Bentley Suites

Allegation investigated: Licensee did not maintain the liability insurance coverage requirements

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 4/9/26. On 4/9/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Assistant Administrator, Muriel Cabacungan and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 1/15/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, a copy of the Certificate of Liability Insurance and a Copy of Professional and General Liability Insurance Policy, issued 8/26/25. Con'd on 9099-C Substantiated The investigation revealed the following: Allegation: Licensee did not maintain the liability insurance coverage requirements It is being reported that this facility does not have the proper liability insurance that is required. On 4/7/26, LPA Felisa Shirley reviewed the Certificate of Liability Insurance provided for Bentley Suites. Per the certificate, the effective date of coverage is 08/26/2025 thru ending date of 8/26/2026. This certificate indicates the coverage of limits one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate. However, this certificate states that this policy has sublimit in the categories of Bed Sore & Elopement, with 100,000 per occurrence and 300,000 being the maximum. A copy of the full Professional and General Liability Insurance Policy for Residential Care Facility was requested and received by the department on 3/30/2026. Per the full policy, one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate are covered, but there is a 10,000 deductible as well as sublimit of $100,000 per claim and 300,00 per yearly occurrence in the categories of Physical and Sexual Abuse, Elopement, Bedsores, Fall Hazards and an added Medical Payment Sublimit of $5,000 per claim, meaning this policy does not provide the required coverage of one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate for this facility. LPA interviewed staff 1 and staff 2 (S-1 and S-2). Of those interviewed 2 out of 2 denied the allegation. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. A deficiency is being issued and an exit interview is conducted with Muriel Cabacungan, Assistant Administrator. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 28, 2026 · control 11-AS-20260106132133

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.605 · Plan of correction due date: Apr 16, 2026

HSC 1569.605 Liability insurance… all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement was not met as evidenced by: Based on records reviewed, the Licensee did not maintain required liability insurance from 8/26/25 to 8/26/26 which includes a break down of the limits of liability which poses an immediate safety risk and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 28, 2026

Plan of correction: Licensee stated they will obtain liability insurance that complies with Health & Safety Code section 1569.605 and submit proof to LPA Felisa Shirley by POC due date of 4/16/26 by email, Attn: LPA Felisa Shirley at felisa.shirley@dss.ca.gov or fax to 424-544-1016.

Allegation investigated: Licensee did not maintain the liability insurance coverage requirements

On 4/9/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Belen Taico and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 1/15/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, a copy of the Certificate of Liability Insurance and a Copy of Professional and General Liability Insurance Policy, issued 8/26/25. Con'd on 9099-C Substantiated The investigation revealed the following: Allegation: Licensee did not maintain the liability insurance coverage requirements It is being reported that this facility does not have the proper liability insurance that is required. On 4/7/26, LPA Felisa Shirley reviewed the Certificate of Liability Insurance provided for Bentley Suites. Per the certificate, the effective date of coverage is 08/26/2026 thru ending date of 8/26/2026. This certificate indicates the coverage of limits one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate. However, this certificate states that this policy has sublimit in the categories of Bed Sore & Elopement, with 100,000 per occurrence and 300,000 being the maximum. A copy of the full Professional and General Liability Insurance Policy for Residential Care Facility was requested and received by the department on 3/30/2026. Per the full policy, one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate are covered, but there is a 10,000 deductible as well as sublimit of $100,000 per claim and 300,00 per yearly occurrence in the categories of Physical and Sexual Abuse, Elopement, Bedsores, Fall Hazards and an added Medical Payment Sublimit of $5,000 per claim, meaning this policy does not provide the required coverage of one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate for this facility. LPA interviewed staff 1 and staff 2 (S-1 and S-2). Of those interviewed 2 out of 2 denied the allegation. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. A deficiency is being issued and an exit interview is conducted with Muriel Cabacungan, Assistant Administrator. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 11-AS-20260106132133

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.605 · Plan of correction due date: Apr 16, 2026

Liability insurance… all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement was not met as evidenced by: Based on records reviewed, the Licensee did not maintain required liability insurance from 8/26/25 to 8/26/26 which includes a break down of the limits of liability which poses an immediate safety risk and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Licensee stated they will obtain liability insurance that complies with Health & Safety Code section 1569.605 and submit proof to LPA Felisa Shirley by POC due date of 4/15/26 by email, Attn: LPA Felisa Shirley at felisa.shirley@dss.ca.gov or fax to 424-544-1016.

Allegation investigated: Facility is in disrepair.

On 03/18/2026, the department conducted an unannounced subsequent complaint visit to the facility and met with Muriel Cabacungan, Assistant Administrator. The department explained the purpose of this visit was to deliver findings for the complaint visit that was conducted on 01/23/2025. The investigation consisted of the following: During the initial visit conducted on 01/23/2025, the department inspected the facility, interviewed Staff S1 and S3-S4, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Resident Information Sheet, Resident Appraisal (dated 10/16/2023), Preplacement Appraisal Information (dated 10/16/23), Physician’s Report (dated 10/25/2023 and 07/18/2024), Admission Orders (dated 10/30/2023), Unusual Incident/Injury Reports -LIC624 (dated 01/02/2025, 11/17/2025, and 02/28/2025), Caregiver Notes (dated 1/16/25, 1/15/25, 1/8/25, 1/7/25, 1/6/25, 1/3/25, 1/2/25, and 1/1/25), Kaiser Permanente After Summary Visit (dated 03/01/2024 & 12/17/2024),Liftech Elevator Services, INC., Proposal (Dated 01/27/2025, 03/10/2026), and Kaiser Permanente Progress Notes (dated 10/23/2023). Report Continued On LIC9099-C Substantiated During a subsequent visit conducted on 04/08/2025, the department inspected R1's room, interviewed Staff S1, and interviewed Residents R2 and R3. On 04/01/2025, the department received a copy of the Kaiser Permanente medical records for R1’s 01/17/2025 hospital admission. The investigation revealed the following: Allegation: Facility is in disrepair The allegation alleges the elevator at the facility is not operational. During record review, LPA received and reviewed a service contract for a new company, Liftech Elevator Services, INC., (Dated 01/27/2025, 03/10/2026). During the visit, LPA observed the lift to the second floor was not operating. LPA observed activities being provided on the first and second floor. Additionally, LPA observed staff taking trays of food up to the second floor for lunch. During interviews with Staff S1, S3-S4, were asked if the wheelchair lift is working properly, three (3) out of three (3) stated the lift has not been working since they returned from the evacuation. Additionally, S1, S3-S4, were asked how residents on the second floor are accommodated while the life was not operational, three (3) out of three (3) stated additional activities are provided on the second floor, and meals are taken to the residents on the second floor. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on observations, records reviewed and interviews, the preponderance of evidence standard has been met, therefore the above allegation Facility is in disrepair is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D. Deficiencies were issued and plans of corrections were discussed on LIC9099D. Note: *Citations that are not cleared by the POC due date of 04/03/2026 will have a $100 fine assessed for each day the citation is not cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. An exit interview was conducted with Muriel Cabacungan, Assistant Administrator, and a hard copy of this Complaint Investigation Report was provided. During a subsequent visit conducted on 04/08/2025, the department inspected R1's room, interviewed Staff S1, and interviewed Residents R2 and R3. On 04/01/2025, the department received a copy of the Kaiser Permanente medical records for R1’s 01/17/2025 hospital admission. The investigation revealed the following: Allegation: Resident sustained unexplained fracture resulting in hospitalization. The allegation alleges a resident was experiencing pain and when transferred to the hospital was diagnosed with a hip fracture. On 01/08/2025 the facility received orders from Los Angeles County officials to immediately evacuate due to Pacific Palisades fires. On 01/09/2025 R1 was picked up by family to stay with until the evacuation order was lifted. During interviews with Staff S1 and S2, stated R1 was not experiencing unusual pain prior to leaving the facility. During an interview with W1 stated when R1 was residing with them, R1 would scream and complain when attempting to use the restroom. Additionally, W1 stated R1 did not experience a fall while staying with them. On 01/15/2025, R1 returned to the facility and was assisted to their room. On 01/16/2025, staff S1 and S2 stated R1 would complain of pain when asked to move. Staff notified R1’s family and Witness W4, who came to the facility. R1 was transferred to Kaiser Permanente Medical Center to get medically evaluated. The medical records from Kaiser Permanente Medical center (01/17/2025) confirmed R1 was diagnosed with a right intertrochanteric femur fracture and right hip osteoporotic fracture. It was also noted R1 has a history of the following conditions: Osteoarthritis, spinal stenosis, moderately advanced degenerative changes of the lower lumbar spine and facets, with central canal stenosis at multiple levels, most prominent at L2-3 and L4-5, Neural foraminal narrowing predominately at L4 prominent at L5 and a previous left femur trochanteric hip fracture that was sustained back in 2023. Based on interviews conducted and records review, there is not enough evidence to place where and when R1 sustained a fall that would have caused the fracture. There is no evidence to support that the fall occurred at the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Resident sustained unexplained fracture resulting in hospitalization. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated Report Continued On LIC9099-C Allegation: Resident sustained multiple falls due to lack of supervision. The allegation alleges that a resident has experienced multiple falls due to lack of supervision. During the facility inspection, LPA observed sensors on R1’s floor in their room that notify staff when R1 attempts to or gets up. LPA observed a sensor pad on R1’s bed that notifies staff if R1 gets up. During record review, LPA received and reviewed Unusual Incident /Injury Reports for R1 dated 02/28/2024, 11/30/2024 and 01/02/2025, that report R1 was found on the floor in their room. In the Unusual Incident Report dated 01/02/2025, stated R1 was found on the floor, staff immediately assisted and checked for any visible injuries. Vitals were checked and were stable and there were no complaints of pain. Medical care was rendered immediately, and proper notifications were made. LPA received and reviewed R1’s Kaiser Permanente discharge paperwork dated 01/27/2025, that lists current medications for R1 is taking. Upon conducting research of the medication, LPA observed four (4) out of four (4) of the Continue taking medications have a side effect that may cause dizziness, lightheadedness, or fainting when getting up from lying or sitting position. One (1) out of four (4) medications may cause an increased risk of bone fracture of the hip, wrist, and spine, more likely to occur if over the age of 50. One (1) out of the four (4) may cause trouble with controlling body movements, which may lead to fall and fractures. During interviews with Staff S1-S4, stated R1 is considered a high risk for falls and precautions are taken such as rounds are conducted every 30 minutes and sensors have been placed in R1’s room to alert staff if R1 gets up unassisted. During interviews with Witness W4, who is a Registered Nurse and has been working with R1, denied witnessing any type of neglect/ lack of care on behalf of the facility staff. During interviews with Resident’s R2 and R3, two (2) out of two (2) stated staff are constantly checking on residents to see if they need anything and assistance is provided immediately. Additionally, Resident’s R2 and R3 stated they have not witnessed any type of neglect or lack of care and do not have any issues or concerns regarding the level of care provided by the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Resident sustained multiple falls due to lack of supervision. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued. An exit interview was conducted with Muriel Cabacungan, Assistant Administrator, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 11-AS-20250122100645

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

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observation, interviews conducted, and record reviewed, Licensee did not ensure elevator was accessible to residents in care upon returning to the facility after the evacuation. This poses a potential health and safety risk to all residents in care. The facility has a proposal from Liftech Elevator Services, INC., and is in the process of reviewing the proposal and estimated costs.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: (1) Administrator will submit a plan regarding repair for the elevator which includes when the elevator will be repaired and running properly. Administrator will submit updated working documents from the contractor with the plan and whether a new elevator will be installed. (2) Additionally, the facility will develop a plan to address how they will ensure the residents’ personal rights are not violated due to their inability to access the elevator. POC letters must be sent to LPA Perry Scott via email at perry.scott@dss.ca.gov by POC due date of 04/03/2026 to avoid monetary penalties.

Type of visit: Required - 1 Year

On 7/9/2025, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced annual comprehensive inspection. LPA was greeted by staff Maricar Hernandez. LPA explained the purpose of the visit and was granted access to the facility. Belen Taico Administrator arrived around 11:15AM and joined the visit. LPA conducted a tour of the facility, there were no obstructions inside or outside. LPA reviewed four (4) staff files, four (4) resident files with all required documents and certifications. LPA conducted an audit of four (4) residents’ medications, found no discrepancies. Last fire/Disaster drill conducted 5/16/25. LPA observed a 5-day supply of perishable & 7-day supply of non-perishable food items stored properly. LPA observed residents’ rooms and bathrooms, which appeared clean and operational, with required furnishings and lighting. Based on observations made during today’s visit, a citation was issued for violating the residents’ rights by having a surveillance camera in Resident 1 (R1) room. An exit interview was conducted, and this report was discussed and provided to Muriel Cabacungan- Hernandez at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Aug 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Aug 12, 2025

Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: This requirement was not met as evidenced by: LPA observed camera in R1's room during the inspection which violates rights of the resident.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: LPA observed cameras being disconnected during the visit. The POC was done at the time of visit.

Allegation investigated: Facility staff does not comply with its neighborhood complaint policy. Facility is not in clean and sanitary condition.

On 07/09/25, Licensing Program Analyst (LPA) Elvira Gonzalez and Licensing Program Manager (LPM) Stephanie Cifuentes conducted an unannounced complaint visit to the facility listed above. LPA and LPM met with Assistant Manager, Muriel Cabacungan, and the purpose of today’s visit was explained. LPA and LPM were granted entry to the facility. Administrator, Belen Taico later joined LPA and LPM for the visit. The investigation consisted of the following: During today’s visit on 07/09/25, LPA interviewed staff #1 - #4 (S1-S4), residents #1 -#4 (R1-R4), and witnesses #1-#2 (W1 -W2) and attempted to interview #3 (W3). LPA received and reviewed the following documents: staff roster, resident roster, and Neighborhood Complaint/Concern Policy. Additionally, LPA and Assistant Manager, Muriel Cabacungan toured the inside and outside grounds of the facility. Unsubstantiated The investigation revealed the following: Allegation: Facility staff does not comply with its neighborhood complaint policy. It is being alleged that neighbors have complained about the facility noise level, and their concerns have not been addressed. On 07/09/25 between 10:45 AM and 11:45 PM, LPA conducted interviews with S1 – S4. Administrator Belen Taico (S1) stated that when a neighbor has a complaint regarding the facility, she will address the complainant and work on a solution. Belen Taico stated that in the past there have been complaints from neighbors, and that when she’s reached out to these neighbors regarding their complaints, the neighbors have dismissed the complaint. Furthermore, 4 out of 4 staff interviewed denied the allegation. On 07/09/25 between 11:50 AM and 12:35 PM, LPA conducted interviews with R1 – R4. Based on interviews conducted, 4 out of 4 residents interviewed stated they did not know of the neighborhood complaint policy. 3 out of 4 residents interviewed said they don’t know if neighbors have complained about the facility noise level. On 07/09/25, between 1:45 PM and 2:10 PM, LPA Gonzalez interviewed W1-W2. Of those interviewed, 2 out of 2 stated they have no problems with the facility. Based on observation, interviews conducted, and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. Allegation: Facility is not in clean and sanitary condition. It is alleged that the residents frequently discard their cigarette buds on neighbor’s property, facility cleaning supplies are left under neighbor’s windows and facility trash cans overflow. On 7/7/2025 LPA and Muriel Cabacungan toured the inside and outside grounds of the facility. During facility tour, LPA observed the facility to be clean and sanitary. LPA inspected the kitchen, resident rooms, and common areas, and observed them to be clean and in sanitary condition. LPA observed that the facility has a smoking area, located on the side of the facility towards the back, secluded and away from staff and residents. LPA observed that the smoking area had an ashtray where the residents throw their cigarette buds. LPA observed the smoking area to be clean. LPA did not observe any buckets filled with bleach or cleaning supplies on the side of the facility. During the facility tour, LPA observed the back alley to be clean and free of trash, or obstructions. LPA did not observe any cigarette buds on the ground or anywhere near the neighbor’s property. LPA did not observe the trash overflowing. Continued on LIC9099-C On 07/09/25 between 10:45 AM and 11:45 AM, LPA conducted interviews with S1 – S4. Based on interviews conducted, 4 out of 4 staff denied the allegation, adding they do not use bleach to clean the facility. S2 stated that staff pour all the used water, after mopping into a container on the side of the house that leads to the drain. On 07/09/25 between 11:50 AM and 12:35 PM, LPA conducted interviews with R1 – R4. Based on interviews conducted, 4 out of 4 residents interviewed said they don’t know if staff leave bleach filled buckets and cleaning supplies right under a neighbor’s window. 4 out of 4 residents interviewed stated that they don’t know if the trash is frequently overflowing. 4 out of 4 residents interviewed said this facility is kept clean and in a sanitary condition. 4 out of 4 residents interviewed stated that their rooms are cleaned daily. 4 out of 4 residents interviewed stated that they are satisfied with the services provided to them at this facility. LPA and Muriel Cabacungan toured the inside and outside grounds of the facility. During facility tour, LPA observed the facility to be clean and sanitary. LPA inspected the kitchen, resident rooms, and common areas, and observed them to be clean and in sanitary condition. LPA observed that the facility has a smoking area, and it is located on the side of the facility towards the back, secluded and away from staff and residents. LPA observed that the smoking area had an ashtray where the residents throw their cigarette buds. LPA observed the smoking area to be clean. LPA did not observe any buckets filled with bleach or cleaning supplies on the side of the facility. During the facility tour, LPA observed the back alley to be clean and free of trash, or obstructions. LPA did not observe any cigarette buds on the ground or anywhere near the neighbor’s property. LPA did not observe the trash overflowing. Based on observation, interviews conducted, and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. LPA did not find any deficiencies during this investigation; therefore, no citations were issued. An exit interview was conducted, and a copy of the report was provided to Assistant Manager, Muriel Cabacungan. LPA did not find any deficiencies during this investigation; therefore, no citations were issued. An exit interview was conducted, and a copy of the report waws provided to Administrator Belen Taico.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 11-AS-20250702145723

Allegation investigated: Staff refused to provide resident's authorized representative copies of resident's file.

On 04/24/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit to the facility listed above. LPA met with Assistant Administrator, Muriel Cabacungan, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit on 04/24/2025, LPA inspected the facility, interviewed Staff S1-S4, interviewed Residents R2 and R3, interviewed resident’s Responsible Party W1-W3, and received documents pertinent to the investigation. LPA received and reviewed the following documents Staff Roster, Resident Roster, Resident Information Sheet (dated 12/28/2022), Admission Agreement (dated 12/29/2022) Admission Record for Culver West Health Center (dated 12/27/2022), Admission Orders (dated 12/27/2022), Physician’s Report (dated 12/27/2022, 08/18/2023, and 08/23/2024), Culver West Health Center Order Summary Report (dated 11/29/2022), and emails between the facility and resident’s representative. The investigation revealed the following: Substantiated Allegation: Staff refused to provide resident’s authorized representative copies of resident’s files. The allegation alleges that a written request was submitted on March 5, 2025, and the facility was contacted multiple times with the request, and the documents have not been provided. During the facility inspection, LPA observed resident file stored in the office. For residents who have moved out or have passed away the files were observed in a locked file cabinet in a second-floor storage room. During record review, LPA reviewed R1’s Admission Agreement that includes Personal Rights in Privately Operated Residential Care Facilities for the Elderly that states on number 21 that residents have the right “To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies.” Additionally, LPA received copies of emails between the Administrator and R1's Representatives offices indicating Invoice Ledgers for R1 were sent. LPA reviewed a letter dated 03/05/2025, that requests “a copy of all writings related to R1 within your care, custody and control. Copies shall include all “resident records’ for R1.” During interviews with Staff S1-S4, were asked if resident R1 was provided with documents requested, four (4) out of four (4) stated yes, R1 was provided with the documents from their file when they moved out. Additionally, S1 stated they emailed the Invoice Ledgers for R1 to the requesting person who is a representative for R1. During interviews with Residents R2 and R3, were asked if there was a time they requested a document and did not receive it in a timely manner, one (1) out of two (2) stated they are provided with the documents right away. Additionally, one (1) out of two (2) stated they have not requested documents from the facility. During interviews with Residents R4-R6’s responsible parties W1-W3, were asked if when they have requested documents from the facility if they received them in a timely manner, three (3) out of three (3) stated they have had no issues and received them right away. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Administrator Assistant, Muriel Cabacungan, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 24, 2025 · control 11-AS-20250416134005

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: May 2, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities,..following personal rights: (19)To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This requirement was not met as evidence based on interviews and record reviews. The licensee did not ensure Resident R1's representitive received copies of documents requested.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Licensee will send copies of R1's documents in thier file to thier representative and will carbon copy (CC) LPA Wendy.Gibbs@dss.ca.gov on the email before the POC due date.

Allegation investigated: Staff did not provide copies of resident's file to authorized representative

On 04/03/25, Licensing Program Analyst (LPA) Mario Leon conducted an initial visit to gather information regarding the above allegation. LPA met with staff one, Muriel Cabacungan (S1) Assistant Administrator, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 04/03/25 LPA requested Resident Roster (dated 03/10/25), staff roster (dated 02/18/25) and Medication list for Resident one (R1), centrally stored medication and destruction record between the dates of 09/01/24 through 12/01/24, Physicians Report for R1, and Admissions Agreement for R1. LPA interviewed three (3) residents (R2-R4), three (3) staff (S1-S3) and one witness (W1). LPA conducted a physical tour of the facility and reviewed paperwork for R1. R1 has been discharged on 12/01/24, LPA was not able to interview R1. Furthermore, staff three (S3) Belen Taico Administrator, is currently on leave. LPA was not able to interview S3. Report continues, please see LIC9099C. Substantiated Investigation revealed the following: Regarding the Allegation, "Staff did not provide copies of resident's file to authorized representative". It has been alleged that on March fifth of the year 2025 (03/05/25) a formal letter was dispatched to Bentley Suites requesting photocopies of all documents pertinent to their client, R1, and that the authorized representative (AR) had not received any response. On 03/28/25 LPA conducted record review of communications from the AR of R1 to the facility. The communications record were listed as follows: at least four (4) electronic communication attempts (e-mail) from AR to the facility between the dates of 03/05/25 - 03/25/25. On 04/03/25 between 09:45AM and 10:45AM, LPA interviewed three (3) residents (R2-R4). R1 was not available for LPA interview. All three (3) residents (R2-R4) disagree with the allegation. On 04/03/25 between 11:00AM and 12:40PM, LPA interviewed two (2) staff (S1-S2). Both interviewed staff (S1-S2) stated that one witness (W1) has received all documentation of R1, as requested, and that W1 has signed R1's emergency ID as reception of documentation of R1 (dates unknown). S1 and S2 have confirmed they had not received electronic messaging from R1's authorized representative (AR). Staff three (S3) was not available for LPA interview. On 04/03/25 between 12:57PM and 1:07PM, LPA interviewed one witness (W1). W1 has stated that they had only received a paper clipped stack of paperwork pertaining to R1, for W1 to bring to R1's new care facility and that R1's AR had not received any response from the facility. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC9099-D. One deficiency has been cited, see LIC9099-D. An exit interview was held with staff one, Muriel Cabacungan (S1). A copy of this report, the deficiency cited, and facilities' appeal rights have been provided to Muriel Cabacungan (S1).the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 11-AS-20250325135422

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: Apr 7, 2025

87506 - Resident Records (c) All information and records...shall be confidential.(1)The licensee shall be responsible for...inactive records... confidentiality of their contents. The licensee..shall make available to...designated representative. This has not been met as evidenced by: The licensee failed to produce any response to a resident's authorized representative (AR) between the dates of 03/05/25-04/02/25.the state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: The licensee, S2, has agreed that the facility will forward all records of R1 to R1's authorized representative (AR). S2 has agreed that the facility will also carbon copy (CC) to mario.leon@dss.ca.gov on or prior to the POC due date which is 04/07/25.

Allegation investigated: Resident sustained an unexplained injury while in care.

On 08/12/24, at 9:25am, Licensing Program Analyst (LPA) David Espana conducted an initial complaint visit to the facility and was greeted by Muriel Cabacungan, Assist Administrator. LPA explained the purpose of this visit is to conduct interviews, gather facility files, and render findings in the complaint. The investigation consisted of the following: An initial complaint visit was completed by LPA David Espana on 08/12/2024. A subsequent visit was completed by LPA Perry Scott on 12/11/2024. The department investigated the allegation mentioned in this complaint and conducted interviews with staff (S1-S4) and residents (R1-R4). Additionally, the department obtained the following documents: Resident Roster (Dated: 04/24/2024), Staff Roster (Dated: 07/18/2024), ID Emergency Information (Dated: 11/18/2023 & 11/14/2023), Resident Appraisal (Dated: 11/21/2023) and Pre-admission Appraisal (Dated: 11/01/2023 & 11/15/2023), Incident reports (Dated: 07/31/2024 & 08/05/2024), Admission Agreement (Dated: 11/17/2023), and Physician’s Report (Dated: 07/18/2024) from the facility. Complaint Investigation Report Continues on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation- Resident sustained an unexplained injury while in care. The details of the complaint alleged that the resident (R1) sustained an unexplained bruise on R1s right eye. On 08/12/24 the department interviewed staff (S1-S3). On 12/11/24, from 09:30am-2:00pm, the department interviewed staff (S4) and residents (R1-R4) regarding the allegation. 4 of 4 staff (S1- S4) denied knowing how the Resident sustained an unexplained injury while in care. All staff (S1-S4) stated that they did not see what happened to cause an injury to R1. S1 states that R1 may have fallen out of a rocking chair in R1s room and hit R1s face but are not sure. S1 also stated that they now have a baby camera in R1s room to monitor the resident, that was authorized by the family, which does not record though. All staff (S1-S4) stated that R1 wanders around a lot and is sundowning. They deny that anyone may have done this to R1 and that R1 may have fallen. They state that R1 has fallen in the past. The department reviewed the Incident Report (Dated: 07/31/2024) that was sent to Community Care Licensing informing the department of the unexplained bruise. The department also reviewed the Physician’s Report (Dated: 07/18/2024) that states that the resident has sundowning behavior and can become confused and disoriented. The department interviewed residents (R1-R4) about the allegation and 3 of 4 residents that were interviewed denied any knowledge of how the Resident sustained an unexplained injury while in care. The majority (3 of 4) residents interviewed stated that they had no knowledge of how the resident was injured and have not been injured or abused themselves by any staff or resident at the facility. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Resident sustained an unexplained injury while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. No citations were issued for this complaint. An exit interview was conducted with Muriel Cabacungan, Assist Administrator, and a copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Dec 11, 2024 · control 11-AS-20240806110431

Allegation investigated: Staff are not safeguarding resident's belongings . Staff mismanaged resident's medication.

On 4/9/25, at approximately 10:10 AM Licensing Program Analyst-PA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Muriel Cabacungan/Assistant Administrator. LPA Iniguez explained the purpose of this visit. On 12/9/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Muriel Cabacungan/Assistant Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Resident’s interviews (R#1-R#4). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#4) Client/Resident Personal Property and Valuables or LIC 621. Evaluation Report continues LIC 9099-C Substantiated Investigation Revealed the Following: Allegation: Allegations: Staff are not safeguarding resident's belongings. The details of the complaint alleged that facility staff are not safeguarding residents’ belongings. During the record review, LPA Iniguez reviewed the (R#1-R#4) inventory. LPA observed that the facility did not document residents’ personal belongings on the list and does not have them sign the form upon admission. During an interview with (R#1-R#4), (4) out of (4) stated that the facility did not make an inventory list of their personal belongings upon admission. Allegation: Staff mismanaged resident's medication On April 9, 2025, at approximately 10:30 AM, during a records review conducted on February 11, 2025, the department received new information indicating that (S#2) reported (R#1) is not taking Metoprolol and Xarelto. (S#2) also stated they are unable to refill these medications, which is why (R#1) does not have them and is not taking them. Additionally, LPA Iniguez reviewed the facility’s Plan of Operation regarding medication policies and procedures. It states, "This facility will assist residents with their medications, provide them with their prescribed medications, and reorder them when necessary." During this investigation, LPA found sufficient evidence to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099D). An exit interview was conducted, and a copy of the Complaint Report was given to Muriel Cabacungan/ Assistant Administrator Amended document: allegation of staff mismanage resident's medications findings changed from unsubstantiated to substantiated. See amended LIC 9099 for more details. Allegation: Allegations: Licensee does not ensure that staff have required medication training. The details of the complaint alleged that facility staff is not trained on how to manage residents’ medications. During the records review, LPA Iniguez reviewed facility staff medication training; a pharmacy provides the training, and it is 8 hours long. The training includes roles and responsibilities, terminology, types of medication, basic rules and precautions of medication assistance, medication forms, procedures for assisting with self-administration, medication documentation, storage, security and documentation, ordering, and the receipt of medications and side effects. The training is provided every year to most of the facility staff. During an interview with the administrator (A#1), she stated that most of the staff members are trained on how to manage and dispense medications and are trained every year. During interviews with residents (R#1-R#4), (3) out of (4) stated that they feel the facility is well-trained regarding medication administration. During interviews with staff (S#1-S#3), (3) out of (3) stated that they are trained regarding medication administration and get trained every year. Evaluation Report continues LIC 9099-C Allegation: Allegations: Staff do not ensure that facility is clean and sanitary. The details of the complaint alleged that facility staff do not ensure facility is clean and sanitary. During a Health and Safety check of the facility, LPA Iniguez randomly inspected three residents’ rooms, kitchens, and common areas; LPA observed that the facility was clean and sanitary. During an Interview with the Administrator (A#1), she stated that the facility is clean and sanitary. During interviews with residents (R#1-R#4), (4) out of (4) stated that the facility is clean and sanitary. During interviews with staff (S#1-S#3), (3) out (3) stated that the facility is clean and sanitary. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. 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. An exit interview was conducted, and a copy of the Complaint Report was given to Muriel Cabacungan/ Assistant Administratorthe state’s words, verbatim · CDSS document, Dec 9, 2024 · control 11-AS-20241202162753

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.153(d) · Plan of correction due date: Dec 23, 2024

1569.153 Theft and loss program; standards, property inventories and surrender of personal effects; secured areas (d) A written resident personal property inventory is established upon admission and retained during the resident's stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident's representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident's behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident's representative, and dated. This requirement was not met as evidence by: Based on a review of records and interviews of (R#1-R#4), the facility staff failed to ensure residents personal belongings list was not created upon their admissions This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Dec 9, 2024

Plan of correction: Licensee will ensure a list of personal belongings is create upon admission of resident. As plan of correction, licensee will re-do personal belongings of existing residents and new ones. A copy of the list will be sent to LPA via email before POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a) · Plan of correction due date: Apr 22, 2025

87208 Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. This requirement was not met as evidence by: Based on a review of records from new proof submitted to the department and the facility plan of operations, the facility staff failed to refill (R#1) medications. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Dec 9, 2024

Plan of correction: Licensee will adhere to Title 22 at all times. Licensee will submitt plan of correction to LPA Iniguez before POC due date.

Type of visit: Required - 1 Year

On 10/10/2024, at 10:15PM Licensing Program Analyst (LPA) Troy Watson conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with the Assistant Administrator Muriel Cabacungan. LPA Troy Watson explained the purpose of today’s visit. Facility is licensed for (44) non-ambulatory residents and (4) bedridden residentS. The facility has an approved hospice waiver for (15) residents.The facility consists of (22) resident bedrooms, (22) bathrooms, (1) living room, (1) dining room, and (1) kitchen and one laundry area. LPA Watson toured the physical plant with the Assistant administrator. There were no bodies of water or obstructions on the premises. A total of (22) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected the carbon monoxide detector and found that it wase in operable condition. The water temperature properly measured between: 114°F and 116°F, between the bathrooms and in the kitchen. Evaluation Report Continues LIC 809-C LPA Troy Watson observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed. Sharps objects and cleaning agents were locked and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available at the property. All fire extinguishers were charged and were operable. A review of (7) residents' service files, (5) staff personnel files were reviewed. LPA checked (7) Medication Administration Records (MAR) and no discrepancies were found. The first AID kit was checked and contained the correct manual. Last facility disaster drill was held in August 2024. LPA observed the facility's infection control practices. And a copy of the liability insurance was on file. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Muriel Cabacungan.the state’s words, verbatim · CDSS document, Oct 10, 2024

Allegation investigated: Facility lifting device is inoperable.

On 06/28/2024 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Muriel Hernandez Cabacungan, assistant administrator (S1), and the purpose of the visit was explained. S1 and LPA toured the facility. The investigation consisted of the following: On 06/28/2024 LPA requested and reviewed facility documents and toured the facility. LPA interviewed three (3) out of thirty-seven (37) residents (R1-R3), one witness (W1) and four (4) out of eleven (11) staff (S1-S4). The investigation revealed the following: Regarding the allegation: "Facility lifting device is inoperable."; it has been alleged that the lift at the above-mentioned facility is currently inoperable, which makes a resident feeling trapped upstairs. Between 09:30AM and 10:00AM, on 06/28/2024, LPA observed 3 "out of service" tags located on the various controls of the lift, to prevent any residents from attempting to use the lift. Report continues, see LIC9099C. Substantiated Interviews revealed that 4 out of 11 staff, one witness and one (1) out of 3 residents have agreed with the allegation. Record reviews revealed that communications between an elevator service company and the above-mentioned facilities' Administrator (S5) have been in contact between the dates of 06/15/2024 and 06/28/2024 to repair the lift. Based on record reviews, LPA's observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. An exit interview was conducted with Muriel Hernandez Cabacungan, Assistant Administrator (S1), and a copy of facilities’ appeal rights and this report has been provided.the state’s words, verbatim · CDSS document, Jun 28, 2024 · control 11-AS-20240621122422

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 9, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This has not been met as evidenced by: Licensee has yet to repair the lift which would allow non-ambulatory resident(s) to freely travel from the second story of the facility to the ground floor.the state’s words, verbatim · CDSS document, Jun 28, 2024

Plan of correction: Assistant Administrator and LPA have agreed that the facility will send video evidence of a working lift, on or prior to the POC due date, via email, to LPA at Mario.Leon@DSS.CA.GOV

Allegation investigated: Staff did not provide adequate supervision resulting in resident wandering away from facility. Resident has lost significant amount of weight while in care.

THIS REPORT SUPERSEDES THE REPORT DATED 11/01/2023 FOR CLARIFY THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS HAVE CHANGED: SUBSTANTIATED Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Bentley Suites facility on 07/21/2023 and was greeted by Administrator Robin Aquino (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. During this investigation, LPA Calderon interviewed A1, S1-S3, R1-R3. These interviews were conducted on 11/17/2022 ,06/08/2023 and 11/01/2023. On 11/01/2023 LPA Calderon obtained and reviewed copies of the following: Physician Report (dated 03/07/2022), Centrally stored medication and destruction records (dated 06/01/2022 to 10/10/2022), Incident reports (dated 07/26/2022 to 11/09/2022), Food Log (September 2022), admission agreement (dated 03/07/2022). The investigation revealed the following: Substantiated Regarding Allegation #1: Staff did not provide adequate supervision resulting in residents wandering away from facility. This complaint alleged that R1 wandered away from the facility. LPA Calderon interviewed with A1. A1 stated that on 07/26/2022 R1 followed a guest out the front door of the facility at 1 pm. Staff searched for R1 when unable to locate inside the facility and then called 911. According to the police report #22-76564, R1 was found blocks away from the facility and was unharmed. LPA Calderon interviewed with S1-S3. 3 out of 3 staff admitted that R1 did wander away from the facility on 07/26/2022 and was recovered with no injuries in tack. facility. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health condition. R2-R3 acknowledged that R1 did wander away from the facility due to the failure of staff supervision. On 11/02/2023 LPA Calderon reviewed the physician’s report (dated 03/07/2022) for R1. The report indicated R1 has a wandering behavior and requires observation and supervision. Regarding Allegation #2: Resident has lost significant amount of weight while in care. This complaint alleged R1 lost a significant amount of weight while in care. LPA Calderon interviewed with A1. A1 stated that R1’s weight on 03/07/2022 was 136 lbs. and that R1 lost 15 lbs. A1 stated that staff did not keep track of R1’s weight, but that A1 had called R1 sister to advise that the facility would need a new doctor’s order regarding R1 weight. A1 stated there were no responses from the R1 family for the new doctor’s order. A1 claimed that the weight loss was not due to overmedication of quetiapine. LPA Calderon interviewed with S1-S3. 3 out of 3 staff stated that most residents lose some weight until they get familiar with the facility and food and then usually gain weight. 3 out of 3 staff stated that R1 did lose some weight which is normal for a new resident. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health condition. R2-R3 stated that new residents usually must get used to the food and lose some weight. R2-R3 reported that they also lost some weight at first but gained weight after getting used to the food being served. On 11/03/2022 reviewed food log notes (dated September 2022) for R1. The percentage of food consumed by R1 is logged in the log. It appears R1 ate 90% of his breakfast, 50% of his lunch, and 10% of his dinner. There were no logs of any changes to R1 weight. Based on interviews, observations, and supporting documents. The preponderance of evidence standard has been met; therefore, the allegation of Staff did not provide adequate supervision resulting in residents wandering away from the facility. Residents have lost a significant amount of weight while in care” is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citations issued (ref LIC9099D). A face-to-face meeting was conducted with Administrator Robin Aquino, and a hard copy was provided. Regarding Allegation #1: Resident fell while in care resulting in injuries. This complaint alleged that R1 fell outside the facility and had bruising to R1’s face and a cut above the left eye. LPA Calderon interviewed with A1. A1 stated that there is no medical report or incident report regarding bruising to R1’s face or a cut above R1’s left eye. LPA Calderon interviewed with S1-S3. 3 out of 3 staff stated that R1 was not injured while inside the facility. 3 out of 3 staff do not recall R1’s having bruises or a cut above R1’s left eye. LPA Calderon interviewed with R1-R3. R1 could not answer any questions due to R1's health conditions. R2-R3 states that R2-R3 has not seen R1 fall and that R2-R3 had not fallen or been injured from any incident. On 11/02/2023 LPA Calderon reviewed incident reports (dated 7/26/2022 to 11/09/2022). The incident report (dated 7/26/22) revealed that R1 left the facility and was found by the police safe and not injured. There is no incident report or medical report that states R1 was injured inside the facility. Regarding Allegation #2: Staff is mismanaging residents’ medication. This complaint alleged staff are over-medicating R1 with quetiapine. LPA Calderon interviewed with A1. A1 stated that the staff did not overmedicate R1 with quetiapine and that the staff gave medication to R1 only as prescribed by doctors’ orders. A1 stated that if the staff had overmedicated R1 with quetiapine R1 would not have wandered away from the facility on 07/26/2022. LPA Calderon interviewed with S1-S3. 3 out of 3 staff reported that R1 is given medications 2 times per day usually before mealtime. 3 out of 3 staff stated that the med-tech administers the medication and will document the Medication Administration Record (MAR) for R1. LPA Calderon conducted an interview with R1-R3 for this complaint. R1 was not able to answer any questions due to R1’s health condition and was unable to carry on a conversation. R2-R3 reported that staff gives medication 3 times per day and residents have noted that staff updates their records on what medication is given to a resident. On 11/02/2023 LPA Calderon reviewed the Centrally Stored Medication and Destruction record (dated 06/01/2022 to 10/10/2022) for R1. Quetiapine 25 mg, 1 tablet daily, 3 refills, there was no change in medication strength observed. Regarding Allegation #3: Staff did not seek medical attention for residents in care. This complaint alleged staff did not seek medical attention for resident in care. LPA Calderon interviewed with A1. A1 stated that staff take care of residents’ medical needs. A1 stated that staff give medical attention to all residents and if residents need help there are staff to take care of residents’ needs. A1 stated that there are no medical or incident reports to suggest R1 was injured inside the facility. LPA Calderon interviewed with S1-S3. 3 out of 3 staff reported that all staff provided the best care and medical attention possible for each resident. 3 out of 3 staff claimed that if a resident is injured staff will seek medical attention right away. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health condition. R2 expressed that R2 is independent, but that stuff is there if R2 requires medical attention. R3 claimed staff are attentive and if the call button for assistance is activated, the staff provides immediate attention. On 06/08/2023 LPA Calderon and S1 toured the facility. It was identified by LPA Calderon that staff members assisted various residents with medical problems, cleaned beds, and answered the call button whenever it was used. Regarding Allegation #4: Facility did not notify residents responsible party of an accident in a timely manner. This complaint alleged facility did not notify residents responsible party of an accident in a timely manner. LPA Calderon interviewed with A1. A1 stated that there were no medical or incident reports noting any injuries to R1. A1 claimed that if R1 or any other resident was injured staff does call the resident family members to update the resident family on status. A1 claimed that R1 was not injured, and no call was made to authorized representatives. A1 indicated that when R1 wandered away from the facility on 07/26/2022, a staff and A1 called R1's family to update them on R1's status. LPA Calderon interviewed with S1-S3. 3 out of 3 staff stated that S1-S3 are fully trained and are mandated reporters. As mandated reporters, any injuries must be reported timely to the administrator. This includes reporting to family representatives when an incident occurs. LPA Calderon interviewed with R1-R3. R1 could not answer any questions due to health condition. R2 expressed being independent and able to handle their own daily needs. R3 reported that family representatives are given status as required. On 11/02/2023 LPA Calderon reviewed incident reports for R1 dated 07/26/2022 to 11/09/2022. LPA Calderon observed staff reported the incident to the R1 family timely. Regarding Allegation #5: Staff use zip ties to lock facility gate. This complaint alleged staff used zip ties to lock the facility’s front gate. LPA Calderon interviewed with A1. According to A1, residents from this facility live together without being segregated including some who are independent and some who require assistance with daily living activities due to memory loss. A1 stated that at no time has staff used any type of zip ties to secure the front door to the facility. A1 claimed that before R1 wandered from the facility on 07/26/2022 the front door had a normal lock. A1 stated that at no time did staff put a zip tie on the front door. A1 reported that since 07/26/2022 the facility’s front door has a security code that only staff knows to prevent residents with wandering behavior from leaving the facility. LPA Calderon interviewed with S1-S3. 3 out of 3 staff denied ever using zip ties to secure the front door. 3 out of 3 staff reported that the front door currently has a security code to prevent residents with dementia from leaving without staff assistance. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health conditions. 2 out of 2 residents stated that they have never observed a zip tie used on the front door, but since 07/26/2022 maintenance changed the front door with a security passcode. 2 out of 2 residents claimed that some residents have dementia, and the security code prevents the resident with dementia from leaving without staff help. On 06//08/2023 LPA Calderon toured the facility and did not witness any zip ties but there is a security code staff must use to unlock the front door. . Regarding Allegation #6: Staff took inappropriate photos of residents while in care. This complaint alleged staff took inappropriate photos of the resident while in care. LPA Calderon interviewed with A1. A1 reported that at no time would any staff member take photos of any resident for any reason without permission. LPA Calderon interviewed with S1-S3. 3 out of 3 staff claimed that they have never taken photos of R1 or any other resident without permission. 3 out of 3 staff stated that A1 has never ordered any of the staff to take any photos of R1. LPA Calderon interviewed with R1-R3. R1 could not answer any question due to health conditions. 2 out of 2 residents said that they had never seen staff take any photo or video of any resident being taken while at the facility. Regarding Allegation #7: Residents denied visitation. This complaint alleged R1 family was denied visitation. LPA Calderon interviewed with A1. A1 reported that no staff member has ever been denied residents visitation rights to friends, guests, or family members for any reason. A1 claimed that there was a situation on 11/04/2022 where R1’s family was aggressive with staff and the staff had to call the Santa Monica Police Department. This information was verified with police report #22-76564. A1 claimed that the police came to the facility and asked R1’s family to leave the premises. LPA Calderon interviewed with S1-S3. 3 out of 3 staff stated that S1-S3 have seen R1’s family visit many times. 3 out of 3 staff state that S1-S3 have never known any resident family or guest denied access to the facility. LPA Calderon interviewed with R1-R3. R1 was not able to answer any questions due to health condition. R2-R3 reported there have been no staff has ever denied them access to family or guest visits. R2-R3 have seen other residents’ family and friends visit over the years with no problems. On 11/03/2023 LPA Calderon reviewed the admission agreement (dated 04/07/2022) for R1. It is indicated under “Policies” concerning family visits, the facility is open to family and guests from “9 am to 7 pm every day”. A review of incident reports from 07/26/2022 to 11/09/2022 revealed there were issues between the facility and the R1 family, but no documentation that the R1 family was denied access to R1 or the facility. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of Resident fell while in care resulting in injuries. Staff are mismanaging residents’ medication. Staff did not seek medical attention for resident in care. Facility did not notify resident's responsible party of an incident in a timely manner. Staff use zip ties to lock facility gate. Staff took inappropriate photos of residents while in care. Residents denied visitation. is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Administrator Robin Aquino (A1).the state’s words, verbatim · CDSS document, Jan 25, 2024 · control 11-AS-20221108082312

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(k)(8) · Plan of correction due date: Jan 29, 2024

87705 care of persons with dementia (k) The fol requirements must be met... doors and perimeter fence gates. (8) delayed agress devices shall not substitute for trained staff... This requirement was not met as evidenced by: Based on LPA observations, interviews conducted and records reviewed the licensee failed to ensure that the delayed egress did not substitute for trained staff, which poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: Administrator agrees to secure all exits with key code locks to prevent residents from leaving the facility without staff help.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jan 29, 2024

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. When changes such as unusual weight gains or losses..This requirement was not met as evidenced by: Based on LPA observations, interviews conducted and records reviewed the licensee failed to ensure that the resident weight loss was not monitored which poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Jan 25, 2024

Plan of correction: Administrator will keep accurate weight loss records for clients in care.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David España is conducting a case management-other visit due to LPA observations on 12/13/2023 deficiencies not related to a complaint that is being investigation today. (Control # 11-AS-20231205153025) LPA met with S#1 who assisted with visit. Upon arriving at the facility, LPA met with S#1 and S#2 who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections. On 12/13/2023 Licensing Program Analyst (LPA) David España confirmed there were Thirty-Six (36) total residents in care. LPA confirmed there are Ten (10) total staff employed as of 12/13/2023. LPA confirmed there is only One (1) resident in care who receives oxygen as of 12/14/2023. LPA confirmed there are Six (6) total staff working at the time of visit 12/14/2023. LPA confirmed there are Twenty-Two (22) total residents in care with dementia at the time of visit 12/14/2023. LPA confirmed there are Twelve (12) total residents in care with wheelchairs at the time of visit 12/14/2023. LPA confirmed there are Seventeen (17) total residents in care with diapers at the time of visit 12/14/2023. The LPA also reviewed the following documents provided by Muriel Cabacugan Assistant Administrator (S1): Staff roster and Client roster. Observation on 12/13/23 at 10:25am made while conduction a walkthrough of the physical plant, LPA observed Room #16 and Room #15 front doors and Room walls with large holes in the drywall that needs maintenance. LPA and S#1 observed Room #3 window bathroom screen missing. LPA and S#1 observed bathroom window not working (did not stay on its track). LPA and S#1 also observed Room #14 and Room #13 had a strong urine odor in both rooms. LPA and S#1 observed private room #12 missing window screen next to the bathroom. LPA and S#1 observed outdoor walkways with materials with little accessibility towards exit of facility (back of facility). LPA and S#1 also observed materials with little accessibility entering the laundry area towards side of facility. Continued on LIC 809-C LPA and S#1 observed during tour observed front and side of facility, and the left-hand side of the facility, noted overgrown grass with no access to the length of the facility. LPA and S#1 noted debris and yellow overgrown grass. LPA interviewed S#1 about access to the side of facility, and S#1 stated there was no door access to the area. LPA noted that flammable grasses blanketed the side of the facility. Lastly, LPA and S#1 observed in the front yard with overgrown plants. LPA and S#1 toured the back side of the facility and noted that the trash bins were not closed. LPA and S#1 observed flies and insects within the facility. LPA and S#1 additionally noted pigeons and pigeon cages within the facility. The following deficiency is being cited in accordance with California Code of Regulations, Title 22, Division 6 Chapter 8 Article 05. Physical Environments and Accommodations 87303 (a-e) Maintenance and Operation and Title 22, Division 6 Chapter 8 Article 05. Physical Environments and Accommodations 87303(f) (1-2) Maintenance and Operation on the LIC 809D. Exit interview was conducted with facility representative and appeal rights as well as report was provided.the state’s words, verbatim · CDSS document, Dec 14, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(f)(1-2) · Plan of correction due date: Jan 14, 2024

87303(f)(1-2) Maintenance and Operation (f)Solid waste shall be stored and disposed of as follows: (1)Solid waste shall be stored, located and disposed of ...transmission of a communicable disease or of odors, create a nuisance, provide a breeding place or food source for insects or rodents. (2)Syringes and.. with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. Based on observation, and interview, the licensee did not comply with the section cited above in, screens in despair, accessibility, and drywall, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: Licensee will fix windows, screens in despair, accessibility, and drywall of the facility by POC due date. Licensee will email proof of correction to David.espana@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a-e) · Plan of correction due date: Jan 14, 2024

87303 (a-e) Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision... the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition…(c) All window screens shall be clean and maintained in good repair. (d)There shall be...the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. (e)Water supplies and.... maintained as follows: (1)All community care facilities where water for human consumption is from a private… Based on observation, and interview, the licensee did not comply with the section cited above in, flammable grasses, no access door to side of facility, pigeons and pigeon cages, and flies and insects, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 14, 2023

Plan of correction: Licensee will address flammable grasses, no access door to side of facility, pigeons and pigeon cages, and flies and insects at the facility by POC due date. Licensee will email proof of correction to David.espana@dss.ca.gov.

Allegation investigated: Staff do not administer residents' medications as prescribed. Staff are not assisting residents with bathing needs. Staff left residents in soiled clothing. Staff are not assisting residents with transfers. Staff not allowing residents to leave the facility.

This is an amendment of the investigation report delivered on 12/13/2023, the purpose of this amendment is to provide additional information and it does not change the investigation findings. On 12/13/2023 at 08:57 am Licensing Program Analyst (LPA) David España conducted an initiated a 10-day complaint investigation visit for the allegation listed above. Upon arriving at the facility, LPA met with S#1 and S#2 (interviewed by via telephone) who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections. The investigation consisted of the following: On 12/13/2023 LPA España confirmed there are Thirty-Six (36) total residents in care as of 12/13/2023. LPA confirmed there are Ten (10) total staff employed as of 12/13/2023. LPA confirmed there is only One (1) resident in care who receives oxygen as of 12/13/2023. LPA confirmed there are Six (6) total staff working at the time of visit 12/13/2023. LPA confirmed there are Twenty-Two (22) total residents in care with dementia at the time of visit 12/13/2023. Continued on LIC-9099C Unsubstantiated LPA confirmed there are Twelve (12) total residents in care with wheelchairs at the time of visit 12/13/2023. LPA confirmed there are Seventeen (17) total residents in care with diapers at the time of visit 12/13/2023. LPA interviewed Six (6) out of Six (6) staff members at the time of visit 12/13/2023. LPA reviewed records of Six (6) out of Thirty-Six (36) total residents in care. LPA interviewed One (1) out of One (1) witness. The LPA also reviewed the following documents provided by Muriel Cabacugan Assistant Administrator (S1): Staff roster, Client roster, Residence and Care Agreement, Needs and Services Plan, Hospice information and Physician Report for Residents, time sheets, MARs log, Shower log, and Death Report etc. Regarding the allegation: Staff do not administer residents' medications as prescribed. LPA interviewed Six (6) of out of Thirty-Six (36) residents in care who stated they take medications in the morning, noon, and at bedtime. LPA interviewed Six (6) of out of Thirty-Six (36) residents in care who stated they receive medications from the MedTech. Review of Six (6) of out of Thirty-Six (36) residents in care medication documents indicate that from October through December 2023, resident were prescribed to take medications in the morning, noon, and bedtime. LPA interviewed Six (6) out of Six (6) staff members who disagree with the allegation “Staff do not administer residents' medications as prescribed.” LPA obtained a copy of Six (6) of out of Thirty-Six (36) residents in care for CCL records. Furthermore, LPA obtained a copy of the Six (6) of out of Thirty-Six (36) residents in care medication log sheet for October, November, December 2023 which indicates that the residents have been taking there medication as prescribed. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met; therefore, the above-mentioned allegation is found to be UNSUBSTANTIATED. Regarding the allegation: Staff are not assisting residents with bathing needs. During an interview with the Six (6) out of Six (6) staff members, stated that every day, there are Five (5) staff members, including S#1 total of Six staff members, tending to the needs of the residents, and on the weekends, there are Six (6) staff. In addition, S1-S6 stated that the hygiene needs of the residents are being met by the facility, which follows a weekly bathing schedule and as needed. LPA confirmed with Six (6) out of Six (6) staff members there is a weekly bathing schedule.During an interview with Six (6) out of Six (6) staff members they stated that the facility is meeting the hygiene needs of the residents, and they bath them every day and as needed in case of incontinence problems. During interviews with Six (6) of out of Thirty-six (36) residents in care stated that the facility meets their hygiene needs and takes showers or baths daily or when needed. Continued on LIC-9099C During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met; therefore, the above-mentioned allegation is found to be UNSUBSTANTIATED. Regarding the allegation: Staff left residents in soiled clothing. It is alleged that facility staff left resident in soiled clothing for an extended period of time. It was reported that residents in care are left in soiled clothing. Based on LPA’s interview, S#1 revealed that all residents are checked daily and their bed, Six (6) out of Six (6) staff members stated that residents are changed daily, their clothes and diaper are well as needed based on daily checks. Six (6) out of Six (6) staff members when they observe urine on resident clothes or beddings, they (staff) change them and give them showers. Interviews with Six (6) of out of Thirty-Seventh (37) residents revealed no resident are left in soiled clothing for an extended period of time. LPA conducted a record review which confirmed Residence and Care Agreement, Needs and Services Plan, Hospice information and Physician Report for Residents, time sheets, MARs log, Shower log on file. At 02:15 pm LPA observed records of Resident #1-#6 (R1-6). Based on interviews with R3, R2, R1 and R6 and Administrator it was verified that R1-6 do receive showers and are checked daily by staff members. Based interviews with S1-S6 LPA verified that S3 has been providing care to residents in care and manages caregivers’ daily supervision. Regarding the allegation: Staff are not assisting residents with transfers. The complainant claims staff do not assist with transfer of residents. LPA interviewed Six (6) of out of Thirty-Six (36) residents about care for diaper changes, bathing, or transfer to a wheelchair and with overall care process with the resident’s needs. According to the complainant, residents in care are not provided with daily living (ADLs)/transfers. LPA interviewed Five (5) of out of Thirty-Six (36) residents who disagreed with the allegation, and the Department conducted a telephone interview S#2. Six (6) out of Six (6) staff members stated the facility provides adequate care and supervision. Six (6) out of Six (6) staff members do not feel any of the residents rights have been violated while in care.Interviews with Six (6) out of Six (6) staff members primary caregivers and med-tech for residents in care, and six (6) of out of Thirty-Six (36) residents verified that resident are provided help in rooms if needed. On 12/13/2023 between 4 pm – 4:20 pm, the Department interviewed private caregiver representatives for residents in person. One (1) out of One (1) witness (W1) reported the facility is very much involved in the care and supervision of residents. W1 stated they were new to the facility, two months or so, and W1 was proactive in notifying the responsible parties about their resident in care at the facility. W1 stated their resident in care did not need support with transfers of any kind. Continued on LIC-9099C During this investigation, LPA did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has noy been met; therefore, the above-mentioned allegation. Regarding the allegation: Staff not allowing residents to leave the facility. During this investigation, LPA interviewed Six (6) of out of Thirty-Six (36) residents and interviewed Six (6) out of Six (6) staff members and One (1) out of One (1) witness (W1) and found there is no evidence to support the allegation mentioned above. An interview with Six (6) of out of Thirty-Six (36) residents stated they can leave the facility independently. Six (6) of out of Thirty-Six (36) residents reported that the facility's house rules require for residents must sign in and out at the front desk. Six (6) of out of Thirty-Six (36) residents claimed they follow the rules and do not ignore the signs and the register book when they leave the premises. Six (6) of out of Thirty-Six (36) residents stated they are aware of the house rules and must notify the office staff when they do not return to the facility on the same day. Interviews with Six (6) out of Six (6) staff members all reported that resident are aware of the facility's house rules and that is recommended that if a resident is not returning the same day, the resident must call and notify the office staff. Six (6) out of Six (6) staff members claimed it is preferred that residents do not leave the facility after 10 pm as the facility conducts daily rounds to verify for resident headcounts. Six (6) out of Six (6) staff members stated it is standard to report a missing person after 48 hours according to local law enforcement. Six (6) out of Six (6) staff members stated they, the facility would submit an incident report to Community Care Licensing to notify any residents or public guardian by telephone of any incident. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. No deficiencies were cited, an exit interview was conducted, and a copy of this report was provided to Muriel Cabacugan Asst Administrator.the state’s words, verbatim · CDSS document, Dec 13, 2023 · control 11-AS-20231205153025

Type of visit: Required - 1 Year

On 11/04/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with care staff Hazel Luguevarra. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to serve (44) non-ambulatory elderly residents of which (4) may be bedridden ages 60 and above. The facility is approved for (15) hospice residents. Currently, the facility has (5) hospice residents. Rooms #1, #3, #4, and #5 are cleared for bedridden residents. The facility is a two-story structure located in a residential neighborhood. It consists of the following: (22) resident bedrooms. Each room has a bathroom in the room, an activity room, dining room, a kitchen, storage closets, an administrative office, and an open patio area. LPA toured the physical plant. There were no bodies of water on the premises. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #1, #2, #7 #10, #17, and #19. Bathrooms were operational. A comfortable temperature was maintained in the facility at 72 - 74 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguishers were fully charged, and smoke detectors and carbon monoxide were operable in each resident's room. The facility has a certificate of liability insurance effective 08/26/23 - 08/26/24. The facility is current on annual license fees. (Evaluation Report continues LIC 809-C) The facility maintains for each resident Centrally Stored Medication Destruction Record and PRN Log. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA conducted an audit of resident #1-#6 (R1-R6) service files, and staff #1-#6 (S1-S6) personnel files were in maintained in place. LPA conducted (2) residents and (2) staff interviews. DEFICIENCIES: During resident file review between 11:30 AM - 12:15 PM, resident #4 is identified as bedridden in room #7 is in a room not cleared for bedridden. - Type A (Civil Penalty) Hot water temperature for rooms #1 & #2 ranged at 161.2-165.9 at 12:34 PM. - Type A Furnishing of bed mattress, wheelchair, and other furniture obstructing passage way adjacent to room #10 at 12:45 PM. - Type A Bathroom baseboards were rusted and filled with mold in room #19 at 12:47 PM. - Type B Open powder bleach found under bathroom sink in room #7 accessible to residents in care at 12:53 PM. Type A Facility has not conducted a quarterly fire drill consistently. Last drill was performed June 2023. - Type B According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D). An exit interview conducted with Hazel Luguevarra, and a copy of the report and appeal rights provided. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *the state’s words, verbatim · CDSS document, Nov 4, 2023