Licensee or board resolved representative Staffing projections for the next (2) weeks specifically for caregivers and medication technicians for all (3) shifts of AM, PM, and NOC Proof of current liability insurance and workman's compensation Updated LIC 610 Board resolution denoting any changes to the representative at this time All requested forms and documents are to be updated, completed, and submitted into CCL by COB of 03/04/2026 for further review by this LPA. There were no deficiencies observed or cited during today's office meeting. A copy of this report will be emailed to the address for the Licensee at shellycha81@gmail.com and a request was made by this LPA for the appointed representative to go ahead and sign the documents and scan a copy back to this LPA. Exit Interviewthe state’s words, verbatim · CDSS document, Mar 2, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA'S) Kesha Lewis and Kimberly Viarella arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA'S were met by administrator. LPA'S explained the purpose of the visit to Administrator. LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 136 bed facility with a current census of 73. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care. LPA also conducted the care tool. No bodies of water were observed at the facility. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings. LPA’S observed the laundry room in memory care to be malodorous, additionally the facility was missing several window and sliding door screens. A patch of ceiling was falling in memory care. LPA'S observed there to be missing base boards on the assisted living side. Gutters along the building had plants growing from them and a gutter on the side of the facility was broken. LPA'S observed the housekeeping supply room to be left unlocked and accessible to residents in care. LPA'S tested the water temperature in resident room 37 and found the water temperature to be above regulation at 149 degrees Fahrenheit in resident bathroom sink. LPA Viarella conducted an inspection of the medication rooms. LPA reviewed the centrally stored medication log and observed a sample count of narcotics to ensure it matched with recorded amounts. LPA also inspected the medication cart and pulled a sample of 5 medications to ensure that none had expired. All were in compliance at this time of this inspection. LPA and the medication technician on duty reviewed medications through the Electronic Medication Administration Record (EMAR) to ensure that all medication passes were in compliance. LPA also reviewed the first aid kit to insure that it contained all of the required elements at the time of this inspection. LPA observed, fire extinguishers inspected on 09/15/2025 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance. See 809 C LPA reviewed four (4) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA reviewed eight (8) resident facility files, four (4) memory care and four (4) Assisted living. COVID-19 Plan, and survey binder. All necessary documents were in place. Exit interview held with staff and copies of reports and appeal rights left at conclusion of visit.the state’s words, verbatim · CDSS document, Jan 15, 2026

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

**This report was ammended to mark the finding as public instead of confidential** Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct a investigation in to the above allegation. LPA met with Mery-lyn Otero to explain the purpose of the visit. LPA observed bugs in the facility, a spider in the lobby and a small flightless bug caught by a resident. The immedate surrounding area where the insect was caught has some areas where bugs could reproduce and feed, cat food dishes, water bowls, bags of alluminium cans, ciggarete waste receptical. The kitchen and garbage cans appeared not to be a source of the insects. LPA conducted interviews of the 2 facility staff and 3 residents, LPA collected the health evaluations for one resident. In interviews mixed representation of the insects exists, in two cases the residents took pictures and made observations of actual insects, amongs many pictures and observations of dust, lint, carpet balls, and paint splatters. the most recent 602 does not indicate any issue with hallucination, a 603 is pending. Based on LPAs observations and 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 Regulation T22 is being cited on the attached LIC 9099D. Citation issued. A copy of the appeal rights was given, a copy of the report was given to the staff, an exit interview was held. Substantiatedthe state’s words, verbatim · CDSS document, Dec 26, 2025 · control 27-AS-20251224083630

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80087 · Plan of correction due date: Jan 2, 2026

80087(a)(1) Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement was not met as evicenced by: direct observation of insects in the facility, as well as sources of insects This presents and immedate health and safety risk to the clients in carethe state’s words, verbatim · CDSS document, Dec 26, 2025

Plan of correction: Facility will get an exterminator on the schedule to take measures against the observed insect types by the POC date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a case management visit on incident reports received. LPA met with RACHELLE REYES and explained the purpose of the visit. Interviews were conducted regarding R1. The incident report received for R2 was dated 12/08/2025 regarding a resident being sent out to the hospital LPA requested current documents for R2. R2 is expected to return to the facility 12/12/2025 and LPA requested the updated care plan and discharge paperwork due by 12/13/2025 EOD. The facility’s dictations first day at the facility was 12/05/2025. This matter is still under investigation LPA will return at a later date to deliver the findings. Exit interview and copy of the report given.the state’s words, verbatim · CDSS document, Dec 12, 2025

Allegation investigated: Facility failed to supervise resdients resulting in sexual assault. Facility failed to meet residents needs resulting in multiple falls and broken shoulder.

On11-17-2025, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to deliver findings for the complaint allegations noted above. LPA met with Administrator Rachelle Reyes and explained the purpose of the visit. Allegation 1 Facility failed to supervise residents resulting in sexual assault The department investigated the above allegation and determined the allegation to be UNFOUNDED based on interview with the R1 who denies the allegation occurred. Also, multiple staff interviews who did not report concerning behaviors between R1 and R2. Also, R2 had no recollection of who R1 was. Allegation 2 Facility failed to meet residents’ needs resulting in multiple falls and broken shoulder. The department investigated the above allegation and determined the allegation to be UNFOUNDED. According to the allegation received, R# sustained multiple falls resulting in a broken shoulder however, during the course of the investigation it was determined resident R3 sustained a fracture which was located on her tibia. Therefore, the allegation is UNFOUNDED. Note that an unfounded finding means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview and copy of report given. Unfoundedthe state’s words, verbatim · CDSS document, Nov 17, 2025 · control 27-AS-20250604161942

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a case management visit on incident reports received. LPA met with RACHELLE REYES and explained the purpose of the visit. The incident reports received were dated for the month of October 2025, regarding resident falls, deaths and the facility dietitian and a power outage. LPA asked for documents including care plans, discharge paperwork from the hospital if available, physician report for each resident R1-R9 also a staff schedule for the month of October 2025. LPA Lewis also requested the death certificate for R5. As of today’s visit, the incident reports for R1-R4,R6-R7 are closed with no further follow-up needed. LPA also received a contract for the nutrition consultant and was informed the facility was waiting for a time schedule for the consultant. LPA also requested power outage procedures. Needs and service plans will be emailed to LPA Lewis by EOD 10/31/2025 due to system outage. Part of this matter is still under investigation; LPA will return at a later date to deliver the findings. Exit interview and copy of the report given.the state’s words, verbatim · CDSS document, Oct 29, 2025

Allegation investigated: Facility staff are mismanaging resident’s medications

On 10-10-2025 at 10:25am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Administrator Rachelle Reyes and explained the purpose of the visit. During this investigation, LPA conducted interviews with five staff members and reviewed medication log sheets for resident1 (R1), as well as additional photographic evidence submitted. Additionally, LPA conducted a facility observation. Allegation: Facility staff are mismanaging resident’s medication. Complainant alleges facility staff are mismanaging medication for R1. Based on interview and record reviews as noted above, it was indicated that R1 has been receiving prescribed medication based on physician orders consistently with exception of R1’s refusal of medication and R1’s exercising of resident’s right of refusal. Facility observation did not reveal instances of medication mismanagement, and interviews did not result in corroborated statements of medication mismanagement of R1. Review of additional evidence did not result in indication of medication mismanagement. {Cont. on 9099C} Unsubstantiated As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.the state’s words, verbatim · CDSS document, Oct 10, 2025 · control 27-AS-20250729152109

Allegation investigated: Resident sustained unexplained injury while in care

On 10-10-2025 at 12:30pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation and deliver findings for the above allegation. LPA met with Administrator Rachelle Reyes and explained the purpose of the visit. During this investigation, LPA conducted interviews with five staff members, and reviewed facility file documentation including employee schedules, actual hours worked, incident reports, facility care notes, hospital discharge paperwork, and reporting protocols. Allegation: Resident sustained unexplained injury while in care. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was revealed that on or about 7-26-2025, resident1 (R1) sustained a fall outside his room at approximately 1:55pm. As a result of this fall, R1 sustained a possible sacral fracture. A review of caregiver schedule and actual hours worked on this day and time revealed all scheduled staff members were on duty. Care notes reviewed also confirmed the fall event. Interviews conducted revealed that R1 was monitored every 15-30 minutes for safety due to history of unstable ambulation and risk for falling as a result. {Cont. on 9099C} Unsubstantiated Additionally, interviews conducted did not reveal any corroborated statements or evidence of lack of appropriate care and supervision of R1. Interviews confirmed date and time of fall with description of R1 found on the floor outside the door of this room with walker beside him. Staff on duty provided pillows for comfort without moving R1 for safety purposes while awaiting for 911 personnel to arrive and assess. Interviews revealed 911 was notified within 1-2 minutes of discovery of fall. Incident was reported to licensing department on or about 8-1-2025. As a result of the above investigation, it was determined that R1 sustained a fall with possible sacral fracture. It was further determined that although this incident occurred, there is not a preponderance of evidence to conclude this incident was due to a lack of adequate care and supervision or other violation of Title 22 or Health and Safety Code violations, therefore, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.the state’s words, verbatim · CDSS document, Oct 10, 2025 · control 27-AS-20250814084722

Allegation investigated: Facility failed to administer medications.

On 10/07/2025, Licensing Program Analyst (LPA) Kesha Lewis arirved unannounced to continue the complaint investagation. R1 moved out of the facility on 6/18/2025, and was amitted on 4/30/2025. R1 required inslin and was unable to administer the medication on their own. LPA reviewed R1's 602, needs and service plan and the medication adminstration recordss from addmission to move out. Based on records reviewed and interview with staff the allegation Facility failed to administer medications is SUBSTANTIATED. R1 was givin an inslin injection by staff. There are also days the facility did not have medication for R1. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. see 9099D page... Exit interveiw and copy of report and appeal rights given. Substantiatedthe state’s words, verbatim · CDSS document, Oct 7, 2025 · control 27-AS-20250604161942

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Oct 8, 2025

87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement was not met as evidenced by: Based on record review of R1'S file the facility did not ensure to follow the 602 the resident was given an injection on at least one occation.This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: The licensee agreed to do a retraining for all med thechs and send the in-service sign in sheet by POC due date. Kesha.Lewis@dss.ca.gov.

Allegation investigated: Facility failed to meet incontinence needs.

On 09/24/2025, Licensing Program Analyst (LPA) Kesha Lewis arirved unannounced to continue the complaint investagation. Based on observation by LPM during another visit to the facility on 08/28/2025 the allegation the Facility failed to meet incontinence needs is SUBSTANTIATED. The hall in the memory care section of the facility is malodorous. This was cited in the case managment on 08/28/2025. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit inter and copy of the report given to RACHELLE REYES. Substantiatedthe state’s words, verbatim · CDSS document, Sep 24, 2025 · control 27-AS-20250604161942

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a case management visit on incident reports received. LPA met with RACHELLE REYES and explained the purpose of the visit. The incident reports received were dated from 09/08/2025 to 09/11/2025, all regarding resident falls there were six (6) incident reports regarding five (5) residents. LPA asked for documents including care plans, discharge paperwork from the hospital if available, physician report for each resident also a staff schedule for the week of September 8th-12th 2025. LPA also interviewed the administrator RACHELLE REYES. This matter is still under investigation LPA will return at a later date to deliver the findings. Exit interview and copy of the report given.the state’s words, verbatim · CDSS document, Sep 24, 2025

Allegation investigated: Facility staff do not ensure resident room is clean Facility staff do not ensure resident hygiene needs are met Facility staff do not ensure that the resident bed is working Facility staff denied residents going on outings

On 8-28-25 at 10:00am, Licensing Program Analyst (LPA) Michael Bilger and Licensing Program Manager (LPM) Liza King arrived unannounced to deliver findings for the allegations noted above. LPA met with licensee designee Merylyn Oltero and explained the purpose of the visit. During this investigation, LPA conducted interview with five staff members. Additionally, LPA conducted facility observations on 8-6-25 and 8-28-25. LPA also reviewed additional written evidence as part of this investigation. Allegation: Facility staff does not ensure resident room is clean. LPA conducted interviews and observations as noted above. Based on observation on 8-28-25, it was revealed that room #14 contained feces on bed and floor. Additionally, based on interviews conducted, it was revealed that staff required to maintain cleanliness of rooms were not performing adequate diligence in regards to maintaining clean room within facility. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Substantiated Allegation: Facility staff do not ensure resident hygiene needs are met. LPA and LPM conducted interviews and observations as noted above. Based on observation conducted on 8-28-25, it was revealed that various rooms in memory care were missing soap and toothpaste products necessary for maintenance of proper hygiene. Additionally, it was observed on 8-28-25, that resident in room #8 was not provided an electric razor despite request and observed to be in need of grooming. LPM also observed various residents not groomed properly within memory care unit. As a result, the preponderance of evidence standard is met and this allegation is SUBSTANTIATED. Allegation: Facility staff do not ensure that the resident bed is working. LPA conducted observation on 8-28-25 and observed bed in room #3 to not be operating properly. Specifically, foot of bed will raise, and head of bed would not raise. It was revealed through interview that bed currently in room #3 was placed in room after hospice company picked up a bed previously in the room. Additionally, it was observed by LPM that room #55 contained an air mattress for a resident which was not functioning properly. As a result, the preponderance of evidence standard is met and this allegation is SUBSTANTIATED. Allegation: Facility staff denied residents going on outings . LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was revealed that on 7-28-25, staff5 (S5) disclosed to a family member via email that per Power of Attorney (POA), family member "cannot take {resident1 (R1)} anywhere." It was further revealed that R1 maintains his rights to visitation with family of choice. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. As a result of this investigation, citations are issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with licensee designee and a copy of this report was provided. Appeal rights and LIC 811 provided.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 27-AS-20250729152109

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 11, 2025

87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement was not met as evidenced by: Based on observation and interviews, licensee did not ensure cleanliness of various rooms. This posed a potential health and safety risk to residentthe state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee will develop and submit a plan ensuring on-going cleanliness of rooms throughout facility. Plan to include checklist of items and reviewed by Administrator for accruracy and completeness. Plan to be submitted to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3) · Plan of correction due date: Aug 29, 2025

87307 Personal Accommodations and Services. (a) Living accommodations and grounds shall be related to the facility's function...(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. This requirement was not met as evidence by: Based on observation, Licensee did not ensure necessary hygiene supplies were available to resident in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee will develop and submit a plan ensuring the proper availability of hygiene supplies for residents in care. Plan to be submitted to LPA by POC due date. Licensee to ensure soap and other hygiene items are available in resident rooms by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 4, 2025

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: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: Based on observation and interview, bed in room #3 is not functioning properly, and air mattress in room #55 is not functioning properly. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee will repair or replace bed and submit photo proof to LPA by POC due date. Licensee will repair or replace air mattress and send photo proof to LPA by POC due date. Licensee will develop and submit a plan ensuring the functionality of resident equipment. Plan to be submitted to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Sep 11, 2025

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: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interview and written evidence, facility staff attempted to stop a desired outing for R1 and R1's family member. This posed a potential health, safety, and resident rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee and designee will read regulation 87468.1(a)(1) and submit a signed declaration to LPA by POC due date.

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

Allegation investigated: Facility failed to provide comfortable temperature Facility failed to provide Windows and sliders that are operable

Licensing Program Analyst (LPA) Michael Bilger and Licensing Program Manager (LPM) Liza King arrived unannounced to conduct facility observations and interviews regarding the above allegations. We were met by licensee designee Merilyn Otero and explained the purpose of our visit. During a facility visit conducted by LPA Renee Campbell on 06/05/25 and todays subsequent visit, it has beeeen confirmed by interview withh the Administrator and documentation receieved includeing repair invoices that the AC stopped working for room #’s, 1, 3, 4, 5 and 7. No IR was submitted at the time. (Administrator wrote an IR upon LPA Campbell's request during this visit.) Residents went without AC between May 21, 2025 and June 03, 2025 when portable AC’s arrived. During the period they didn’t have AC, staff checked on residents every two hours and inquired if they felt comfortable. It residents expressed feeling hot, fans were provided. Cont. Substantiated During todays visit 0n 8/28/25 a window in the Memory Care was observed to be broken and a resdients slider was inoperable. Based on observation and interviews it was determined the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations is being cited on the attached LIC 9099D. Appeal Rights have been provided and an exit interview with designee Otero was conducted to discuss these finding. No citations were issued. An exit interview with XXXXX was conducted to discuss these finding.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 27-AS-20250604161942

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 29, 2025

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This was not met as evidenced by: Residents went without AC between May 21, 2025 and June 03, 2025 when portable AC’s arrived. During the period they didn’t have AC, staff checked on residents every two hours and inquired if they felt comfortable. It residents expressed feeling hot, fans were provided. Additionally sliders and windows were pobserved to be inoperable. This poses a potential health and safety risk since the weather was not excessively hot during these days.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Poratble AC have been prurchased and are currently being used. Additionally poratble ACs are being used in resident rooms. Sliders and windows will be checked by maintenance and repaired by eod 8/29/25.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Michael Bilger and Licensing Program Manager (LPM) Liza King arrived unannounced to conduct a follow up visit regarding a complaint investigation and follow up on incident reports receieved. LPM and LPA met with Marilyn Oterl and explained the purpose of the visit. LPM conducted a tour of the facility and observed: Memory Care area – resident restrooms do not contain soap for handwashing. Interview with the designee reported that soap is not allowed in memory care area, technical guidance was provided by LPM on non toxic soap or soap dispensers that should be in each restroom area. Additionally interview with a family member reported that residents are not allowed electric shavers, numerous residents observed unshaven. Guidance provided that resdients are allowed access to electrical razors. Tour of memory care rooms revealed sliders and windows inoperable in the common area and in one room toured. Additionally more than 5 rooms observed to have toxins accessible. Breakfast service was done at 8:30 except for those eating in their rooms and included hot cereal, eggs bacon, sausage and coffee cake. LPM also observed juices, oranges and banannas being served. Residents were seated in the lobby area, activites were to begin at 9 am which was not observed to occur. Guidance was provided on allowing resdients to remain in the dining area which was locked and activities such as morning news, talk shows or music to be on while others congregate in the lobby area reducing the number of residents in that area. Additionally it is acceptable to have a TV or music area in the lobby as long as the fire exit is accessible and clear from traffic in case of emergency. Engageing residents throughout the memory care area should allow for this and engage the residents. An additional tour was conducted after lunch, no activites were being offered and the dining room was locked again. Additional guidance provided. First hall in MC is malodorous. Temperature comfortable although portable units located throughout building. Linen available in washroom. Cont Assisted Living was toured residents appeared content. Resident rooms were inspected for clean linen, cleanlieness and odor as well as operable windows and sliders. During the inspection two rooms were observed to be dirty, inc. used briefs in garbage, excess garbage and clutter and dirty floors. Two residents reported that housekeeping is provided one time a week. Common areas were observed to be clean. House Keeping room was open and assessable to clients. Common door on hall to the exterior was locked from inside and not accessible. This should remain unlocked during busineess hours. One room was toured with an excess of 10 O2 canisters unsecured documentation was reviewed, on two occasions the facility has reached out to the company to provide holders, no other means of securing for safety have been made. LPM interviewed the chef regarding meal substitutions. A request was made to review consultation notes from the facilities registered dietician. The chef confirmed that they have not met the dietician and reports were not available for review. Vegartariens are provided substitutions but there is no record of what is being served and if it meets requirements. A review of incident reports occurred for 11 residents. Documentation was requested via email and included hospital discharge (DC) documentation, Medication administration records (MARS) and care plans(CP) for review prior to todays visit. R1 had 2 unwitnessed falls between the months of 05/2025 and 07/2025, one of which resulted in a fracture. The hospital documentation was reviewed as well as the CP during this time period. Although the CPs were updated the change in condition is not noted and pain management is not addressed. Additional follow up is needed and R1s resident records are being requested today to include the following: Admissions Agreement, Emergency Contact information, current and prior LIC602, Preadmissions appraisal, any reappraisal for the period of April 2025 to current, service notes for the period of April 2025 to current, any hospital discharge documents for the period of April 2025 to current, and MARs for the period of April 2025 to current, any documentation of communications to the responsible party or MD regarding reportable conditions. R2 had 5 unwitnessed falls in a period of less than 3 months. A review of medical records was conducted, CPs are documented as being updated, however there is no update to the problems or interventions thus it does not appear that interventions were not put in place to address residents’ risk of falls. No fall risk is identified on the CP. Additionally, interventions are generalized and are not personalized ie staff to understand resident’s activity preference. cont. R3 had 3 incident report, 2 of which resulted from the resident themselves calling 911 for assistance due to pain and the third resulted in a higher level of care being needed. A review of the CPs provided and dated 3/13/25, 5/03/25 and most recently 5/28/25. 05/28/25 CP documents that a third party provider will provide and manage skin care. No showering or toileting assistance is provided on the 5/8/25 CP. Home Health documentation shows the resident was being seen by homehealth 2xwk for woundcare on four separate areas. Additionally, no interventions or frequency of homehealth is documented. The condition worsened requiring a higher level of care. The CP although updated did not document the change in condition including new or worsening wounds, facility oversite of care being provided and pain management. Additional follow up is needed and R3s resident records are being requested today to include the following: Admissions Agreement, Emergency Contact information, current and prior LIC602, Preadmissions appraisal, any reappraisal for the period of April 2025 to current, service notes for the period of April 2025 to current, any hospital discharge documents for the period of April 2025 to current, and MARs for the period of April 2025 to current, any documentation of communications to the responsible party or MD regarding reportable conditions. R4 was hospitalized on 2 separate occasions in the past 6months. A review of medical records was conducted, CPs have been updated. Interventions are generalized and are not personalized ie there is a third party vendor in place to assist with management of skin care/wounds, however no description of the wound(s) locations, status, treatment or measurable goals are noted on the resident’s CP. R5 additional follow up is needed. The RO has requested the licensee to collect and provide the Death Certificate by 10/01/25. Additionally, statements on the CP are not personalized ie “staff to provide diet as indicated on the dr order” (resident is on a texture modified diet which is not identified in the treatment/intervention area of the CP). R6 had 4 falls from 5/2025 to 08/2025, 3 of which occurred during the same month. A review of the CPs was conducted which revealed that although the CP is documented as being updated, the generalized intervention remains, “staff will provide oversight and complete interventions to help reduce residents fall risk”. Interventions are not documented and the CP is not updated to address the fall risk. Additionally a change of condition CP was provided and dated 08/03/2025 which is incomplete and lacks problem statements and interventions. cont. R7 was sent to the ER due to agitation a change of medication was noted and 2 subsequent falls were reported. A review of the CP documents updates were made, however it is unclear what changes were made. Interventions do not include behavior modifications or monitoring for side effects of new medications which may have attributed to falls. Additionally, a review of R7s MARS for the months of June 2025 thru Aug 2025 was conducted and revealed on 6/26/25 am meds were not documented as being provided. Additionally an inhaler was not provided during the month of June, July or August. According to documentation provided by the facility and dated 03/15/25 the resdient had a high co pay therefore medications were not ordered. The facility was reminded that the facility should have paid for the medications and billed the resident or communicated with the physician to seek an alternative, In addition, medications were refused on the following dates, 07/11, 13, 16, 17, 17, 20, 25. No IR received for refused of missed medications, however communication was provided to the collaborative agency. R8 has 4 unwitnessed falls from May 2025 to Aug 2025, one of which resulted in a fracture. A review of CPs, hosprpital DC documents, Hospice Admissions and Hospice Care Plan and MARS was conducted. Additional review is needed, additional documentation has been requested and received. R9 had 3 falls from June to July 2025 one of which resulted in a fracture. A review of the CPs during that time period was conducted as well as hospital DC documents. Additional follow up is needed and R9s resident records are being requested today to include the following: Admissions Agreement, Emergency Contact information, current and prior LIC602, Preadmissions appraisal, any reappraisal for the period of April 2025 to current, service notes for the period of April 2025 to current, any hospital discharge documents for the period of April 2025 to current, and MARs for the period of April 2025 to current, any documentation of communications to the responsible party or MD regarding reportable conditions. R10 over a 1 month period had 5 ER visits and is currently hospitalized. A review of the CPs and Mars for the same period was conducted. Additional follow up is needed. Additional follow up is needed and R9s resident records are being requested today to include the following: Admissions Agreement, Emergency Contact information, current and prior LIC602, Preadmissions appraisal, any reappraisal for the period of April 2025 to current, service notes for the period of April 2025 to current, any hospital discharge documents for the period of April 2025 to current, and MARs for the period of April 2025 to current, any documentation of communications to the responsible party or MD regarding reportable conditions. cont. R11 had 6 unwitnessed falls over a 2 month period. A review of the DC documents, CPs and MARs was conducted. Although CP documents fall risk and to ensure all staff are aware of fall risk, no specific interventions are noted just that they will be implemented. This is a generalized statement not specific to the care of this resident. On 06/19/25 the department was notified of a resident on resident altercation via an incident report. The incident did result in a resident being sent to the ER no significant injury wass noted, however one resident does have a history of agitation. Any altercation should be submitted via a SOC341 and cross reported to all parties. Technical Assistance is provided. An exit interview was conducted with designee Marilyn Otero, citations were issued and are attached on the D page. Appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 28, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(b) · Plan of correction due date: Aug 29, 2025

(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. The licensee failed to do this asevidenced by Multiple residents had generalized ststements incl R2 had 5 unwitnessed falls, no interventions were documented on the CP to address the fall risk, R6 had 4 falls the generalized intervention remains after the update “staff will provide oversight and complete interventions to help reduce residents fall risk”. Interventions are not documented and the CP is not updated to address the fall risk. Additioanlly the 080325 reappraisal is blank. R11 had 6 unwitnessed falls no specific interventions are noted just that they will be implemented, statement is the same across this resdients CPs. This poses an immediate risk to resdients in carethe state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: The licensee agrees to audit the apprasiasals and update 5 per week. Monthly an audit reconcilation will be sent to to Kesha.Lewis@dss.ca.gov.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87609(b)(2) · Plan of correction due date: Sep 3, 2025

The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care.This was not met as evidenced by R3 - . The CPs although documented as updated did not document the change in condition including new or worsening wounds, facility oversite of care being provided, observation of wounds and pain management for this resident. Additionally the 05/28/25 CP did not document any showering or toileting assistance. R4 was hospitalized on 2 separate occasions in the past 6months. A review of medical records was conducted, CPs have been updated. Interventions are generalized and are not personalized ie there is a third party vendor in place to assist with management of skin care/wounds, however no description of the wound(s) locations, status, treatment or measurable goals are noted on the resident’s CP, nor any direction to staff such as observe for changes. This poses an immediate risk to resdients in carethe state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licenssee will observe the resdients and collaborate with home health. Updates will be made to the home health progress notes and sign in sheet. A copy will be provided to to Kesha.Lewis@dss.ca.gov.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 3, 2025

(4) The licensee shall assist residents with self-administered medications as needed. This was not as evidenced by: a review of R7s MARS for the months of June 2025 thru Aug 2025 was conducted and revealed on 6/26/25 am meds were not documented as being provided. Additionally an inhaler was not provided during the month of June, July or August. medications were refused on the following dates, 07/11, 13, 16, 17, 17, 20, 25.No IR received for refusal or missed medications. This poses an immediate risk to clients in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee agrees to audit medications to determine which residents are currently out of medications then submit LIC624 and plan for each to Kesha.Lewis@dss.ca.gov.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87463(c)1-3 · Plan of correction due date: Sep 3, 2025

(c) If the licensee observes or is made aware of behavioral expression, as defined in Section 87101, that has caused or may cause harm to the resident or others, the licensee shall document all of the following in the resident’s reappraisal:(1) A description of the behavioral expression. (2) If known, identification of events occurring just prior to the behavioral expression including, but not limited to, interactions with other residents or staff, sudden or recent changes in the physical environment, signs of possible new physical illness or injury (such as fever, cough, urinary urgency, or limping), overstimulation (such as from noise or visitors), or physical sensations a resident may not be able to express verbally that may include, but are not limited to, fatigue, heat, cold, pain, hunger, thirst, boredom, fear, wanting to walk, or need for toileting. (3) Interventions to be implemented to minimize the risks to the health and safety of the resident or others associated with the resident's behavioral expression. The licensee shall use the least restrictive intervention to manage the behavioral expression based on the individual needs of the resident.The facility failed to implement this as evidenced by: R7 was sent to the ER due to agitation a change of medication was noted and 2 subsequent falls were reported. A review of the CP documents updates were made, however it is unclear what changes were made. Triggers are not identified and Interventions do not include behavior modifications or monitoring for side effects of new medications which may have attributed to falls. Additionally prn medications were available and not used prior to sending the reisdent to the ER for agitation two times in one day.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licnesee will update the care plans of residents in Memory Care and submit examples to Kesha.Lewis@dss.ca.gov.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309 · Plan of correction due date: Aug 28, 2025

(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents. This was not met as evidenced by A tour revealed a housekeeping closet open and accessible in the Assisted Living Area of the building with chemicals present. Additionally the Memory Care resident rooms had shampoo conditioner periwash toothpaste and deoderant accessible. This poses an immediate threat to resdients in carethe state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee removed all toxins and locked the door to housekeeping during todays inspection. NO POC necessary.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87613(b)(3)(E) · Plan of correction due date: Aug 29, 2025

(E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. This was not met as evidenced by LPM observed one room with 9 oxygen canisters not secured. This poses an immediate threat to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee has contacted the complany to safety store the oxygen if there is no response then a storage room will be identified, used and signage posted. If this is the practice an updtaed facility sketch willbe submitted.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(f)(5) · Plan of correction due date: Aug 29, 2025

(5) Interior and exterior space shall be available on the facility premises to permit residents with dementia to wander freely and safely. This was not met as evidenced by Facility locks dining room of Memory Care area so that resdients cannot access this area during the day. This poses a potential risk to clients in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee will ensure that dining area is open and supervision is provided immediately.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555 · Plan of correction due date: Sep 11, 2025

87555(17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency, nature and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility. This was not met as evidenced by: The facility was unable to provide any records of consult visits from a Registered dietician or dierty consultant service. This poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee agrees to have a diertery consultant visit the facility within 30days.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.2 · Plan of correction due date: Sep 3, 2025

1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. The facility fails to do this as evidenced by a R:R altercation occuring in which one resident is known to require additional supervision. An IR was received which documented a R:R altercation occuring in which one resident is known to require additional supervision.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Updates are currently being made to the CPs to address behavioral expressions. An audit will be made of those resdients that have hx of agitation and a list will be made of the resdietns name and triggers to asssit staff in identifying when incidents may occur. In addition to triggers modiciations will be identified and documented on the audit. This will be provided to to Kesha.Lewis@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(3) · Plan of correction due date: Sep 26, 2025

(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This was not met as evidenced by The MC area was malodorous this is a potentail risk to clients in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee will order air freshner for the area and continue with monthly shampooing of carpet.

Type of visit: Office

An informal meeting was conducted today on 08/19/25 at the Sacramento Regional Office via Microsoft Teams. : "The purpose of this informal meeting was to discuss the recent trends that have been observed at Legacy Oaks, as Balance Assisted Living and Memory Care is affiliated with Legacy Oaks." Present at this meeting were Regional Manager (RM), Stephenie Doub, Licensing Program Managers (LPMs), Stephen Richardson, Liza King, Lisa Rios, Licensing Program Analyst (LPAs) Arielle Pascua, Kimberly Viarella, and Noel WolfPetersen. Representatives of IRIS VND PARTNERS LLC/PREMIER SR LIVING MGMT LLC included Jacob Reinhardt, Licensees Christine Soriano and Shelly Cha, Regional Quality Assurance/Performance Improvement Director, Ashley Sylvie, Regional Nurse, Carolyn Appeal, Director of Special Projects and Designated Administrator Marlene Bremer, Administrator , Rachelle Reyes, Administrator Farial Shokoor, Assisted Living Waiver Coordinator, Caroline Easton, and Ombudsman, Ron Carrera. As it related t this facility, LPM King provided technical assistance (TA) on updating care plans when there has been a change in condition, when unusual incidents occur that create a patten such as several falls or or several consecutive days of refused medications. Additional TA was provided on documenting on an SOC341 and cross reporting incidents of Resident on resident abuse or altercations. It was acknowledged that while Legacy Oaks of Sacramento may exhibit specific areas of concern, at this time,these instances have not been documented at Balance AL. The Licnesee expressed practices and procedures be consistent across the licensed facilities and updates to the facilities Plan of Operation will be provided.. cont. The facility will do the following : · Provide an updated plan of operation by August 08/29/2025 to reflect operational standards throughout all facilities highlighting the topics discussed. The regional office will do the following: · Continue to collaborate and provide assistance to licensee as needed Licensees were offered and agreed to an opportunity to participate in Department's Technical support Program. These actions are not punitive, but collaborative as ways to improve on areas of concern which may or may not effect this facility. Per California Code of Regulations (CCR) - Title 22 - no deficiencies are being cited. An exit interview was held, and a copy of the report was sent via email. Licensee to send a signed copy to LPM King.the state’s words, verbatim · CDSS document, Aug 19, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to conduct a Case Management visit on 7/7/25 at 9:30am LPA stated the purpose of the visit. Administrator claims In regard to the service plans that show "CNA", it is automatically generated by the program we are using which is Alis.com. When it is pertaining to staff in general, not just caregivers, it will show "staff". If it pertains to the caregiver, it will show "CNA". Based on emails received by the department the facility is listing care staff as CNA'S when they are not certified nursing assistants. The preponderance of evidence standards has been met. Per California Code of Regulations, Title 22 Division 6, Chapter 6, deficiencies are being cited during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The acting administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held, Appeal Rights discussed, Copy of report given.the state’s words, verbatim · CDSS document, Jul 7, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Jul 8, 2025

False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by: Service plans that were sent to the department show CNA'S but they are only caregivers and by the admission of the admisnstrator. which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Jul 7, 2025

Plan of correction: Administrator RACHELLE REYES will go over the regulation and email LPA Lewis stating she understands the regulation.

Type of visit: Case Management - Incident

At 8:30 AM, Licensing Program Analyst (LPA) Kesha Lewis arrived and opened a case management regarding Multiple incident reports dating from 04/13/2025 to 04/18/2025 involving nine (9) residents. LPA met with the administrator and explained the purpose of the visit. The incident reports ranged from unwitnessed falls to swelling of the legs or face and resident on resident-on-resident altercation. The LPA requested the Needs and services plans, Physician's reports (LIC 602), care notes and discharge paperwork for all residents involved. LPA will return at a later date after reviewing all documents to deliver any findings for the incidents referenced above. These matters are still under investigation. No citations were issued during today’s visit.the state’s words, verbatim · CDSS document, May 6, 2025

Allegation investigated: Facility not following covid protocols No hot water in mens bathroom in hallway Inadequate emergency food supply

On 4/8/2025 at 10:01am, Licensing Program Analysts (LPAs) Michael Bilger and Noel Wolf Petersen arrived unannounced to deliver findings for the allegations noted above. LPA met with Administrator Rachelle Reyes and explained the purpose of the visit. During this investigation, LPA conducted interviews with nine staff members, three residents in care, and conducted observations on 1-17-2025 and 4-8-2025 within the memory care unit of facility, assisted living, and kitchen area. Additionally, LPA reviewed facility documentation including facility menus and facility’s infection control policy and procedures. Allegation: Facility not following covid protocols. LPA conducted interviews, record reviews, and observations as noted above. Based on interviews and observation it was revealed that facility had previously experienced a covid outbreak in the memory care unit and assisted living section which was reported to licensing department. It was further revealed that facility engaged in covid safety protocols at the onset of the outbreak including utilization of masks, gowns, gloves, and hand sanitizer as necessary. Social distancing of memory care and other residents was in place as well. {Cont. on 9099C} Unsubstantiated Based on review of facility’s infection control policy and procedures, it was determined that facility provided a linear approach to covid safety. LPA’s observation of facility revealed adequate amounts of personal protective equipment (PPE) in place as well as availability of hand sanitizers and isolation carts. As a result, there is a not a preponderance of evidence to conclude facility was not following necessary covid protocols, therefore, this allegation is UNSUBSTANTIATED. Allegation: No hot water in men’s bathroom in hallway. LPA conducted interviews and observations as noted above. Based on interviews conducted it was revealed that facility has consistently maintained hot water in men’s bathrooms and all other sections of facility since 1/1/2025 to current. Observations conducted revealed adequate hot water in men’s bathrooms and other sections throughout facility. As a result, there is not a preponderance of evidence to conclude facility has not maintained hot water availability in men's bathroom and other areas of facility, therefore, this allegation is UNSUBSTANTIATED. Allegation; Inadequate emergency food supply. LPA conducted interviews, observations, and record reviews as noted above. Based on interviews and observations, it was revealed that facility has consistently maintained adequate amount of food including two days of perishable and seven days of non-perishable items necessary for facility’s census. Observations conducted revealed facility has a designated section for emergency food which was stocked with adequate amounts. A review of facility’s menus revealed food items matched facility’s current stock of food on hand. As a result, there is not a preponderance of evidence to conclude facility did not maintain adequate emergency food supply, therefore this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights and LIC 811 provided.the state’s words, verbatim · CDSS document, Apr 8, 2025 · control 27-AS-20250113134019

Type of visit: Case Management - Incident

At 2:35, PM Licensing Program Analysts(LPAs) Noel Wolf Petersen and Michael Bilger arrived and opened a case management regarding a unobserved falling incident and an observed falling incident. They met with the administrator and interviewed her and requested documents related to the two incidents of falling that occurred on 03/10/2025 and 3/12/2025. At approximately 7pm on the tenth of march 2025, a resident was observed to be laying on the floor by her bed. Resident stated she was trying to change into her pajamas when she lost her balance and fell. Resident was assessed for injury by the Med Tech, resident stated no injury or pain and was assisted back into her bed. The facility put her on regular status check, and assessed the living space for fall safety hazard, called the family, and scheduled her for a Primary Care Physician(PCP) visit for further evaluation. The needs and services plan was updated to meet the needs of the client after the PCP visit. At approximately 2:30pm on the twelfth of march 2025, a second resident had an observed fall, and the facility called 911 and documented the resident refused the ambulance, notified the family, and updated their needs and services plan as needed by the recommendation of the PCP. The LPA's went over the Needs and services plans and the incident report with the facility representative. After the LPA's reviewed available documents and interviewed staff regarding the incident and the intervention by staff it was concluded that the facility complied with relevant regulation involving their intervention practices and reporting requirements. The LPA's discussed the incident with the administrator, read the report, and delivered it to the facility administrator. No citation issued.the state’s words, verbatim · CDSS document, Apr 8, 2025

Type of visit: Post Licensing

On 4/8/2025, Licensing Program Analysts(LPAs) Noel Wolf Petersen and Michael Bilger arrived unannounced to perform the 90-day post licensing visit. They were met by administrator Rachelle Reyes. The LPA requested and reviewed five (5) staff files, and found evidnce fingerprint clearance and first aid/cpr training. The required trainings are present, LPA interviewed 5 staff at random to assess their knowledge of the required actions and found no deficiency. The facility is a RCFE 134-bed facility with 64 clients currently, no bedridden, some on hospice. The physical plant was inspected. No bodies of water were observed. Fire alarms, Carbon monoxide alarms, first aid kit, door alarms were functional. The average response time to their alarm pager system was 2 minutes 53 seconds. The fire extinguisher was last checked 9/12/24. The field inspection included but was not limited to, the residents bathroom, residents bedroom, kitchen, open recreational spaces, the outside. Evactuation routes were free of obstruction and in good repair. The sharps and toxics were in locked and away from the residents in care. The facility has adequate perishable food for 2 days and nonperishable food for 7 days. All food is within its best by date. The required posters, ombudsman, personal rights, federal workers rights, theft and loss, and evacuation plan were up and available to residents. The facility was found to be largely in compliance. The report was read and delivered to the facility representative.the state’s words, verbatim · CDSS document, Apr 8, 2025

Type of visit: Case Management - Other

On 12/20/2024, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to amend pre-licensing report from visit on 12/19/24. LPA met with Administrator Jonathan Aguilar and explained the purpose of the visit. LPA amended report regarding capacity and left copy with Administrator. An exit interview was conducted with Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 20, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Michael Bilger and Licensing Program Manager (LPM) Liza King conducted an unannounced pre-licensing visit to this facility on 12-19-2024 at 9:45am and was met by current Administrator Jonathan Aguilar. Brief interview was conducted with the Administrator. It was learned that this facility is a residential care facility for the elderly (RCFE) applying for licensure due to change of ownership, and will now serve up to 136 non-ambulatory clients of which 30 may be bedridden, and 30 may be hospice due to staffing and office room changes. There are currently 59 clients present during today's pre-licensing visit. Tour of the facility was conducted. Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time. LPA observed no obstruction of emergency exits. Exit signs in place as appropriate. Fire extinguishers in place in hallways, kitchen, and other areas are fully charged with expiration date of 9/12/24. Facility map indicating emergency exits posted in appropriate locations. Resident rights poster in place. Kitchen area was toured. Food supply for 2-day perishable and 7-day nonperishable quantities were reviewed to make sure that this facility was in compliance at this time. Medication room, located in assisted living and memory, was observed to be locked and inaccessible to residents in care. First aid kit was observed to be present and contained all required components at this time. A tour of various resident bedrooms was conducted. Furnishings and furniture intended for use by the clients were observed to be sufficient and able to meet the needs of the clients at this time. A tour of various resident bathrooms was conducted. Hot water temperatures were taken and measured within the range of 105-120 degrees. Linen closets were observed to contain a sufficient supply of towels and linens able to meet the needs of the residents at this time. LPA and LPM reviewed five resident records as part of this investigation to ensure compliance. {Cont. on 809C} A tour of the exterior grounds was conducted. A review of the facility perimeter fence, side gates, delayed egress doors, and walkways were observed to be maintained in compliance at this time. This facility has been found to be in compliance at this time. There were no deficiencies observed during today's Pre-licensing visit. Component III waived due to experience of Administrator. An exit interview was conducted with Administrator and a copy of this report was provided. .the state’s words, verbatim · CDSS document, Dec 19, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Avelina Martinez and Licensing Program Manager (LPM) Liza King arrived announced to conducted a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA and LPM met with Jonathan Aguilar who assisted in today’s inspection. Facility has a fire clearance for 115 non-ambulatory residents and 30 bedridden residents. Jonathan Aguilar, will be the Administrator of this facility and holds a current administrator’s certificate. LPA, LPM, Jonathan Aguilar, Daisy Aguilar, and Serena Villanueva inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. The following Items were not in good repair: exposed wires throughout the facility signal system not set up Ombudsman poster is not the required size Ring Camera needs to be included in the plan operation (audio needs to be shut off) Facility equipment not in use should be removed Memory Care Egress Door Hinge needs to be replace. (door not self latching/closing) Fence boards at back of building need to be repaired (Memory Care/Assisted Living Side) Swamp Cooler located in facility kitchen is not in good repair (not cooling efficiently) Memory Care unit alarms are not in good repair Screens missing throughout the facility. Smoking area in assisted living area need to be cleaned and drains need caps Facility common areas are locked during business hours (open door policy needs to be put in place) Continued... 13. bathroom furnishings need to be repaired both in Memory Care and Assisted Living. 14. Assisted Living Hallway floor transition board needs to be replaced. (not wheelchair accessible) 15. Dry rot of building boards in Memory care need to be replaced. 16. Carpet throughout the facility needs to be cleaned. 17. Memory Care sliding glass door needs to be replaced or repaired. 18. Kitchen refrigerator needs to be clean. (Frost bite build up) 19. Pest control services are required throughout the facility. 20. Repair light fixture in emergency food storage room. 21. Female resident room located in assisted living unit has a wall behind door (copy of the permit shall be emailed to CCLD by 08/20/2024) 22. Plan of Operation update: egress, Dinning program, dementia plan, security Video, smoking area, food supply policy, meal tray service policy, and dinning room table settings and space (dinning tables accommodate 32 residents) . 23. Facility Sketch needs to be updated to show bedridden room, egress doors, staff bathrooms, and hospice rooms. 24. Rails in Memory care need to be added. 25. Trash cans need lids. 26. Memory Care unit needs a common area for resident use. The applicant has not passed the pre-licensing component of the application process. An LPA will return to facility to complete pre-licensing visit once above items have been corrected. an exit Interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 20, 2024

Type of visit: Office

Component II completion: Successful Facility Type: Resident Care Facility for the Elderly (RCFE) Application Type: Change in Ownership (CHOW) Capacity: 145 Census (if any clients in care): 69 COMP II Participants: Shelly Cha, Applicant Stephen Ratliff, Applicant, Merlene Bremer, Administrator Interview Method: Virtual interview (Microsoft Teams) On June 21, 2024 at 9:00AM, applicants and administrator participated in COMP II. Identification of the applicants and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicants and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. During COMP II, CAB analyst confirmed Applicants and Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with applicants and administrator. Report sent via email and request to return sign copy by end of business day.the state’s words, verbatim · CDSS document, Jun 21, 2024