Bayshire Yorba Linda

Type of visit: Case Management - Deficiencies

On this day Licensing Program Analyst (LPA) Edward Kim conducted a case management deficiency visit unrelated to a complaint investigation (Complaint# 22-AS-20251126095611) On July 16, 2026, LPA Kim was notified in person by the facility that Administrator Austin Morris stepped down as the Administrator on July 7, 2026, and Chad Coleman would be filling in as a temporary Administrator from July 8, 2026 to July 19, 2026. LPA Kim notified the facility and Temporary Administrator Chad Coleman to send a written notice within 30 days of when Administrator Morris stepped down and Administrator McMillan took over as the new Administrator. As of September 25, 2026, the facility has not sent the Orange County Regional Office with a written notice when Administrator Austin Morris relinquished his role on July 7, 2026, and when the new Administrator Kip McMillan took over on July 20, 2026. A deficiency was cited during the inspection visit according the California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted, and a copy of this report and the appeal rights were provided to Administrator Kip McMillan.the state’s words, verbatim · CDSS document, Sep 25, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87407)k) · Plan of correction due date: Oct 9, 2026

87407(k) Whenever a certified administrator assumes or relinquishes responsibility...he or she shall provide written notice, within thirty (30) days, to: (1) The local licensing office responsible for receiving information regarding personnel changes... This requirement was not met evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above. The facility did not provide a written notice to CDSS CCLD OC regional office when Administrator Austin Morris stepped down on July 7, 2026, Interim Administrator Chad Coleman filled in fromthe state’s words, verbatim · CDSS document, Sep 25, 2026

Plan of correction: from July 8, 2026, to July 19, 2026, and Administrator Kip McMillan took over on July 20, 2026. This poses a potential health, safety or personal rights risk to persons in care Licensee stated they will send a written notification and all the necessary paperwork to complete the change of administrator process to CCLD via email Edward.kim@dss.ca.gov by POC due date October 9, 2026.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Deficiencies

On July 28, 2026, Licensing Program Analysts (LPAs) Brandon Lopez and Tran Nguyen made an unannounced visit to the facility to conduct a Case Management - Deficiencies visit. Resident Services Director Mirian Im was present and assisted on today's visit. This visit is being conducted in conjunction with complaint control number 22-AS-20240417153456. Per California Code of Regulations, Title 22 Section 87211(a)(1)(d) states the following: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." During the complaint investigation, the Department discovered that Resident #1 (R1) sustained a total of nineteen falls between the dates of May 4, 2023, to May 4, 2024. The Department observed that R1 was hospitalized as a result of three of the falls. The Department also discovered that Resident #2 (R2) sustained a total of twenty five falls between the dates of June 21, 2023, to April 30, 2024. The Department observed that R2 was hospitalized as a result of two of the falls. The Department observed that the facility only reported two out of the nineteen falls that R1 sustained to Community Care Licensing, and therefore, seventeen falls were not reported as required by regulations. The Department observed that the facility only reported four of the twenty five falls for that R2 sustained to Community Care Licensing, and therefore twenty one falls were not reported as required by regulations. CONTINUED ON LIC809-C Based on the information gathered during the visit, a deficiency is being cited on the attached LIC809-D page. An exit interview was conducted with Resident Services Director Mirian Im. A copy of the report and appeal rights were provided at time of visit.the state’s words, verbatim · CDSS document, Jul 28, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 3, 2026

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency...(1) ... within seven days of the occurrence...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not evidenced by: Based on records reviewed, the Licensee did not ensure that each fall that Resident #1 and Resident #2 sustained at the facility were reported as required by regulations. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 28, 2026

Plan of correction: The Resident Services Director stated that she will complete a statement of understanding regarding the regulation cited and will adhere to the requirements. The Resident Services Director agreed to provide LPA the statement of understanding via email or fax by POC due date.

Allegation investigated: Staff did not provide appropriate wound care to residents. Staff did not provide adequate supervision resulting in residents sustaining multiple falls and injuries.

On July 22, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Resident Services Director Mirian Im and Exeuctive Director Kip McMillan were present and assisted on today's visit. During the course of the investigation, the Department conducted interviews with residents, interviews with staff, reviewed and obtained pertinent documents for this complaint. Regarding the allegation, staff did not provide appropriate wound care to residents, the following has been concluded: It was alleged that staff did not provide appropriate wound care to Resident #1 (R1) and Resident #2 (R2). During the course of the investigation, the Department conducted a file review for R1 and observed that R1 moved into the facility on September 3, 2023. The Department reviewed R1's Physician's Report that was completed upon admission to the facility and is dated August 15, 2023. CONTINUED ON LIC9099-C Substantiated Per R1's Physician's Report, R1 had a diagnosis of dementia, was considered non-ambulatory, and that R1 did not have a history of skin breakdown. The Department also reviewed a resident care evaluation that was completed by the facility upon R1's admission on September 3, 2023. Per the resident care evaluation, R1 did not have an issues with her skin upon admission and was not receiving any wound care treatment. The Department then reviewed the facility's progress notes for R1 between the dates of September 3, 2023, and May 1, 2024. The Department observed that on September 3, 2023, staff did not observe any skin breakdown on R1. On September 14, 2023, R1 was admitted to hospice. On September 23, 2023, staff noted R1 with an open wound to her left buttocks area. Staff were also advised by hospice to reposition R1 every two hours. On October 19, 2023, R1 was evaluated by wound care specialist due to the wound on her left buttocks area not improving. On February 14, 2024, staff noted that the residents wound to her left buttocks area had progressed to an unstageable wound. Staff noted that R1 was receiving hospice services for her wound three times a week and wound care specialist once a week at this point. The Department observed that by May 1, 2024, R1's wound did not improve. The Department reviewed R1's hospice records between September 14, 2023, and May 1, 2024. Per R1's hospice records dated March 11, 2024, R1 was diagnosed with an unstageable pressure ulceration to her left buttocks. The Department reviewed R1's plan of care between September 3, 2023 and May 1, 2024. The Department observed that R1's plan of care did not describe her wound care treatment and did not describe in which areas the facility would be assisting R1 with her wound care. The Department conducted a file review for R2 and observed that R2 moved into the facility on September 18, 2022. The Department reviewed R2's Physician's Report that was completed upon admission to the facility and is dated August 22, 2022. Per R2's Physician's Report, R2 had a diagnosis of mild cognitive impairment, was considered non-ambulatory, had a history of skin breakdown, but was not indicated to have an open wounds. The Department then reviewed the facility's progress notes for R2 between the dates of September 18, 2022, and May 1, 2024. The Department observed that on R2 was admitted under hospice on March 28, 2023. On May 4, 2023, staff noted R2 to have an open blister to her buttocks area. On May 11, 2023, staff noted R2 to be bleeding from the open wound to her buttocks area. On July 5, 2023, staff were given instructions by hospice to reposition R2 every two hours to prevent further skin breakdown. On March 12, 2024, staff noted R2's wound to her buttocks area worsened and progressed to a stage three pressure wound. CONTINUED ON LIC9099-C The Department observed that between May 4, 2023, and May 1, 2024, R1's wound did not improve and only progressed in size. The Department reviewed R1's hospice records between March 28, 2023, and May 1, 2024. Per R1's hospice records dated September 30, 2023, R2 was diagnosed with a stage three pressure ulceration to her buttocks. The Department reviewed R2's plan of care between August 22, 2022 and May 1, 2024. The Department observed that R2's plan of care did not describe her wound care treatment and did not describe in which areas the facility would be assisting R2 with her wound care. The Department conducted five staff interviews. Three out of the five staff interviewed confirmed that R1 and R2 developed wounds while at the facility. Two out of the five staff further corroborated the allegation and reported that improper wound care was provided to R1 and R2. They further stated that staff would not follow R1's or R2's plan of care regarding repositioning. CONTINUED ON LIC9099-C Regarding the allegation that, staff did not provide adequate supervision resulting in residents sustaining multiple falls and injuries, the following has been concluded: It was alleged that staff did not provide adequate supervision resulting in Resident #3 (R3) and Resident #4 (R4) sustaining multiple falls and injuries. During the course of the investigation, the Department conducted a file review for R3 and observed that R3 moved into the facility on May 4, 2023. The Department observed that R3 passed away on May 4, 2024. The Department reviewed R3's Physician's Report dated September 18, 2023. Per R3's Physician's Report, R3 was diagnosed with dementia, was considered non-ambulatory, and was noted as a fall risk. The Department reviewed the facility's progress notes for R3 between the dates of May 4, 2023, through May 4, 2024. The Department observed that during R3's stay at the facility between May 4, 2023, and May 4, 2024, R3 sustained a total of nineteens falls. The Department observed that R3 was hospitalized as a result of three of the falls. The Department reviewed R3's plan of care between May 5, 2023, and May 4, 2024. The Department observed that the facility stated that they will aim to minimize R3's falls, but did not state what interventions of fall prevention techniques they would be implementing. The Department observed that R3 was not reassessed until April 12, 2024, to determine if she required a higher level of care due to her falls. The Department attempted to conduct an interview with R3 for this allegation, however, R3 was unable to be qualified for an interview due to her cognitive condition. CONTINUED ON LIC9099-C The Department conducted an additional four resident interviews. Two out of the four residents were unable to be qualified for an interview due to their cognitive conditions. However, two residents denied the allegation and reported no issues with their incontinence care. The Department conducted five staff interviews. Two out of the five staff corroborated the allegation and reported that there have been multiple times where they have observed residents to be left soiled. However, three out of the five staff interviewed denied the allegation. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the one allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Resident Services Director Mirian Im. A copy of the report and appeal rights were provided at time of visit. During the course of the investigation, the Department conducted a file review for R4 and observed that R4 moved into the facility on June 21, 2023. The Department reviewed R4's Physician's Report dated May 19, 2023. Per R4's Physician's Report, R4 was diagnosed with dementia, was considered non-ambulatory, and was confused/disoriented. The Department reviewed the facility's progress notes for R4 between the dates of June 21, 2023, through April 30, 2024. The Department observed that during R4's stay at the facility between June 21, 2023, and April 30, 2024, R4 sustained a total of twenty five falls at the facility. The Department observed that R4 was hospitalized as a result of two of the falls. The Department reviewed R4's plan of care between June 21, 2023, and April 30, 2024. The Department observed that the facility stated that they will aim to minimize R4's falls through increased checks as needed. However, there were no other interventions or fall prevention techniques put in place to address this need. The Department also observed that R4 was not reassessed during this period, to determine if he required a higher level of care due to his falls. The Department attempted to conduct an interview with R4 for this allegation, however, R4 was unable to be qualified for an interview due to his cognitive condition. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the two allegations listed above. The preponderance of evidence standards has been met; therefore, the above allegations are SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D page. An immediate civil penalty is also being issued in the amount of $500.00. An additional civil penalty is pending determination by the Community Care Licensing Division under Health & Safety Code 1569.49(f). An exit interview was conducted with Resident Services Director Mirian Im and Executive Director Kip McMillan and a copy of the report was provided at time of visit.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 22-AS-20240417153456

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jul 23, 2026

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not evidenced by: Based on documents reviewed and interviews conducted, the Licensee did not ensure that R1 or R2 received appropriate wound care. Both residents wounds developed/progressed while at the facility. This poses an immediate health and safety risk to persons in care. Civil Penalty Assessedthe state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: The Resident Services Director stated that she will review the regulation cited. The Resident Services Director agreed to provide a written statement of understanding of the regulation and will conduct an in service training to all staff regarding monitoring resident's wounds. The Resident Services Director agreed to provide LPA the written statement and proof training via email or fax by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jul 23, 2026

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. ... This requirement was not evidenced by: Based on interviews and records reviewed, the licensee did not reassess R3 or R4 to determine if there was a change in condition or more supervision was necessary, due to the amount of falls sustained while at the facility. This posed an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: The Resident Services Director stated that they will conduct an in-service training course with all facility staff regarding observing changes in residents’ conditions. The Resident Services Director agreed to provide LPA proof of the training via email or fax by POC date.

Allegation investigated: Staff did not meet a resident's incontinence needs Staff are not properly trained

On July 16, 2026, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Resident Services Director (RSD) Mirian Im and explained the purpose of the visit. RSD Im contacted Interim Administrator (ADMIN) Chad Coleman and LPA Kim explained the purpose of the visit. Interim ADMIN Coleman stated he could not attend today's visit and RSD Im could sign on behalf of the facility. The investigation consisted of the following. LPA Kim toured the facility. LPA requested and obtained copies of the resident and staff rosters. LPA requested copies of four residents service records which include Physician’s Report, Appraisal/Needs and Services Plan, hospice care plans, admission agreements, facility progress notes, and other document records.. The investigation revealed the following: Continued on LIC9099C Unsubstantiated Allegation: Staff did not meet a resident's incontinence needs. It is alleged for Resident #2 they were complaining about how staff was not handling the Purewick correctly and that led to labial bleeding. Based on record review, R2’s Physician Order dated September 29, 2025, that the family will provide the PureWick. It states on the physician order that the PureWick will be applied and removed in the morning in a clean canister after each use. It is also states the collector tube will be replaced every 60 days. There is no order from the doctor to indicate this was to be applied by facility staff. R2’s Physician Order dated October 23, 2025, the PureWick system was discontinued due to itchiness. There is nothing on the physician’s order that states the facility were to apply or assist in using the PureWick with R2. R2’s Physician’s Report dated June 11, 2025, stated that R2 did not have bowel impairment or bladder impairment. Progress Notes dated on October 23, 2025, noted blood on the Pure Wick Insert, and stated R2 did not complain of pain and no more blood was noted on a later routine check. Based on interviews conducted, four out four staff and one resident denied the allegation. R2 stated that they used the PureWick for a short period because the doctor recommended it. They stated the liked the idea but the issue was it kept slipping out because they were moving too much when they were sleeping. They stated they don't recall experienced any injury or bleeding. When shown a photo of what was in the PureWick that made it red, they stated they had no idea. After trying for a short period of time, R2 stated they stopped using it because it made them feel uncomfortable. Four staff stated that R2 took care of it themselves in applying the PureWick to themself. The four staff do not recall if they cleaned it regularly, but would assist if the resident asked to help clean the product as requested. Based on the information gathered, there is no sufficient evidence to corroborate the above allegation. The facility did not need to meet the incontinence needs for the PureWick based on the Physician’s Order. There is no order that specifies that the facility is to apply and remove the PureWick for R2. Allegation: Staff are not properly trained It is alleged that there is no training for care staff for handling R1’s CPAP and R2’s PureWick. Based on interviews conducted, four out of four staff and six out of six residents denied the allegation. All four staff stated that the Nocturnal (NOC) shift would help R1 place the CPAP machine mask on R1, and the Morning (AM) shift would help remove the CPAP machine mask off of R1 as indicated in the Physician’s Continued on LIC9099C order. All four staff stated that R2 placed the PureWick on themselves and would assist in cleaning the device if requested. There was no training records for the CPAP and PureWick because training was not required for either. S2 and S3 stated that they had training for CPAP from a different facility, but it probably wasn’t in the records. Based on record review, R1’s Physician Order dated August 23, 2023, stated the facility would help assist the resident with putting on CPAP in the PM and removing the CPAP in the AM. R2’s physician order states that the PureWick will be applied and removed in the morning in a clean canister after each use. It is also states the collector tube will be replaced every 60 days. There is no order from the doctor to indicate this was to be applied by facility staff. There are no training records for CPAP and PureWick as verified by staff interviews. S2’s and S3's file did not have CPAP training in their file from their previous facility. Based on the information gathered, there is no sufficient evidence gathered to corroborate the above allegation. It is determined that all staff did not need training based on R1’s and R2’s Physician’s order. For R1, staff would assist in putting on and removing the CPAP mask. For R2, there is no instructions from the physician for the staff to help apply the PureWick or remove the PureWick. Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegations staff did not meet a resident's incontinence needs and staff are not properly trained. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted and a copy of the report was provided to Resident Services Director Mirian Im.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 22-AS-20250911123217

Allegation investigated: Resident developed pressure injuries while in care Staff do not assist resident with ambulation Staff do not observe resident for change in condition Staff do not ensure that resident's care needs are met Staff do not ensure that the facility has an auditory system for residents in care Staff handles resident in a rough manner

Licensing Program Analyst (LPA) Rose Ruppert made an unannonced visit to investigate a complaint received in the Regional Office. LPA was greeted and granted entry by the receptionist at 1:20pm. LPA met with Executive Director (ED) Austin Morris and explained the purpose of the visit. LPA requested a current resident and staff roster for Assisted Living (AL) and Memory Care (MC). Per review of the resident roster, the resident for this complaint does not reside in the AL or MC and resides in the Post Acute facility; which is not licensed under Community Care Licensing. Addtional paperwork obtained include the Clinical Resident Profile, Post Acute Face Sheet and Post Acute roster to confirm the resident resides in Post Acute. The resident has never resided in the AL or MC areas of the facility. Based on LPA document review and interviews, the allegations above are Unfounded. LPA will cross-report the complaint to the California Department of Public Health (CDPH). An exit interview was conducted with Executive Director (ED) Austin Morris and a copy of this report was provided to the facility. Unfoundedthe state’s words, verbatim · CDSS document, Jun 24, 2026 · control 22-AS-20260615094947

Allegation investigated: Staff mismanaged resident's medication

Licensing Program Analyst (LPA) Edward Kim conducted an unannounced subsequent complaint visit to deliver complaint investigation findings. LPA met with Administrator (ADMIN) Austin Morris and explained the purpose of today’s visit. The investigation is as follows: On February 13, 2025, LPA Kim initiated the complaint investigation and conducted a health and safety inspection with ADMIN Austin Morris. LPA Kim obtained copies of resident records for review which include the following: Resident/Staff Rosters, Staff Schedule, Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans/Reappraisal, Medication Administration Records, Incident reports, home healthcare records, and hospital records. The investigation revealed the following Continued on LIC9099C Substantiated Allegation: Staff mismanaged resident's medication It is alleged that facility did not monitor R1’s medication upon transfer from the Skilled Nursing facility and discontinued R1’s insulin. On February 10, 2025, around 8:00 AM, R1 did not respond to staff’s verbal or tactile stimuli. R1 was breathing normally and unlabored. R1’s blood sugar level was at 978, blood pressure at 72/47, and a heart rate of 78, 9-1-1 was called and R1 was taken to the hospital. R1 was diagnosed with Diabetic Ketoacidosis (DKA), Severe Anemia, and Seizure. Based on the investigation, record review shows R1 was admitted to the Memory Care unit of the facility on February 4, 2024. Per Discharge Summary from Providence Skilled Nursing facility dated February 3, 2025, Lantus Solostar was noted with 4 refills with start date February 3, 2025, and without an end date. Per review of R1’s Medication Administration Record (MAR), the start date for Lantus Solostar was February 4, 2025, and discontinued date on February 5, 2025. R1 did not receive any Lantus Solostar per interviews with four out of four staff. However, there is no physician’s order for R1 to discontinue the Lantus Solostar. During the interviews, four out of four staff and four out of four witnesses corroborated with the allegation that staff mismanaged resident's medication due to lack of communication between the facility and Skilled Nursing Facility regarding R1’s discharge medications. S2 stated the facility did not administer the Lantus Solostar as it was marked as “discontinued” (DC) per Order Summary report. W4 stated that Lantus Solostar was circled to confirm that the medication needed to be continued. W3 and W4 also confirmed that on page 2 of Providence discharge summary dated February 3, 2025, lists Lantus Solostar as a continued medication. W3 stated that R1 has uncontrollable diabetes which could go extremely high or low without proper medication. All witnesses and staff confirmed that the Lantus Solostar medication was mismanaged causing R1’s hospitalization. R1 was diagnosed with Diabetic Ketoacidosis, severe anemia, and seizures. Continued on LIC9099C. Based on information gathered through interview and record review, the preponderance of evidence standard has been met, therefore, the allegation Staff mismanaged resident’s medication was found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6 Chapter 8. An Immediate Civil Penalty is being assessed in the amount of $500. See the attached LIC421IM. A Civil Penalty is pending determination as per Health and Safety Code 1548(c)(1). An exit interview was conducted, and a copy of this report including the LIC421, LIC811, and the appeal rights were provided to Administrator Austin Morris.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 22-AS-20250212084002

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

87465(a)(4) A plan for incidental medical ... shall be developed by each facility. The plan shall encourage routine medical ... for assistance ... by compliance with... The licensee shall assist residents with self administered medications as needed. This requirement is not met evidenced by: R1 missed prescribed insulin medication from 2/4/2025 to 2/10/2025, due to staff mismanagement of R1’s medications, which resulted in hospitalization. R1 was subsequently diagnosed with diabetic ketoacidosis, severe anemia, and seizures. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Licensee states they will send a copy of an in service training on the policy and procedures regarding medication knowledge required to safely assist with prescribed medications which are self administered prior to admittance to the facility to CCLD via email to edward.kim@dss.ca.gov by POC due date April 24, 2026. An Immediate Civil Penalty for $500 is assessed during the visit.

Allegation investigated: Staff neglect resulted in a resident sustaining a fracture due to a fall. Facility is understaffed.

Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Administrator (ADMIN) Austin Morris and explained the purpose of today’s visit. The investigation consisted of the following: On March 6, 2025, LPA Kim conducted a health and safety visit with ADMIN Austin Morris. LPA Kim reviewed and obtained copies through email of nine (9) resident records, which include: Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans/Reappraisal, Incident reports, and other pertinent records. LPA requested and obtained resident roster and staff roster. The investigation revealed the following Continued on LIC9099C Unsubstantiated Allegation: Staff neglect resulted in a resident sustaining a fracture due to a fall. It is alleged that R1 had a fall that could have been prevented but the evening staff were inattentive and did not take the appropriate actions to make sure R1 had adequate assistance. Based on records review, R1 was admitted to the facility on March 24, 2024. R1 is non-ambulatory and is unable to independently transfer to and from bed. R1 needs full assistance with self-care, besides feeding self. R1 is confused/disoriented; however, R1 is able to follow instructions and communicate needs. Since admission, R1 had the first fall in January 2025, where a facility staff found R1 sitting on the floor next to their bed. No injuries were reported from this incident. Based on progress notes dated February 28, 2025, at 8:49 PM, staff noted R1 had a second unwitnessed fall. During the investigation, interviews were conducted where six staff out of six staff denied the allegation. Based on two out of six staff interviews, on February 28, 2025, R1 got up from bed in order to close the door but fell. S2 stated that R1 was found by a staff on the floor, upright, leaning against their bed, while conducting a routine resident check. Record review indicates immediately following the incident, R1 was given a full body assessment, and PRN medication was administered but it was ineffective. Subsequently, R1 expressed pain and requested to contact their son and be taken to the hospital. S6 called 911 and R1 was taken to the hospital. Interviews were conducted with residents. R1 stated that they noticed the door was open, attempted to get out of bed to close the door and subsequently fell. R1 acknowledged that they did not request staff assistance and did not utilize their wheelchair or walker when attempting to close the door. Additionally, two resident interviews indicated that staff are attentive to resident care, and both residents denied the allegation. The evidence indicates that R1 did not request staff assistance and did not utilize their wheelchair or walker, which resulted in an unwitnessed fall, and subsequent injury. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Continued on LIC9099C Allegation: Facility is understaffed. It is alleged the facility has cut staff hours and retaliates against caregivers, so they are not fully staffed. Based on records reviewed, the facility had twenty-three staff assigned to provide care to residents in the memory care unit, according to the Staff Schedule dated February 2025. On February 28, 2025, there were four staff assigned to the first shift, and three staff assigned to both the second shift and NOC shift. Based on the LPA’s observations during visits conducted on March 16, 2025, and August 15, 2025, there were four staff on duty providing care and supervision to residents in the memory care unit and no staffing concerns were observed. Based on interviews conducted, six out of six staff and three out of three residents denied the allegation. Two out of two staff stated that when staff called out, the facility would seek coverage by offering overtime to staff from other shifts, contacting part-time staff, or utilizing an outside agency. Three out of six staff stated there was sufficient staffing in the memory care unit and that residents were routinely checked at least once per hour or more often. Based on the information gathered, there is insufficient evidence to corroborate the allegation. Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegations that staff neglect resulted in a resident sustaining a fracture due to a fall and facility is understaffed. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Administrator Austin Morris.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 22-AS-20250305164943

Allegation investigated: Staff does not respond to call button in a timely manner. Staff do not ensure resident's care plan is updated.

On April 23, 2026, 9:30 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced initial complaint visit at the above facility for the above allegations. LPA Kim met with Administrator Austin Morris and explained the purpose of the visit. The investigation consisted of the following: on August 27, 2025, LPA Kim conducted a physical plant tour inside and outside of the facility and no concerns were observed. LPA Kim reviewed one staff record, which include: LIC501, LIC503, staff training records, and nine resident’s record, which include: Admission Agreement, Identification and Emergency Information, Physician's Report, Needs and Services Plans/Reappraisal, Medication Administration Records, Incident reports, and other pertinent records. The investigation revealed the following: Continued on LIC9099C Unsubstantiated Allegation: Staff are not trained to provide medications to residents. It is alleged that a staff administered a medication without training. It is also alleged that it was not charted in the Medical Administration Record and was recorded written on a separate medication chart. Based on record review, R1’s Controlled Drug Administration Record had S1 sign off on August 16, 2025, at 1:32 AM. R1’s Medication Administration Record only has a record of another staff administering the medication on August 16, 2025, at 9:08 PM. While reviewing S1’s training, the staff did not have training to administer medication to residents. Based on interviews conducted four out of five staff confirmed the allegation. One staff out of the five staff could not confirm or deny the allegation. Four out of five staff stated, S1 assisted R1 with their prescribed medication which was self administered. Based on information gathered through interview and record review, the preponderance of evidence standard has been met, therefore, the allegation Staff are not trained to provide medications to residents was found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6 Chapter 8. An exit interview was conducted, and a copy of this report including LIC811, and the appeal rights were provided to Adminstrator Austin Morris. Allegation: Staff does not respond to call button in a timely manner. It is alleged the time between the residents' pendants are pushed and when a caregiver can respond can be up to 20 minutes. Based on record review, the facility policy Resident Alert Call System states that the facility is equipped all residents with an alert call system. Staff will respond to all activation of the resident call system. It also states when a resident alert call system is activated, a caregiver will respond. There is no indication of a time frame of how fast the staff needs to respond to a call button being pressed. Based on interviews conducted, seven out of eight staff and nine out of nine residents denied the allegation. One out of eight staff confirmed the allegation. All residents stated that the staff responded in a timely manner when their call button was pressed. They also stated there was not a time they waited more than twenty minutes to receive assistance after pressing the call button. Seven out of eight staff stated that the staff responds within fifteen minutes to when a call button is pressed. Based on observations, on September 17, 2025, LPA observed two resident rooms where staff responded to call button being pressed within five minutes. On April 23, 2026, LPA observed five resident rooms where staff responded to the call button being pressed between 32 seconds to 19 minutes. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Staff do not ensure resident's care plan is updated. It is alleged new residents are not updated to shower schedule and level of care changes addressed correctly, for weeks. Based on record review, four residents out of nine residents have a shower schedule posted on their bathroom door. Based on resident appraisals, the facility keeps an update of all resident care plan needs. Based on interviews conducted, seven out of eight staff and nine out of nine residents denied the allegation. All residents who needed assistance for showers stated they have received showers on a regular basis and have not miss any showers. All residents stated prior to coming into the facility they recall having a care plan being done. They all stated that the facility regularly checks in on them and checks on their level of care and if there needs and services need to be updated. Seven out of eight staff stated that they regularly check with each other through crossover and through charting notes of any resident changes. Continued on LIC9099C Based on information gathered, there is not sufficient evidence to corroborate the above allegation Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above allegations Staff does not respond to call button in a timely manner and Staff do not ensure resident's care plan is updated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted a copy of the report was provided to Administrator Austin Morris.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 22-AS-20250819172952

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(3)(D) · Plan of correction due date: May 7, 2026

87411 (c)(3)(D)All RCFE staff who assist residents... shall receive initial and annual training. The training shall include... the following: (D)Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4)... This requirement is not met evidenced by Based on observation, the licensee did not comply with the section cited above. LPA observed S1 administered a medication to R1 according to Controlled Drug Administration Record of R1. This poses an potential health or safety risk to persons in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Licensee states they will conduct an in-service training with S1 and send a copy of training S1 understand that authorized staff with medication knowledge required to safely assist with prescribed medications which are self administered will only administer medication to residents. Licensee will send a copy of the email of completed training to CCLD via email to edward.kim@dss.ca,gov by POC due date May 7, 2026

Type of visit: Required - 1 Year

On April 6, 2026, at 8:00 AM, Licensing Program Analysts (LPAs) Edward Kim and Nancy Guillen conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs met with Resident Service Director (RSD) Mirian Im. LPAs met with Executive Director (ED) Austin Morris and explained the purpose of the visit. The facility is licensed to operate for one hundred fourteen (114) non-ambulatory, of which ten (10) may be bedridden, and maintains a hospice waiver for twenty (20) residents. The facility is a two-story structure, which consists of the following: one hundred twelve (112) resident bedrooms, thirteen (13) offices, one hundred sixteen (116) bathrooms, waiting area, hair salon, first floor activity area, second floor activity area, memory care dining room, main dining room, kitchen, memory care courtyard, and two outdoor areas with outdoor covered patio. LPAs toured indoor and outdoor physical plant with RSD Im. There is an fountain with no water in one of the outdoor areas. All rooms were inspected. Beds and bedding supplies were in good condition with adequate lighting as well as storage for each resident’s personal belongings were observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The following resident apartments were inspected: 105, 113, 120, 123, 135, 143, 158, 203, 254 and 271. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 106.7 degrees F and 114.2 degrees F. A comfortable temperature of 75 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Some storage areas for personal hygiene, toxins, cleaning supplies, and sharps objects were stored and inaccessible to residents. LPAs observed housekeeping cart kept under staircase across from room 126 had an Envio Care Natural Disinfectant spray bottle and Betco Smoke & Odor Spray Bottle that were not locked away and were accessible for residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food and supplies are stored in the kitchen and in a storage room closet next to the kitchen. Emergency water is stored in a storage closet in Skilled Nursing across from room 183 and room 184. A working telephone (714) 844-0967 remains available. LPA Kim reviewed the facility’s plan of operation, emergency and disaster plan, and fire/safety drill log. The facility last conducted an Emergency Drill on March 25, 2026. The facility has fire extinguishers that are charged, and they were all serviced on October 23, 2025. Smoke detectors and carbon monoxide detectors were operable and tested by CAL Building Systems on March 23, 2026. First Aid was maintained and contained all the necessary elements. LPA Kim conducted an audit of ten (10) resident files (R1-R10), ten (10) staff files (S1-S10), and medication and medication administration record that were in order and complete. LPA conducted seven (7) resident interviews and six (6) staff interviews. Based on today’s visit, a deficiency is being cited as per the Title 22 Division 6 Chapter 8 of California Code of Regulations (CCR). LPA observed in staircase across from room 126, there was a housekeeping cart left under the staircase with cleaning supplies left out. LPA observed an Envio Care Natural Disinfectant spray bottle and Betco Smoke & Odor Spray Bottle that were not locked away and were accessible for residents. An exit interview was conducted, and a copy of this report, LIC809D, and appeal rights were provided to Executive Director Austin Morris.the state’s words, verbatim · CDSS document, Apr 6, 2026

Allegation investigated: Staff did not properly assist a resident with medical device

On November 20, 2025, at 1:00 PM, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Resident Services Director (RSD) Mirian Im and explained the purpose of the visit. LPA called Executive Director (ED) Austin Morris who stated they could not attend today’s visit and that RSD Im could sign on behalf of the facility. The investigation consisted of the following. LPA Kim toured the facility with ED Austin Morris. LPA requested and obtained copies of the resident and staff rosters. LPA requested copies of three residents service records which include Physician’s Report, Appraisal/Needs and Services Plan, hospice care plans, admission agreements, facility progress notes, and other document records. LPA conducted interviews with four staff. The investigation revealed the following: Continued on LIC9099C Unsubstantiated Allegation: Staff did not properly assist a resident with medical device It is alleged that the resident cannot reach or place their CPAP device on the side of the table. It is also alleged that staff has not been able to place the CPAP device on the resident properly. Based on interviews conducted, four out of four staff denied that staff did not properly assist R1 with a medical device. All staff stated that the NOC or PM shift assisted with placing R1’s CPAP Mask on. All staff stated either NOC or AM shift assisted with removing the mask in the morning. S1 stated there was atime when R1 wouldn’t have it on. R1 would say it was too tight. S2 heard that R1 would remove the CPAP mask on their own. There were no issues with putting on the mask at night or removing the mask. S2 stated R1 would remove the mask on their own. All staff stated they felt comfortable and able to put on or remove the mask as needed. All staff stated that the machine was not too far for the resident to reach or for R1 to reach for the mask. Based on LPA’s observations, on September 17, 2025, LPA observed and took photos of R1’s CPAP machine. The CPAP machine was in reach of the resident’s bed. The mask can be placed on the stand next to the bed within reach of R1. Based on record review, R1’s physician’s order dated August 26, 2023, stated the facility staff to assist with putting on CPAP at night and removing it in the morning. There are no notes on the progress notes dated August 18, 2025, to September 13, 2025, that indicated R1 expressed any concern the stand was too far for them to reach for the CPAP machine or their own mask. On the progressnotes dated September 9, 2025, and September 10, 2025, staff noted R1 removed the CPAP mask. Based on the information gathered, there is no sufficient evidence gathered to corroborate the above allegation. It is determined that all staff denied that the staff did not properly assist a resident with their medical device. LPA observed and took the photos of the machine and mask was right next to the resident’s bed. Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegations that the staff did not properly assist a resident with their medical device. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted and a copy of the report was provided to Resident Services Director Mirian Imthe state’s words, verbatim · CDSS document, Nov 20, 2025 · control 22-AS-20250911123217

Allegation investigated: Licensee is not ensuring that staff are adequately trained.

On November 20, 2025, at 8:15 AM, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Resident Services Director (RSD) Mirian Im and explained the purpose of today’s visit. LPA Kim called Executive Director Austin Morris who stated they would not be here for today's visit and stated that RSD Im could sign on behalf of the facility. The investigation consisted of the following. LPA Kim toured the facility with ED Austin Morris. LPA requested and obtained copies of the resident roster, staff roster, and resident files which include Physician’s Report, Appraisal/Needs and Services Plan, staff training hours, and other pertinent records. LPA conducted interviews with nine staff and eight residents. The investigation revealed the following: Continued on LIC9099C Substantiated Allegation: Licensee is not ensuring that staff are adequately trained. It is alleged that care staff are missing initial training and Executive Director said to remove training because they are not in budget. It is alleged the facility cancelled January Training. Based on interviews conducted, five out of nine staff corroborated the allegation the facility is not ensuring staff are adequately trained. Eight out of eight residents and four out of nine staff denied licensee is not ensuring that staff are adequately trained. Four out of nine staff members stated the facility does not have regular required training. A staff member stated the facility had canceled training dates for December 2024 and January 2025. S9 stated that staff who were hired in 2024 did not have the initial completed training. Based on records reviewed, LPA audited 7 staff training files. Caregivers, Medication technicians, and other care staff need an initial 40 hours of training once hired and then an additional 20 hours of additional annual training. As of November 20, 2025 at the time of the visit, LPA obtained and reviewed all in-service and online training programs, and discovered the facility did not have the initial 40 hours of training service for the seven staff [S2 (care staff), S3 (caregiver), S4 (caregiver), S5 (caregiver), S6 (medication technician), S7 (medication technician), and S8 (care staff)]. LPA reviewed the staff online training program and in-service hours that demonstrated the staff did not complete the required hours for 2025. S2 only completed 2 hours out of 20 hours for 2025. S2 attended 2 in-service training with no listed duration of time. S3 completed 10.5 hours out of 20 hours required for 2025. S3 attended 7 in-service training with no listed duration of time. S4 completed 1 hour out of 20 hours required in 2025. S4 attended 4 in-session training for 2025 with no duration of time. S5 completed 4 hours out of 20 hours required for 2025. S6 completed 3 hours out of 20 hours required for 2025. S6 attended 8 in-service training for 2025 with no duration of time listed. S7 completed 6 hours out of 20 hours required for 2025. S7 attended 1 in-service training for 2025 with no duration of time listed. S8 completed 4.5 hours out of 20 hours required for 2025. S8 attended 1 in-service training for 2025 with no duration of time listed. Continued on LIC9099C Based on information gathered, there is sufficient evidence to corroborate the above allegation. Based on five out of nine staff interviews who corroborated the facility is not ensuring staff are trained adequately. Based on record review, seven out of seven staff did not have a record of completed initial training and the required 20 hours annual trainings for 2025. Therefore, based on the interviews which were conducted and the records that was reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Licensee is not ensuring that staff are adequately trained deemed SUBSTANTIATED. A deficiency is being cited on the attached LIC9099-D as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. One deficiency is being cited on the attached LIC9099D. Exit interview was conducted a copy of the report, appeal rights, LIC9099D, and LIC811 were provided to Resident Services Director Mirian Im.the state’s words, verbatim · CDSS document, Nov 20, 2025 · control 22-AS-20250131171222

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

87411 Personnel Requirements- General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by: Based on observations, record review, and interviews, seven out of seven staff did not complete their initial training and their annual 2025 training. This poses a potential health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 20, 2025

Plan of correction: Licensee states they will send a completed initial training and annual training of all current employees, S4, S7, and S8, to CCLD via email to edward.kim@dss.ca.gov by POC due date December 5, 2025.

Allegation investigated: Facility staff neglect resulting in residents developing pressure injuries while in care. Food services are inadequate. Licensee is retaining residents with higher level of care needs.

On November 19, 2025, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Executive Director (ED) Austin Morris and explained the purpose of today’s visit. ED Morris could not stay for the visit and said that Resident Services Director Mirian Im could sign on behalf of the facility. The investigation consisted of the following. LPA Kim toured the facility with ED Austin Morris and observed three meal services. LPA requested and obtained copies of the resident and staff rosters. LPA requested copies of residents service records which include Physician’s Report, Appraisal/Needs and Services Plan, hospice care plans, admission agreements, facility progress notes, weekly food menus, and other document records. LPA conducted interviews with eight residents and eight staff. The investigation revealed the following: Continued on LIC9099C Unsubstantiated Allegation: Facility staff neglect resulting in residents developing pressure injuries while in care. It is alleged that residents in Memory Care have Stage 3 and 4 decubitus ulcers. It is alleged that residents were left in their bed because they have behaviors. Based on records reviewed, R6’s Hospice flow chart from October 4, 2023, indicated a wound care professional came to the facility to follow up on their wound. R6’s hospice flow sheet from October 4, 2023, to July 23, 2025, does not state that the wound has gotten worse. The report states that either treatment was done or treatment was refused because R6 was aggressive. R6’s facility’s progress notes from November 13, 2024, to February 5, 2025, stated R6 was receiving wound care from their hospice company. There are no notes that indicate the wound was a result of staff neglect nor did the staff note that the condition got worse. R9 was admitted to the facility on August 31, 2019, according to their face sheet dated March 5, 2022. R9 returned to the facility from a skilled nursing facility on January 24, 2025, according to the facility progress notes dated January 24, 2025. Progress notes dated January 26, 2025, staff discovered a right heel wound and coccyx stage 2 wound. R9’s hospice care plan start date for the pressure 2 wound on coccyx was on January 31, 2025. There are no indications on record from the facility progress notes, hospice care plans, and other documents that the facility staff neglect led to pressure injuries for the residents in care. Based on interviews conducted, eight out of eight residents and eight out of eight staff denied allegation that the facility’s staff neglect resulted in residents developing pressure injuries while in care. All staff and residents stated that they have not heard a resident develop pressures due to staff neglect. Based on observations, LPA Kim did not see any form of neglect at the times of visit on February 6,2025, and August 15, 2025. Based on the information gathered, there is no sufficient evidence gathered to corroborate the above allegation. It is determined that all resident interviews and all staff did not corroborate that the pressure injuries occurred to residents due to staff neglect. LPA was able to verify that staff did not neglect residents leading to pressure injuries based on reviewing resident hospice care plans, facility progress notes, and other document records. Continued on LIC9099C Allegation: Food services are inadequate. It is alleged that staff and family often complained of the meals distributed to the memory care residents. Based on interviews conducted, eight out of eight residents and four out of eight staff denied food services are inadequate. Residents stated they liked the food and met their needs. Four out of eight staff stated the food was of good quality, good portion size, and did not have any concerns about the food. Based on the observations of the food service conducted on February 6, 2025, LPA observed lunch was served at 11:00 AM and dinner at 4:30 PM. Residents were served a mixed green salad with dressing, seasoned grilled chicken with brussel sprouts and seasoned potatoes for lunch. On a subsequent visit conducted on August 15, 2025, at 11:15am, LPA observed seasoned chicken, rice, and assorted vegetable medley was served for lunch. LPA observed staff followed all guidelines in distributing fresh and quality for the residents in the memory care dining room as well as the residents receiving food delivered to their unit. Based on record review, LPA reviewed the weekly menus from December 1, 2024, to March 1, 2025, and August 2025. The menus identify 3 healthy meals are given per day. In review of the weekly Food Menu dated February 2, 2025, to February 8, 2025, lists mixed green salad, lemon herb chicken, brussel sprouts, bread/roll, and a choice of beverage for lunch on February 6, 2025. For the lunch menu on August 15, 2025, reads mixed green salad with dressing, honey basil glazed chicken, rice medley, sugar snap peas, fried rice, stir fry vegetable, and a choice of beverage. Based on the information gathered, there is no sufficient evidence gathered to corroborate the above allegation. It is determined that all resident interviews and four out of eight staff did not corroborate that the food was inadequate. LPA was able to verify based on two inspection dates that food served was of quality, portion, and healthy which was also aligned with the weekly menu. Allegation: Licensee is retaining residents with higher level of care needs. It is alleged that the facility moved in residents who need higher level of care. It is alleged the facility moved a resident that needs a higher level of care because they cannot do anything on their own and has a stage 3 wound. It is also alleged that a resident returned from skilled nursing with wounds on their backside. Continued on LIC9099C Based on record review, on February 6, 2025, LPA received a list of all residents with stage 3 pressure injuries provided from ED Morris. R2’s admission agreement was signed and dated January 9, 2025. R2’s Hospice Care Plan dated January 9, 2025, lists pressure ulcer of sacral region unstageable. R2’s physician report dated February 14, 2025, lists that R2 has a right ankle unstageable wound, right ankle/right lateral wound unstageable, and right lateral stage 2 wound. R4’s face sheet dated November 19, 2025, stated resident was admitted to the facility on September 18, 2025. R4’s Hospice Care plan dated February 13, 2024, stated on September 30, 2023, has a stage 3 pressure injury on their right upper buttocks. R9 was admitted to the facility on August 31, 2019, from the facility face sheet dated March 5, 2022. The facility progress notes dated December 27, 2024, R9 diagnosed with UTI Sepsis and was discharged to a Skilled Nursing facility. R9’s returned to the facility on January 24, 2025. On January 26, 2025, Care staff discovered a right heel wound and stage 2 coccyx wound. R9’s Hospice care plan start date for their coccyx pressure 2 injury and right heel were on January 31, 2025. R12’s Hospice care plan dated February 7, 2025, indicated that R12 had a stage 2 ulcer on their right toe since January, 29, 2025, and a stage 3 ulcer on their sacral region since January 29, 2025. All residents are listed have a hospice care plan to take care of their stage 3 or unstageable wounds, thus do not need to have a higher level of care met. Based on interviews conducted, eight out of eight residents and five out of eight staff denied the allegation the facility is retaining residents with higher level of care needs. All residents stated they have not observed or heard other residents needing a higher level of care. Five out of eight staff stated they do not see any resident needing a higher level of care. Based on LPA’s observations, there were no residents that needed a higher level of care at the time of the visits on February 6, 2025, August, 15, 2025, and October 20, 2025. Based on the information gathered, there is no sufficient evidence gathered to corroborate the above allegation. It is determined that all resident interviews and five out of eight staff do not corroborate that the that residents need a higher level of care. LPA was able to verify that the residents didn't need a higher level of care based on reviewing resident hospice care plans, facility progress notes, and face sheets. Continued on LIC9099C Therefore, based on observation, interviews, and records review, LPA did not find sufficient evidence to corroborate the above allegations that Facility staff neglect resulting in residents developing pressure injuries while in care, Food services are inadequate, and Licensee is retaining residents with higher level of care needs Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted and a copy of the report was provided to Resident Services Director Mirian Imthe state’s words, verbatim · CDSS document, Nov 19, 2025 · control 22-AS-20250131171222

Allegation investigated: The Administrator is not present in the facility.

On October 20, 2025, Licensing Program Analyst Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Executive Director (ED) Austin Morris and explained the purpose of today’s visit. The investigation consisted of the following. On February 6, 2025, LPA Kim toured the facility with ED Austin Morris. LPA requested and obtained copies of the resident roster and staff roster. LPA requested copies of residents service records which include Physician’s Report, Appraisal/Needs and Services Plan, and other pertinent records. LPA interviewed six (S1-S6) staff and three residents (R1-3). LPA attempted four resident interviews. The investigation revealed the following: Unsubstantiated Allegation: Licensee is not ensuring the facility Administrator is qualified. It is alleged that Executive Director Austin Morris does not possess an RCFE Administrator Certification. During a complaint investigation visit, the LPA observed the Administrator’s Certificate displayed at the facility entrance. The certificate lists Chad Coleman as the Administrator, with an effective date of January 10, 2023, and an expiration date of May 10, 2025. Upon further investigation and review of the CDSS Administrator Certification Online Application Portal, the LPA confirmed that Chad Coleman submitted all required documentation and completed the necessary training for his certification renewal. It was also verified that Chad Coleman is the current Facility Administrator, and that Austin Morris is not required to hold an Administrator certification. Based on the information gathered during the investigation through observations and document review, the allegation mentioned above is deemed Unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview was conducted and a copy of the report was provided to Executive Director Austin Morris. Allegation: The Administrator is not present in the facility. It is alleged that the Administrator was last seen in the community in October 2024 and on January 16, 2025. Based on interviews, three out of three residents denied the allegation that the administrator was not present in the facility. Five out of six staff denied the allegation, while one confirmed that the administrator was not present in the facility. Additionally, five staff confirmed the administrator is at the facility at least two times during the week, four to eight hours a day. Based on review of the facility’s staff schedule, administrator’s name was not included, however, during an unannounced visit at the facility in September 2025, LPA Kim observed the administrator was present. Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted and a copy of the report was provided to Executive Director Austin Morris.the state’s words, verbatim · CDSS document, Oct 20, 2025 · control 22-AS-20250131171222

Type of visit: Case Management - Incident

On September 17, 2025, at 8:45 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced Case Management Visit to follow-up on a death report received from the facility. LPA Kim was greeted by Executive Director (ED) Austin Morris and LPA Kim explained the purpose of the visit. ED Morris could not stay for the visit and stated Resident Service Director Mirian Im could sign on behalf of the facility. During today’s visit, LPA conducted a health and safety check, and there were no imminent health/safety concerns observed. Facility is maintained at a comfortable temperature for the residents in care. LPA obtained Staff Roster, Resident Roster, and R1’s records which includes the Physician’s Report, Emergency Information, Appraisal and Needs/Service Plan, and other pertinent documents. LPA interviewed two staff and one witness. Based on record review, the Incident report received by the Orange County Regional Office on September 12, 2025, R1 was sent to the hospital on September 10, 2025, due to shortness of breath and noticeable confusion during a Home Health Nurse visit. On an incident report dated September 16, 2025, dated on September 13, 2025, around 2:00 AM, R1 passed away. The incident report dated September 16, 2025, and the hospital discharge summary dated September 12, 2025, both stated R1 returned to the facility on September 12, 2025, diagnosed with Chronic Obstructive pulmonary disease (COPD). The hospital discharge report on page 6 stated COPD is a lung disease, where the lungs get damaged making it hard to get air in and out of the lungs. The damage cannot be changed. R1’s physicians report dated July 15, 2025, diagnosed R1 with COPD. There is no coroner’s report but a card with the coroner case number and death report number was provided to the facility. Evaluation Report Continues on LIC 809-C Based on interviews conducted, one witness and two staff denied this to be a questionable death. W1 stated R1 passed away due to natural causes. There is no foul play suspected from the facility. S2 stated on September 10, 2025, a home health nurse noticed that R1 had a collapsed lung. From the recommendation of the nurse, the facility sent R1 to the hospital to be treated. Based on record review and interviews conducted, this incident is not a questionable death. No deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report was provided to the Resident Service Director Mirian Im.the state’s words, verbatim · CDSS document, Sep 17, 2025

Allegation investigated: Facility does not have hot water.

On August 15, 2025, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Executive Director (ED) Austin Morris and explained the purpose of today’s visit. The investigation consisted of the following: On July 10, 2025, LPA Kim toured the facility with ED Austin Morris. LPA Kim requested and obtained copies of the resident and staff rosters, staff schedule, and other pertinent documentation. The investigation revealed the following: Continued on LIC9099C Unsubstantiated Allegation: Facility does not have hot water. It is alleged that half of the building is experiencing issues with hot water. It also alleged facility is not resolving the issues with a plumber and is shutting the water off intermittently. Based on observations, on August 15, 2025, LPA measured the temperatures in the exercise room on the second floor that measured at 115.0 degrees F, on the first floor common bathroom across the beauty salon that measured at 113.5 degrees F, and twelve bedrooms that measured in room 103 at 117.3 degrees F, room 106 at 118.0 degrees F, room 112 at 116.6 degrees F, room 122 112.6 degrees F, room 126 at 114.4 degrees F, room 135 at 113.7 degrees F, room 132 at 116.2 degrees F, room 150 at 115.7 degrees F, room 218 at 114.8 degrees F, room 226 at 114.4 degrees F, and room 260 at 109.7 degrees F. Based on interviews conducted, one witness and three out of twelve staff confirmed the allegation. Five out of twelve staff and five out of five residents denied the allegation. Three out of twelve staff did not confirm or deny the allegation. S1, S2, S3, S4, and S5 stated hot water for the showers and the bathroom sinks would take about 5 minutes to warm up. From their time at the facility, S1, S2, S3, S4, and S5 stated there were no hot water issues in the facility to their knowledge. R1, R2, R3, R4, and R5 stated there have not been any issues with the hot water in their showers and bathroom sink during their time at the facility. Based on record reviews, LPA examined the water log temperature dated from July 6, 2025, to August 13, 2025, where the water temperature never fell below 105.0 Degrees F or above 120 degrees F. Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted, and a copy of the report was provided to Executive Director Austin Morris.the state’s words, verbatim · CDSS document, Aug 15, 2025 · control 22-AS-20250703163459

Type of visit: POC

On this day, Licensing Program Analyst (LPA) Edward Kim conducted a case management POC visit to clear deficiency observed during a case management visit on July 10, 2025, and in conjunction with the investigation of complaint 22-AS-20250703163459. During a tour of the physical plant, LPA observed the water temperature readings for the following bathrooms: resident room 103 measured at 117.3 degrees F, resident room 112 measured at 116.6 degrees F, and resident room 135 measured at 113.7 degrees. Executive Director Austin Morris provided the 24 hour water temperature log that was completed on July 11, 2025.A facility representative was provided with the POC letter documenting the corrections. An exit interview was conducted, and a copy of this report and POC letter were provided to Executive Director Austin Morris.the state’s words, verbatim · CDSS document, Aug 15, 2025

Type of visit: Case Management - Other

On this day, Licensing Program Analyst (LPA) Edward Kim conducted a case management visit to document a deficiency observed during the investigation of complaint 22-AS-20250703163459 but unrelated to the allegations investigated. During a tour of the physical plant, LPA observed the water temperature readings for the following bathrooms: resident room 103 measured at 125.0 degrees F, resident room 112 measured at 125.0 degrees F, and resident room 135 measured at 121.4 degrees. A deficiency was cited by Title 22 Division 8 Chapter 6. The facility did not maintain a hot water temperature between 105 degrees F and 120 degrees F for resident rooms 103, 112, and 135. An exit interview was conducted, and a copy of this report and appeal rights were provided to Executive Director Austin Morris.the state’s words, verbatim · CDSS document, Jul 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jul 11, 2025

87303(e)(2) Faucets used by residents... shall be maintained to automatically regulate the hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above. LPA observed that rooms 103, 112, and 135 water temperature measured above 120 degrees F. This poses an immediate health or safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: Licensee states will adjust the water temperature and will create a temperature log for each bathroom (103, 112, and 135). Licensee will measure the temperature every two hours from July 10, 2025, 7:00 PM to July 11, 2025, 7:00PM. The licensee will send this proof to CCLD via email to edward.kim@dss.ca.gov by POC due date July 11, 2025.

Allegation investigated: Facility does not have sufficient staff in the memory care unit. Facility failed to take the appropriate precautions to safeguard resident's property. Facility failed to ensure adequate personal care supplies are available for residents.

On May 5, 2025, Licensing Program Analysts (LPAs) Edward Kim and Jessica Cho conducted a subsequent complaint visit to deliver complaint investigation findings. LPA met with Executive Director (ED) Austin Morris and explained the purpose of today’s visit. The investigation consisted of the following: On February 13, 2025, LPA Kim toured the facility with ED Austin Morris. LPA Kim requested and obtained copies of the resident and staff rosters, resident records which include the Physician’s Reports, Appraisal/Needs and Services Plans, and other pertinent records for nine residents, Residents #1-#9, (R1-R9). LPA Kim interviewed four staff, Staff #1-#4 (S1-S4), and seven residents, (R1-7). The investigation revealed the following: Continued on LIC9099C Unsubstantiated Allegation: Facility does not have sufficient staff in the memory care unit. Based on LPA Kim’s observations conducted on February 13, 2025, there were twenty-two memory care residents present and four staff providing direct care. LPA observed residents’ needs were met during the visit. Based on interviews conducted, seven out of seven residents and two out of four staff denied the allegation. The remaining two out of four staff confirmed that the facility does not have sufficient staff in the memory care unit. One staff explained each shift is sufficient to meet the care and needs for all the memory care residents. There are four caregivers with one Medication Technician (MT) per shift for AM and PM. There are two caregivers and one MT during the NOC Shift. Based on records review, the facility has twenty-two memory care residents per the Facility Register and twenty-three staff providing care to resident in memory care unit per the Staff Schedule. The facility staff schedule shows morning shift is from 6:00 AM to 2:00 PM with two staff, and an additional staff is staggered from 10:00 AM to 6:00 PM with one staff. The afternoon shift is from 2:00 PM to 10:00 PM with two staff and an additional staff from 6:00 PM to 6:00 AM. Based on the schedule, there are four staff work as deemed necessary. Per review of the plan of operations there isn’t a required number of staff. Based on information gathered, there is no sufficient evidence gathered to corroborate the above allegation. Allegation: Facility failed to take the appropriate precautions to safeguard resident's property. It is alleged the facility takes supplies from other residents if they run out. It is alleged that the management at the facility has instructed staff to take supplies from other residents if they run out. It is alleged that families have started to complain because they notice the supplies they purchase for their family member runs out too quickly and suspect they are being used for other residents in care. Based on LPA’s observation, the facility stores memory care supplies are in a storage room. Each memory care resident has their own cubby with their names written on the hygiene supplies. During the visit, LPA Kim did not witness a situation where staff took supplies from one resident to be used for another resident in the memory care unit. LPA Kim examined multiple bathrooms and did not see any items marked with another person’s name nor any residents saying that those hygiene items belonged to somebody else. Continued on LIC9099C Based on interviews conducted, seven out of seven residents and two out of four staff denied the facility failed to take appropriate precautions to safeguard resident’s property. The remaining two out of four staff have confirmed that the facility failed to take the appropriate precautions to safeguard resident’s property. Six out of seven residents stated they have not heard or observed any resident’s supplies or property been taken without permission. One resident stated they have observed in their room that low value items were moved or taken. That same resident stated they have not observed any staff or resident take any hygiene supplies from one room to the next. The resident stated the facility has taken the appropriate precautions to safeguard their property. Two out of the four staff stated that they do not know of any staff who would take and use supplies from one resident supplies for another and management has not instructed staff to take supplies from other residents. One staff stated that families have complained about incontinence supplies running out quickly, but explained that these supplies often get used faster by the resident than the family expects. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Facility failed to ensure adequate personal care supplies are available for residents. It is alleged that the facility does not have sufficient hygiene supplies for residents. It is alleged that the facility runs out of hygiene supplies that are needed for residents such as wipes, toothpaste, deodorant, and towels. It is alleged that staff at the facility have had to purchase hygiene supplies on their own for residents or else they would not have any. Based on observation, LPA Kim observed the memory care supplies in a storage room in the facility. Each memory care resident had a cubby with their names listed on their items. Additional supplies are also stored in the second floor in additional storage rooms providing all necessary care supplies. Based on interviews seven out of seven residents and two out of four staff denied the facility failed to ensure adequate personal care supplies are available for residents. The remaining two out of four staff confirmed facility failed to ensure adequate personal care supplies are available for residents. All residents, stated the facility provides toilet paper, paper towels, and soap for all residents. One out of four staff stated that all hygiene supplies such as toothbrush, toothpaste, shampoo, and incontinence supplies are provided by the resident’s responsible party or hospice and is acknowledged in the admissions agreement. Continued on LIC9099C Based on record reviews, the Admission Agreement states that the facility assumes that the residents provide their own supplies for personal care and hygiene such as hand soaps, towels, etc. However, if they are unable to provide such supplies, the facility will provide the residents with basic personal items for an additional fee. In Appendix A, personal items are listed with a charge of it being individually priced. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Based on observations, interviews, and records review, LPA did not find sufficient evidence to support the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted, and a copy of the report was provided to Executive Director Austin Morris.the state’s words, verbatim · CDSS document, May 5, 2025 · control 22-AS-20250211134439

Type of visit: Required - 1 Year

On May 5, 2025, at 8:00 AM, Licensing Program Analysts (LPAs) Edward Kim and Jessica Cho conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs met with Resident Service Director (RSD) Miriam Im. RSD Im called over the phone Executive Director (ED) Austin Morris who stated they would arrive to join the physical tour and LPA Kim explained the purpose of the visit. The facility is licensed to operate for one hundred fourteen (114) non-ambulatory, of which ten (10) may be bedridden, and maintains a hospice waiver for twenty (20) residents. The facility is a two-story structure, which consists of the following: one hundred twelve (112) resident bedrooms, thirteen (13) offices, one hundred sixteen (116) bathrooms, waiting area, hair salon, first floor activity area, second floor activity area, memory care dining room, main dining room, gym, kitchen, memory care courtyard, and two outdoor areas with outdoor covered patio. LPA Kim toured indoor and outdoor physical plant with RSD Im. ED Morris joined the tour around 9:00 AM. There is a fountain in one of the outdoor areas. All rooms were inspected. Beds and bedding supplies were in good condition with adequate lighting and refrigerator as well as storage for each resident’s personal belongings were observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The following resident apartments were inspected: 103, 107, 119, 140, 151, 156, 235, 260, and 274. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured between 106.7 degrees F and 114.2 degrees F. A comfortable temperature of 74 degrees F was maintained in the facility. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and inaccessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food and supplies are stored in the kitchen and in a storage room closet next to the kitchen. Emergency water is stored in a storage closet in Skilled Nursing across from room 183 and room 184. A working telephone (714) 844-0967 remains available. LPA Kim reviewed the facility’s plan of operation, emergency and disaster plan, and fire/safety drill log. The facility last conducted an Emergency Drill on April 28, 2025. The facility has fire extinguishers that are charged, and they were all serviced on October 4, 2024. Smoke detectors, and carbon monoxide detectors were operable and tested by CAL Building Systems on April 22, 2025. First Aid was maintained and contained all the necessary elements. Evidence of Liability insurance is effective on November 1, 2024, and expires on November 1, 2025. LPA Kim conducted an audit of nine (9) resident files (R1-R8), eight (8) staff files (S1-S8). LPA conducted six (6) resident interviews, four (4) staff interviews, audited medications for the nine residents. LPA discussed the following: to ensure that the medications are given according to the physician’s directions and Tuberculosis (TB) test result is maintained for S1. Based on today’s visit, deficiencies are being cited as per the Title 22 Division 6 Chapter 8 of California Code of Regulations (CCR). An exit interview was conducted, and a copy of this report and appeal rights were provided to Executive Director Austin Morris.the state’s words, verbatim · CDSS document, May 5, 2025

Type of visit: Case Management - Incident

On April 2, 2025, at 8:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced Case Management Visit to follow-up on incident reports received from the facility. LPA Kim was greeted and granted entry by Executive Director (ED) Austin Morris and LPA Kim explained the purpose of the visit to ED Morris. During today’s visit, LPA conducted a health and safety check, and there were no imminent health/safety concerns observed. Facility maintained at a comfortable temperature for the residents in care. LPA obtained Staff Roster, Resident Roster, and R1’s and R2’s records which includes the Physician’s Report, Admission’s Agreement, Emergency Information, Incident Reports, Appraisal and Needs/Service Plan, and other pertinent documents. During the visit, LPA Kim interviewed two staff members and one resident. No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided to the Executive Director Austin Morris.the state’s words, verbatim · CDSS document, Apr 2, 2025

Allegation investigated: The Administrator is not present in the facility. The Administrator is not qualified to be an Administrator.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding a complaint that was filed May 23, 2024. LPA Haley was greeted by staff and explained the reason for the visit. Regarding the allegations above, 2 of 2 staff members provided evidence that contradict the complaint allegations. Staff 1 (S1) is the current Administrator and has a current Administrator’s certificate. S1 served as an Administrator in a previous RCFE from 2021 – 2024. S1 says scheduling fluctuates, so sometimes S1 is in the building once a week or sometimes three times a week. According to S1, Staff 2 (S2) is designated to serve as the backup Administrator, and Staff 3 (S3) is a qualified Administrator with a current Administrator Certificate. S1 explained, S3 can also serve as a backup Administrator and will be the designated backup Administrator when S2 moves into the role as Administrator. S2 is currently a Nursing Home Administrator and has completed and submitted all the training requirements to become an RCFE Administrator. Continued on LIC9099C Unfounded According to S2, the Administrator’s (S1) hours vary, “It varies. Sometime (S1) can be here 10-15 hours a week… sometimes more, sometimes less.” S2 said S1 was in the facility last week. Based on the information gathered during the investigation through interviews, observations, and document review, the allegations mentioned above are deemed Unfounded, meaning the allegations are false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 29, 2024 · control 22-AS-20240523163241

Allegation investigated: Unqualified staff are allowed to work at the facility

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding a complaint that was filed May 2, 2024. LPA Haley was greeted by staff and explained the reason for the visit. Regarding the allegation: Unqualified staff are allowed to work at the facility. 2 of 2 staff members interviewed denied the complaint allegation. Staff 1 (S1) provided a copy of a valid Administrators Certificate, work, and employment history for Staff 3 (S3). Based on the information gathered during the investigation through interviews and document review, the allegation mentioned above is deemed Unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, May 7, 2024 · control 22-AS-20240502113510

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit to follow up on an incident report sent to the Regional Office dated April 13, 2024, and received April 15, 2024. During the visit, LPA Haley conducted interviews with facility staff and briefly spoke with one resident to gather additional information on the incident reported to the Regional Office. During the visit, supporting documents were provided. As a result of today’s case management visit and the information gathered through staff interviews, and document review, deficiencies will be cited. Staff interviews and document review confirmed a personal rights violation occurred. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 16, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 17, 2024

87468.1 (a)(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 is not being met as evidenced by staff interviews and document review that confirmed, Staff 1 (S1) restrained Resident 1 (R1) by grabbing the resident by the arms and confined the resident to their wheelchair. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 16, 2024

Plan of correction: An internal investigation was completed, and the staff involved was terminated. Executive Director Jeff Stewart agrees to schedule an in-service training on Personal Rights of Residents for all staff. Executive Director Stewart will email LPA Haley a detailed breakdown of the topics covered in the in-service training and the sign-in sheet of everyone who attends. Executive Director Stewart will email LPA Haley the date(s) of the scheduled in-service training by the close of business Wednesday, April 17, 2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(1) · Plan of correction due date: Apr 17, 2024

87355 (e)(1) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department… This requirement is not met as evidenced by document review. Staff 1 (S1) and Staff 2 (S2) have not been properly cleared and associated to the facility prior to working in the facility as required. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 16, 2024

Plan of correction: Executive Director Jeff Stewart agrees to have everyone associated with the facility by Thursday, April 18, 2024 at 1:00PM. Anyone who is not cleared and associated at that time will be removed from the schedule until properly cleard and associated. Executive Director Stewart will email LPA Haley a new LIC500 with everyone associated with the facility, no later than Thursday, April 18, 2024 at 1:00PM.

Type of visit: Prelicensing

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an announced visit to conduct a pre-licensing visit. LPA was greeted and granted entry into the facility by Marie Stern, Director of Operations and Hrag Bekerian Administrator and explained the reason for the visit. An initial application was submitted on 08/25/2023 with a fire clearance for 104 non-ambulatory and 10 bedridden granted on 02/14/2024. LPA Mendivil and Director of Operations Marie Stern and Administrator Bekerian toured the facility. The facility is a two story building with Assisted Living taking up two levels and Memory Care occupying the rear of the first floor. Assisted Living has 90 bedrooms and currently has 60 residents occupying rooms. Memory Care has 23 bedrooms with 22 residents occupying the rooms. The first level on assisted living contains staff offices, dining room, activity room, and beauty room. At 9:15 AM, LPA toured the entire community, interior and exterior, including a sampling of resident apartments. Hot water in resident apartments tested between 107.1-119 degrees F. Fire extinguishers were mounted and charged. Smoke detectors were centrally wired throughout and have been checked by the fire department on 03/18/2024. Carbon monoxide detectors were observed and are operational. There are E-Vac chairs present in all stairwells. There was a locked medication room for both assisted living and memory care for residents who need medication management. There were a number of locked janitorial closets for storage of toxins and cleaning equipment. An emergency call system was in place in each apartment and tested. First aid kits are located in the medication room and memory care. Kitchen was stocked with food to meet the regulatory amounts. LPA observed activity calendars posted, menus and activities available. There is a country kitchen on the second floor, tv room, salon, laundry room and activity room. LPA observed the medications and med-techs providing medications in a locked cart to residents. Facility is ready to be licensed. Component III completed. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 26, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 114 Interview Method: Telephone interview On 3/19/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant 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. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Mar 19, 2024