Beverly Hills Senior Care

Type of visit: Case Management - Annual Continuation

License Program Analysts (LPA) Luis De Leon conducted an annual continuation required visit. LPA met with Administrator Dana Ordonez. The purpose of today’s visit was explained. The facility is licensed to serve 45 non-ambulatory residents for 60 years and over, six (6) of which may be bedridden, and hospice waiver approved for twenty (20) residents. The LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted as follows: On 7/21/2026, LPA conducted initial annual visit. During visit, the LPA inspected the physical plant, review staff and resident records, and observed the following: FACILITY PHYSICAL PLANT The facility is a two-story building located in a residential neighborhood.. The facility consists of basement area which contains the facility’s storage area, kitchen, and laundry room. The first floor contains a reception area, a dining room, a storage room for linens and towels, and resident bedrooms. The second floor contains an activity room, storage for linens and towels, and additional resident bedrooms. LPA toured nine (9) of the resident rooms and measured the hot water temperatures for all the rooms. Hot water temperature measured below the required 105–120-degree Fahrenheit range in all nine rooms. In addition, LPA observed mildew/mold in room 107, resident’s shower ceiling. Deficiencies are noted on licensing report LIC-809D. (Report continues on page LIC-809C...) REVIEW OF FILES Residents record review consisted of Admission Agreements, Identification and Emergency Info, Physicians Report, Consent Report, Needs and Service Plan, and Personal Rights. LPA records review revealed that R1 and R2 do not have a TB screening in file. A deficiency is noted in licensing report LIC-809D. Staff record review consisted of Personnel Report, Health Screening, Criminal Record Statements, Fingerprint Clearance, Training, First Aid and CPR. LPA reviewed facility’s liability insurance, infection control plan and emergency and disaster plan. Observations during facility tour: Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPA observed that there were clean linen, bath towels, and personal hygiene with reasonable closet space available for residents. Hallways were clean and free of obstructions. Exterior walkways were clear from any obstructions. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food. Dining room has sufficient seating area. Weekly food menu is posted at facility. Sharps are locked inside the basement kitchen room and inaccessible to residents. Also, disinfectants and cleaning supplies are locked and secured inaccessible to residents in the laundry room. Smoke detectors were observed in all bedrooms and carbon monoxide detectors were observed in hallways. Fire extinguishers were observed throughout building and were fully charged with last inspection on 03/31/2026. Last fire and disaster drill was conducted on 05/17/2026. Front and back yards are free of hazards. The facility provides a shaded seating area for residents to enjoy in the rear of the building. On today’s visit, LPA conducted staff and client interviews. In addition, LPA reviewed client medications. LPA reviewed four (4) resident medications and did not find any health and safety risks to residents in care. LPA conducted four (4) staff interviews and four (4) residents interview. There were no concerns reported by residents in care. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview was held and a copy of the report was provided to the administrator Dana Ordonez.the state’s words, verbatim · CDSS document, Jul 27, 2026

Type of visit: Required - 1 Year

License Program Analysts (LPA) Luis De Leon conducted an unannounced annual required visit. LPA met with Administrator Dana Ordonez. The purpose of today’s visit was explained. The facility is licensed to serve 45 non-ambulatory residents 60 years and over, six (6) of which may be bedridden, and hospice waiver approved for twenty (20) residents. The LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. The visit consisted as follows: FACILITY PHYSICAL PLANT The facility is a two-story building located in a residential neighborhood.. The facility consists of basement area which contains the facility’s storage area, kitchen, and laundry room. The first floor contains a reception area, a dining room, a storage room for linens and towels, and resident bedrooms. The second floor contains an activity room, storage for linens and towels, and additional resident bedrooms. LPA toured nine (9) of the resident rooms and measured the hot water temperatures for all the rooms. Hot water temperature measured below the required 105–120-degree Fahrenheit range in all nine rooms. In addition, LPA observed mildew/mold in room 107, resident’s shower ceiling. Deficiencies are noted on licensing report LIC-809D. (Report continues on page LIC-809C...) REVIEW OF FILES Residents record review consisted of Admission Agreements, Identification and Emergency Info, Physicians Report, Consent Report, Needs and Service Plan, and Personal Rights. LPA records review revealed that R2 does not have a TB screening in file. A deficiency is noted in licensing report LIC-809D. Staff record review consisted of Personnel Report, Health Screening, Criminal Record Statements, Fingerprint Clearance, Training, First Aid and CPR. LPA reviewed facility’s liability insurance, infection control plan and emergency and disaster plan. Observations during facility tour: Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPA observed that there were clean linen, bath towels, and personal hygiene with reasonable closet space available for residents. Hallways were clean and free of obstructions. Exterior walkways were clear from any obstructions. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food. Dining room has sufficient seating area. Weekly food menu is posted at facility. Sharps are locked inside the basement kitchen room and inaccessible to residents. Also, disinfectants and cleaning supplies are locked and secured inaccessible to residents in the laundry room. Smoke detectors were observed in all bedrooms and carbon monoxide detectors were observed in hallways. Fire extinguishers were observed throughout building and were fully charged with last inspection on 03/31/2026. Last fire and disaster drill was conducted on 05/17/2026. Front and back yards are free of hazards. The facility provides a shaded seating area for residents to enjoy in the rear of the building. Due to time constraints, the annual inspection will be continued later. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC-809D page. Exit interview was held and copies of reports LIC-809, LIC-809C, LIC 809D, and Appeal Rights were discussed and provided to Administrator Dana Ordonez.the state’s words, verbatim · CDSS document, Jul 21, 2026

Allegation investigated: Staff do not prevent residents from disturbing other residents in care. Staff opened resident mail.

Licensing Program Analyst (LPA) Christian Gutierrez conducted an initial complaint visit to investigate the above allegations. LPA met with Administrator Dana Ordonez and discussed the purpose of today's visit. During this visit, LPA Gutierrez obtained a copy of the staff and resident rosters. LPA also obtained R1 and R2’s face sheet, physician report LIC 602, and history and physical notes. LPA interviewed Administrator, staff #1-staff #4 (S1-S4), and residents# 1-residents #6 (R1-R6). LPA Gutierrez also delivered findings. Refer to LIC 9099C Unsubstantiated In regard to the allegation” Staff do not prevent residents from disturbing other residents in care.” it is alleged that R2 sings in the early morning hours and that R1 can’t sleep furthermore it has been brought up to staff and nothing is being done. During interview with Administrator and staff five (5) out of five (5) staff stated that R1 has not been observed singing but has been observed snoring. Administrator stated that they have already changed R1’s first roommate for another situation. Staff stated that they are always changing resident rooms to make sure they are compatible. According to documents obtained by LPA R1 has been experiencing altered mental status. During interview with residents five (5) out of the six (6) residents interviewed stated that they have never had any problems with other residents disturbing them. R2 stated that staff has woken him/her up not residents. R1 stated that R2 stares too much and staff stated they would try to switch rooms but R1 stated “That’s my room. I feel comfortable there. Why do I need to leave? They're the problem”. In regard to the allegation” Staff opened resident mail.” It is alleged that staff are opening R1’s mail which R1 does not approve of. During interview with Administrator and staff five (5) out of five (5) staff all stated they do not open mail without residents’ consent. Four (4) staff stated that Administrator is the only person allowed to handle mail and once received it is put in her office. Administrator stated that she does not open mail unless the resident is aware of it, she did state that some residents are conserved and that their responsible parties are given mail or instructions on what to do with mail. During interview with residents five (5) out of the six (6) residents interviewed stated that they have never had any problems with mail at the facility. Three (3) residents did state that medical mail was opened with their permission. R1 stated that he/she has never addressed this issue with Administrator and that last week he/she did receive bank mail unopened but wants all mail to be given unopened. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to Dana Ordonez.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 28-AS-20260609101016

Allegation investigated: Staff are allowing selling of drugs in the facility. Staff are not providing adequate food service to residents in care.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegations. LPA met with Dana Ordonez, Administrator and explained the purpose of the visit. The investigation consisted of the following: LPA toured the dining areas (1st & 2nd floors) & facility kitchen (basement) including food supply and obtained copies of the staff & resident rosters, house rules, sample random resident's admission agreement, Personnel policies, Weekly menu, Visitor/Resident sign in and out sheets (Jan-Feb 2026), Dairy King Food invoices/receipts (Jan-Feb 2026). LPA interviewed Staff #1 (S1) - Staff #5 (S5) and Resident #1 (R1) - Resident #5 (R5). The investigation revealed the following: Regarding the allegation: "Staff are allowing selling of drugs in the facility." It is alleged that a staff member’s boyfriend comes into the facility and sell drugs to the residents and that a resident may have had a drug overdose about 2-3 months ago. *****CONTINUED ON LIC9099-C***** Unsubstantiated (5) of (5) staff interviewed denied that drugs are either bought or sold in the facility. Staff stated that drugs are not allowed in the facility. Staff stated that if residents buy drugs outside of facility, staff are unaware but indicated that staff are aware that drugs are not allowed in the facility and breaking this rule could result in eviction from facility. S1 stated that one of the residents experienced a seizure on 02/04/2026 as a result of their medical condition but not from a drug overdose. S1 also denied having a boyfriend who comes and works at the facility. Interviews with (5) residents revealed that they have not seen any resident use drugs. All residents interviewed stated that there is no drug use in the facility and are aware that drugs are not allowed in the facility. LPA toured the facility and did not observe any evidence of drug use, drug paraphernalia, or drug odors. Review of files revealed that the facility's house rules (#5) specifically prohibit illegal drugs and/or activities in the facility. Based on interviews conducted with staff, residents and LPA's observations, there was not enough supportive evidence to concur with the reported allegation. Regarding the allegation: "Staff are not providing adequate food service to residents in care."It is alleged that the residents are often not fed if the kitchen staff don’t show up, and the residents are not provided any other food options. (5) out of (5) staff interviewed denied the allegation. Staff stated that the facility offers three (3) meals plus snacks daily and food are always available for the residents. S1 stated that they follow a weekly menu and there is a back-up cook who is available to prepare meals for the residents. One staff indicated that if a resident goes out to eat, they would even leave them a plate of food in their room. All (5) residents interviewed denied the allegation and stated that they were never deprived of their meals and facility provided alternative food options in case they did not like what was being served on a given day. LPA observed the weekly menu was posted in the kitchen as well as on the dining room doors. LPA also observed that the facility had an adequate amount of perishable and non-perishable food during today's visit. Therefore, there is not enough supportive evidence to concur with the reported allegation. Based on LPA's observations, documentation reviewed and interviews conducted with staff and residents, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Dana Ordonez, Administrator.the state’s words, verbatim · CDSS document, Feb 24, 2026 · control 28-AS-20260220145242

Allegation investigated: Facility staff are not providing agreed upon items per the admission agreement. Facility staff are not meeting residents’ nutritional needs Staff is not safeguarding residents’ personal belongings Staff are not ensuring the facility is free of pests Staff are harassing a resident in care Facility is not allowing resident payment options for monthly rent Facility is in disrepair

*** This report supersedes the LIC-9099 dated 7/18/2025 to clarify findings. The findings remain the same. *** Licensing Program Analyst (LPA) Luis De Leon conducted an unannounced subsequent complaint visit to re-deliver findings on the above allegations. LPA met with Administrator Dana Ordonez and explained the purpose of today's visit. During the initial visit on 6/13/25, LPA conducted a physical plant tour, obtained copies of the staff roster, client roster, Admission Agreements for residents R1-R4 including R1’s agency placement notes, Physicians Report for residents R1-R4, Resident Personal Property and Valuables, Facility weekly food menus, invoices of food orders, and pest control invoices. Report continues on page 9099C... Unsubstantiated *** This report supersedes the LIC-9099C dated 07/18/2025 to clarify findings. The findings remain the same. *** During subsequent visit on 7/17/2025, LPA conducted interviews and conducted physical plant tour of common areas. LPA conducted five (5) staff interviews, five (5) resident interviews, and an interview with R1's placement agency program associate. LPA obtained the following documents: R1’s monthly invoice, facility maintenance logs, pest control invoices, and R1’s admission agreement dated 04/05/2025. During today’s visit, LPA re-delivered licensing report and findings. Regarding allegation: Facility staff are not providing agreed upon items per the admission agreement. It is alleged that upon residents’ admission to the facility, an agreement was made between the resident, the facility administrator and the resident’s placement agency. The agreement was that resident’s placement agency would provide monies to Administrator in order for the resident to have a television and a refrigerator for R1 to store R1’s purchased food. The refrigerator was agreed upon in order for the facility to be able to meet the residents’ dietary needs. The investigation consisted of LPA’s interviews five (5) residents, five (5) staff, and one witness #1 (W1). LPA reviewed resident #1 (R1’s) admission agreement and pertinent documents in R1s file. Tour of the physical plant including R1s room which contained a television set and a mini refrigerator. The investigation revealed the following: The administrator denied agreeing to provide a television and/or a refrigerator. The Administrator stated that she did not make any offers to provide R1 with a television and/or a refrigerator as part of the admissions agreement upon R1s initial placement at the facility. The administrator stated that a mini refrigerator was provided in R1’s room; however, R1 was not satisfied with the size of the refrigerator. LPA reviewed R1’s admission agreement dated 04/05/2025 which did not indicate that a television and/or refrigerator along with monies for food or clothes would be provided to R1. Four (4) out of five (5) staff stated that they are not aware of an agreement and/or a conversation with prospective residents and had no knowledge of an agreement to provide a resident with a television and/or refrigerator. Interviews with R1 revealed that the facility had agreed to provide R1 with a Television and a refrigerator as part of the admission agreement. R1 stated that facility was not able to accommodate R1’s dietary needs and R1 needed a refrigerator to store R1's own purchased food to meet R1's dietary needs. Interviews with three (3) of five (5) residents revealed that items such as televisions and/or refrigerators are not provided by the facility. Residents stated that televisions and/or refrigerators in residents' rooms had been provided to residents by the previous facility owner, or items were already in residents room when residents moved into the facility, or the items were donated by residents’ family. (Report continues on page 9099C...) *** This report supersedes the LIC-9099C dated 07/18/2025 to clarify findings. The findings remain the same. *** LPA’s interview with witness #1 (W1) revealed that R1’s placement agency does not provide or offer items such as a television and/or refrigerator. W1 does not believe R1’s placement agency staff would make such an offer; otherwise, W1 would have heard about it. W1 stated that R1’s placement agency requests clothing from facilities, if facility has any available; otherwise, residents can buy clothing using their Personal and Incidental Allowance (P&I money). Based upon the investigation, residents, witness, and staff interviews, document review, and LPA observations, facility and/or placement agency did not make any offer during initial resident placement for items such as a television or a refrigerator. Regarding allegation: Facility staff are not meeting residents’ nutritional needs. It is alleged that the facility would not be able to meet R1’s dietary needs due to R1 restricted health condition and that the facility’s food alternatives were not going to meet R1's needs. Therefore, the Administrator, resident #1 (R1) and R1's placement agency, agreed to provide R1 with a refrigerator, so that R1 could be provided with meals delivered by meals on wheels and meal would be kept in R1’s room. The investigation consisted of LPA interviews with five (5) residents, five (5) staff, and one (1) witness (W1). LPA reviewed the R1’s facility file, including the admission agreement, physician’s report, the facility’s weekly food menu, and alternative food menu. LPA obtained a copy of the kitchen modified diet menu, which lists residents’ modified diets and observed R1 has a modified diet in place. Interviews with residents revealed that four (4) out of five (5) residents had no issues with food service at the facility. One (1) of five (5) residents interviewed reported that staff accommodate residents when requesting meal changes to manage the resident’s weight. LPA interviews with staff revealed that Administrator received a specific food request from R1 for R1’s food diet which included salmon, steak, chicken, tuna, turkey, lentils, vegetables, and fruits. Excluded food listed were pasta, pork, and bread. LPA reviewed R1’s physician report dated 02/11/2025 which did not indicate that R1 was on a modified diet. LPA interviewed five (5) staff, three (3) out of five (5) staff indicated that as part of facility protocol, staff reaches out to each resident two hours prior to each meal. The resident has the opportunity to request an alternative meal from the published food menu. The staff communicates residents’ choice for kitchen staff to prepare the residents’ meals. Interview with Staff #4 (S4) revealed that R1 requested S4 to not offer R1 breakfast, because R1 doesn’t eat breakfast. However, later on, S4 observed R1 requesting breakfast from another staff member. In addition, S4 has not received any requests from R1 regarding R1 choosing meals from the alternative food menu. (Report continues on page 9099C...) *** This report supersedes the LIC-9099C dated 07/18/2025 to clarify findings. The findings remain the same. *** LPA observed that in R1's room, the refrigerator contained R1's own meals that R1 prepares using the dining room’s microwave. LPA interviewed W1, which revealed that R1’s placement agency did not offer R1 with assistance in obtaining food for delivery from meals on wheels or from another food delivery service. Based upon the investigation, residents, witness, and staff interviews, document review, and LPA observations, facility is meeting residents’ dietary needs as documented on resident’s physicians’ orders and following food menu planning. Regarding allegation: Staff is not safeguarding residents’ personal belongings. It is alleged that the facility staff is not safeguarding residents #1 (R1) personal belongings, and as a result, R1 has had items damaged in R1’s room such as cigarettes burns on dining table and bed mattress. Investigation consisted of LPA interviews with five (5) residents and five (5) staff and reviewed documents, including R1’s Resident Personal Property and Valuables (LIC-621). LPA observed R1’s cell phone and phone charger. LPA observed clothing on hangers by R1’s room entrance door. LPA interviews with four (4) out of five (5) residents indicated that residents denied having any personal property lost or damaged at facility. One (1) of five (5) residents stated that when attending the day program, the residents left their room door open and none of the residents’ items were lost or damaged. One (1) out of five (5) staff mentioned that there have been some instances where resident’s laundry has been mixed up, but staff sorted out the laundry. Five (5) out of five (5) staff denied knowledge of hearing any residents complain about residents’ personal items lost or damaged. One (1) of Five (5) staff member stated that upon R1's admission to the facility, R1 requested staff to not enter R1s room and staff was informed of R1’s request. LPA gained access to R1’s room for R1 interview via back-room door leading to dining area and observed that R1 barricaded R1s room main door leading to hallway to prevents anyone from entering R1's room. LPA observed a chair and/or table blocking entrance to R1’s room from the hallway door thus preventing anyone from accessing R1’s room. LPA observed that during previous facility visits, R1 had prevented LPA and Administrator from entering R1 room when R1 was not at the facility. Based upon the investigation, residents, staff interviews, document review, and LPA observations, there is insufficient evidence to support the allegation that staff are not safeguarding residents’ personal belongings. (Report continues on page 9099C...) *** This report supersedes the LIC-9099C dated 07/18/2025 to clarify findings. The findings remain the same. *** Regarding allegation: Staff are not ensuring the facility is free of pests. It is alleged that the facility is infested with roaches and spiders in all common areas of the facility, including residents’ rooms and that the facility staff are failing to ensure that facility is free of pests. Investigation consisted of LPA interviews with five (5) residents, five (5) staff and reviewed documents. Administrator explained that the facility has a service agreement with a pest control company for monthly treatments. In addition, the administrator may call for pest control services on an as needed basis. Administrator stated that during the Pest Control company’s monthly visit, the administrator provides the pest control technician with the various rooms to be fumigated. The Pest Control service agreement includes services to control pests such as roaches, ants, and spiders. Interview with residents revealed that four (4) out of five (5) residents have observed roaches. Three (3) out of five (5) residents have observed roaches in their rooms and one (1) out of five (5) residents observed roaches coming out from the elevator shaft. However, three (3) residents stated that the facility staff took care of pests by fumigating the affected area. Residents have observed exterminators frequently spraying around facility rooms and common areas. Interviews with three (3) out of five (5) staff revealed that staff have seen roaches in the resident rooms or in the kitchen area. Staff stated that in all instances involving observed pest, a fumigation treatment was performed, and staff have not seen any pest or roaches since the treatment. During LPAs physical plant tour, LPA observed roaches only in R1's room and LPA did not observe any roaches or pest in any other part of the facility, including other resident’s room, the kitchen or common area of the facility. Administrator provided LPA with facility notes dated 04/23/28 and 05/28/25, which indicated that R1 denied access to the pest control exterminator to treat R1’s room for pests. Based upon the investigation, residents, staff interviews, document review, and LPA observations, the facility is making effort to maintain the facility free of pest and provided documentation of pest control monthly visits since 10/23/24. Regarding allegation: Staff are harassing a resident in care. It is alleged that the facility staff is damaging resident's table and mattress with cigarette burns, removing items from resident's room. It is alleged that the staff harassment is due to the residents age, the resident and other resident’s skin color, and resident's damaging facility property. Investigation consisted of LPA interviewed with five (5) residents, five (5) staff, and witness #1 (W1). Interview with residents revealed that four (4) out of five (5) residents denied being physically or verbally harassed by staff. (Report continues on page 9099C...) *** This report supersedes the LIC-9099C dated 07/18/2025 to clarify findings. The findings remain the same. *** Two (2) out of four (4) residents denied being harassed by staff because of their skin color and all stated that they were happy to be at the facility. LPA observed during R1's interview that R1 had behavioral issues. In addition, interviews with W1 described a similar experience when R1's placement agency staff attempted to meet with R1 to discuss R1’s services. As of 07/18/25, R1’s placement agency staff have not been able to speak with R1 due to R1’s refusal to speak with placement agency staff. Interviews with staff revealed that five (5) out of five (5) staff denied the allegation above. Staff reported that during staff meetings, staff were given reminders from administration to always be nice and respectful to facility residents. Three (3) out of five (5) staff denied harassing residents and stated that staff speak respectfully to residents. Based upon the investigation, interviews with staff and residents, witness interview, and LPA observations, the facility staff were not found to be harassing residents in care. Regarding allegation: Facility is not allowing resident payment options for monthly rent. It is alleged that the facility does not allow resident payment options for monthly rent. The administrator has refused to accept rent for the last two months and refuses payments in the form of a money order. It is also alleged that the administrator requests that residents’ payments are in cash. The investigation consisted of LPAs interviews with five (5) residents, five (5) staff, and document review. LPA review of R1's admission agreement revealed that agreement states that rent payment can be made in the form of checks and/or money orders under the section of “Payment Provisions.” Administrator stated that residents have payment options for monthly rent and even though the admission agreement does not state that cash is accepted, the cash option is also available for private-pay residents. Interviews with staff revealed that four (4) out of five (5) staff are not aware of how payments are made to the facility administration. Interview with four (4) out of five (5) residents revealed that none of the residents have had any issues with making the monthly rent payments. All four (4) residents stated that they are not aware of how payments are made since rent payments are directly made by the Social Security Administration (SSI) or other social services agencies. Based upon the investigation, residents and staff interviews, witness interviews, and document review, the facility does offer payment options in the form of personal check, money order and/or cash. (Report continues on page 9099C...) *** This report supersedes the LIC-9099C dated 07/18/2025 to clarify findings. The findings remain the same. *** Regarding allegation: Facility is in disrepair It is alleged that the facility and a resident’s room are in disrepair. Per the details of the allegation, the lock to resident’s room is broken, there are holes in the walls from nails in the resident’s room that are not patched, the resident’s mattress cover is torn and burned, and the floor molding is loose. The investigation consisted of LPA interviews with five (5) residents, five (5) staff, LPA tour of the physical plant, and document review. During the physical plant inspection conducted on 06/13/25, LPA toured residents’ rooms and common areas of the facility. LPA did not observe any health and safety concerns and/or risks to residents. LPA observed a water leak under the sink of a resident’s room that was reported to the administrator. Administrator sent repair requests to in-house maintenance staff to address water leak issue. LPA toured R1’s room and observed that R1’s room had various holes from nails on walls, unpainted wall patch, a mattress cover that was torn and had cigarette burns, and floor molding that was dirty. Interviews with four (4) of out five (5) residents revealed that none of the residents have observed any issues with their rooms or common areas of the facility. All residents stated that staff maintenance quickly responds when issues are reported for repairs to their rooms. A resident stated that administration and staff keep up the facility in good repair. Interviews with staff revealed that five (5) out of five (5) staff denied the allegation above. Five (5) out of five (5) staff stated that requests for repairs are reported to administration. Normally, repairs are completed within one day, unless an outside vendor is needed to repair an issue. Staff described that repairs are completed as soon as possible and staff stated that the administration responds quickly to residents’ requests for repairs. LPA reviewed maintenance logs for facility and observed repair request since November 2023. An interview with maintenance staff (S3) revealed that S3 is responsible for repairing minor jobs throughout the facility. However, if a job requires a professional service, administration places call for repair services. Administrator provided LPA with invoices for recent repairs made by commercial contractors. Administrator shared with LPA facility notes dated 04/23/2025, the notes indicate that R1 refused to allow an electrician into R1’s room to inspect R1's bathroom socket, due to an adjacent dining room socket not having power. On 04/07/25, R1 indicated verbally to staff that no one, including staff, are allowed in R1's room and R1 would do R1's own cleaning and changing of the bed linen and sheets. Interview with one of five staff revealed that since R1's first day of admission, R1 requested that staff #2 (S2) not enter R1’s room. (Report continues on page 9099C...) *** This report supersedes the LIC-9099C dated 07/18/2025 to clarify findings. The findings remain the same. *** During the 07/18/2025 visit, R1 allowed maintenance staff (S3) to come to R1’s room with LPA to take note of repairs needed to be done in R1’s room. R1 accused S3 of harassing R1; however, LPA did not observe staff harassing R1. S3 took steps back against wall, face down, and S3 took notes of repairs to be done in R1's room. Administrator stated that R1 has not allowed staff entry into R1's room to inspect the room for repairs and staff have made prior attempts to perform repairs to R1's room. Based upon investigation, residents and staff interviews, document review and LPAs observations, the facility is not in disrepair, with the exception of R1’s room due to R1 denying staff entry to R1's room. Staff continue to work with R1 to make any necessary repairs to R1's room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held with Administrator Dana Ordonez. A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 28-AS-20250611135715

Allegation investigated: Staff did not ensure that facility was kept free of cockroaches

Licensing Program Analyst (LPA) Vaid conducted initial 10-day complaint investigation visit and met with Administrator Dana Ordonez and explained the reason of the visit. LPA Vaid and Administrator Ordonez toured the physical plant and did not observe any health and safety issues. LPA Vaid requested, obtained and reviewed the following documents: Staff roster LIC 500, resident roster, monthly pest control invoices from June 2025-January 2026. Interviewed staff and residents. Requested and obtained five residents face sheets and physicians report. Regarding the allegation: Staff did not ensure that facility was kept free of cockroaches. It is alleged that the staff is not ensuring the facility is free of cockroaches in R1’s room, bathroom, and around the water dispensers and microwaves in the dining area. Five of five staff interviewed deny the allegation. CONTINUED ON 9099C................ Unsubstantiated According to staff the pest control company performs monthly pest control service visits to prevent and keep the facility pest free. Staff are performing their housekeeping and janitorial duties daily to ensure the facility is kept clean and pest free. Staff stated housekeeping in all rooms is done daily. Records review observed pest control company services are performed monthly for pest control spraying and prevention. Pest control technician stated they have not observed cockroaches within the interior and exterior of the facility. Administrator Ordonez explained that the facility has a service agreement with a pest control company for monthly treatment. In addition, Administrator Ordonez may call pest control as per need basis. Administrator Ordonez stated that on each monthly visit, Administrator Ordonez provides various rooms to be fumigated. The service agreement includes service control for roaches. Six out of seven residents interviewed could not corroborate this allegation. Five of seven residents interviewed stated they have not observed cockroaches in the facility. Four of seven resident stated they have seen the pest control company performing pest control services on a monthly basis. Visual observations by LPA Vaid were made in seven residents’ rooms: around and under the beds and in the bathrooms-under the sink and shower areas, dining areas- water fountains and the microwave areas. LPA Vaid did not observe any cockroaches in the above-mentioned areas. Based on interviews, observations and records reviewed, 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 copy of this report was given to Administrator Dana Ordonez.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 28-AS-20260123154107

Allegation investigated: Staff not maintaining resident’s hygiene.

Licensing Program Analyst (LPA) Nune Margaryan conducted the initial visit to investigate the above allegation. LPA met with Cindy Morales. Administrator Ordonez Dana arrived shortly after. Purpose of todays visit was explained. During this visit, LPA obtained a copy of the Resident and Staff rosters, obtained relevant documentation, interviewed Resident #1 (R-1), Resident #9 (R-9), Facility Administrator, Staff #1 (S-1) and Staff #3 (S-3). LPA also conducted a facility tour. Continue 9099C Unsubstantiated Allegation: Staff not maintaining resident’s hygiene. It was alleged that residents are not being taken care of properly and has a bad smell coming from them. Staff interviews revealed staff meet resident’s hygiene needs. Interviewed Administrator and staff indicated that they assist residents with their activities of daily living, including bathing / showering. Interviewed Administrator stated that per the Facility Admission Agreement and house rules, it indicates that grooming and hygiene (ADL) must comply by the residents, however in some cases and situations, some residents were having difficulty in following house rules to their diagnosis, behavior practice of refusing. If there's an instance where residents refused to perform grooming, hygiene or shower, staff explained the risk and importance to them. Interviewed staff stated that they shower residents that require assistance per their schedule and/or if they had an accident, they would give residents an extra shower to make sure they are clean and there is no bad smell coming from them. They stated staff try their best to encourage residents to shower based on their shower schedule. Most residents are responsible when it comes to showers, but there is 1-2 residents who have trouble with showering. Interviewed S1 and S2 stated that they try up to 3 times once they refuse the third time, they cannot force them. Administrator and staff stated there is a residents daily shower log and residents laundry schedule (copies were provided to LPA). Staff regularly washed residents clothes, linens, bath towels etc. Also facility provide incontinent supplies such as diapers, briefs / pull ups, wipes. LPA conducted a facility tour and observed the residents to be clean (including their clothing) and did not observe residents to be malodorous. Resident interviews revealed that staff maintaining their hygiene needs. Interviewed residents indicated they do not have any concerns regarding this matter. Based on interviews conducted and observation there was not enough supportive evidence to concur with the reported allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Exit interview conducted with Administrator and the copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 28-AS-20250916124208

Allegation investigated: Facility staff are not providing agreed upon items per the admission agreement. Facility staff are not meeting residents’ nutritional needs Staff is not safeguarding residents’ personal belongings Staff are not ensuring the facility is free of pests Staff are harassing a resident in care Facility is not allowing resident payment options for monthly rent Facility is in disrepair

Licensing Program Analyst (LPA) Luis De Leon conducted an unannounced subsequent complaint visit to deliver findings on the above allegations. LPA met with Administrator Dana Ordonez and explained the purpose of today's visit. LPA delivered findings to Administrator Dana Ordonez. During the initial visit on 6/13/25, LPA obtained copies of the staff roster, client roster, Admission Agreements for residents R1-R4 including R1's placement agency notes, Physicians Report for residents R1-R4, Resident Personal Property and Valuables, Facility weekly food menus, invoices of food orders, and pest control invoices. Report continues on page 9099C... Unsubstantiated During subsequent visit on 7/17/2025, LPA conducted interviews and conducted physical plant tour of common areas. LPA conducted five (5) staff interviews, five (5) resident interviews, and an interview with placement agency program associate. LPA obtained the following documents: R1’s monthly invoice, facility maintenance logs, pest control invoices, and R1’s admission agreement dated 04/05/2025. During today’s visit, LPA obtained additional facility notes from Administrator which documents administration and staff interactions with R1. Regarding allegation: Facility staff are not providing agreed upon items per the admission agreement. It is alleged that it was agreed between Administrator, R1 and R1's placement agency that the placement agency would provide money to the facility to provide R1 with a television, and a refrigerator for R1's room for food as well as clothing and alleges the refrigerator was agreed upon because the facility would not meet R1's dietary needs. Investigation consisted of LPA interviewed five (5) residents, five (5) staff, one witness #1 (W1) and records review. The investigation revealed the following: The administrator denied making offers for a television and a refrigerator as part of the initial placement agreement for R1. LPA reviewed the admission agreement and there was no statement indicating a television or refrigerator was offered. Four (4) out of five (5) staff stated that they are not aware of initial administration conversations with prospective residents with offers of facility providing items such as television and/or refrigerator. Interviews with R2, R3, and R5 revealed that items such as television or refrigerator had been provided by previous facility owner, or items were already in the room when residents initially moved in, or was donated by resident’s family. LPA interview with witness #1 (W1) revealed that R1's placement agency does not provide or offer items such as television and/or refrigerator. W1 stated that W1 does not believe R1's placement agency staff would make such an offer; otherwise, W1 would have heard about it. W1 stated that placement agency requests clothing from facilities, if facility has any available; otherwise, residents can buy clothing using their Personal and Incidental Allowance (P&I money). Administrator stated that a mini-fridge was provided to R1's room; however, R1 was not satisfied with the refrigerator size. Based upon the investigation, residents, witness, and staff interviews, document review, and LPA observations, facility and/or R1's placement agency did not make any offer during initial resident placement for items such as television and/or refrigerator. Report continues on page 9099C... Regarding allegation: Facility staff are not meeting residents’ nutritional needs. It is alleged that the facility would not be able to meet R1’s dietary needs. It is alleged that the facility’s food alternatives were not going to meet R1 needs. It is alleged that the facility’s food alternatives were not going to meet R1 needs so they all agreed on a fridge so that meals on wheels could drop off R1’s food and be kept in R1’s room. Investigation consisted of LPA interviewed five (5) residents, five (5) staff, and one (1) witness (W1). LPA reviewed the admission agreement, physician’s report, facility’s weekly food menu, and alternative food menu. LPA obtained from the facility a kitchen menu where kitchen staff has resident’s modified food diet, where R1 is included. Interviews with residents revealed that four (4) out of five (5) residents had no issue with food served at the facility. R3 shared that staff is accommodating when requesting meal changes to manage R3’s weight. LPA interviews with staff revealed that Administrator received a specific food request from R1 for R1's diet which included Salmon, Steak, Chicken, Tuna, Turkey, Lentils, Vegetables, and fruits. Food to be excluded from his food diet: pasta, pork, and bread. LPA reviewed physician’s report for R1 and observed no reference to R1 having a modified diet. LPA interview with staff revealed that three (3) out of five (5) staff stated that, for each meal and two hours prior to serving meal, staff approaches residents to inquire if residents wish to make changes to the meal offered to residents. The staff communicates residents request for kitchen to prepare meals. Interview with S4 revealed that R1 requested from S4 not to offer breakfast because R1 doesn’t do breakfast. Later S4 observed R1 requesting breakfast from another staff. In addition, S4 stated that S4 has not received any request from R1 choosing meal from the alternative food menu. LPA observed R1 room refrigerator with own meals that R1 prepares own meal using the dining room’s microwave. LPA interview with W1 revealed that R1's placement agency did not offer to obtain assistance in obtaining food from meal on wheels and did not believe R1's placement agency staff would make that promise to residents; otherwise, W1 would have heard about request for meals on wheels from placement agency staff. Based upon the investigation, residents, witness, and staff interviews, document review, and LPA observations, facility is meeting residents’ dietary needs as documented on resident’s physicians’ orders and following food menu planning. Report continues with page 9099C... Regarding allegation: Staff is not safeguarding residents’ personal belongings. It is alleged that the facility staff is not safeguarding residents’ personal belongings and, as a result, R1 has had items missing or damaged in R1’s room. Investigation consisted of LPA interviewed five (5) residents and five (5) staff and reviewed documents. LPA interviews with four (4) out of five (5) residents denied having any property lost or damaged for all the time that residents have been residing at facility. One staff mentioned that there have been some instances where laundry has been mixed up, but it was sorted out. R4 stated that when attending the day program, R4 has left the room open and did not have any items lost or damaged. Five (5) out of five (5) staff denied hearing any resident’s complaint about items lost or damaged. One staff member stated that R1 requested from day one not to enter room and observed that R1 barricades door and prevents anyone from entering room. LPA experienced on previous visit that R1 prevented LPA and Administrator from going into room when R1 was not on premises. LPA observed objects on door preventing anyone from accessing the room. LPA obtained records indicating that R1 had previously prevented an electrician and the exterminator from entering the room. Based upon the investigation, residents, staff interviews, document review, and LPA observations, the facility is safeguarding residents’ personal belongings. Regarding allegation: Staff are not ensuring the facility is free of pests. It is alleged that the facility is infested with roaches and spiders in all common areas and residents’ rooms and that facility is failing in ensuring that facility is free of pests. Investigation consisted of LPA interviewed five (5) residents, five (5) staff and reviewed documents. Administrator explained that the facility has a service agreement with a pest control company for monthly treatment and the facility may call pest control as per need basis. Administrator stated that on each monthly visit, the facility provides various rooms to be fumigated. The service agreement includes service control for roaches, ants, and spiders. Interview with residents revealed that four (4) out of five (5) residents have observed roaches. Three residents observed roaches in their rooms and one resident observed roaches coming out from the elevator shaft. Report continues on page 9099C... Three (3) out of four (4) residents stated that the facility took care of incidents by fumigating the affected area. Residents have observed exterminators frequently spraying around facility rooms and common areas. Interviews with staff revealed that three (3) out of five (5) staff have seen roaches in the rooms or the kitchen area. Staff stated that in all instances fumigation was done and have not seen any roaches since then. During physical plant tour, LPA observed roaches on R1 room only and did not observe any roaches on any other resident’s room, kitchen or common facility area. Administrator provided contemporaneous notes for R1’s interaction and noted that on 4/23/28 and 5/28/25, R1 denied access to pest control exterminator to treat R1’s room. Based upon the investigation, residents, staff interviews, document review, and LPA observations, the facility is making effort to maintain the facility free of pest and provided documentation of pest control monthly visits since 10/23/24. Regarding allegation: Staff are harassing a resident in care. It is alleged that the facility staff is harassing R1 by taking away items from the room, cigarette burns on table and on the mattress. R1 alleges discrimination based on R1's age and color. R1 alleges that another African American resident in care was also harassed because of color and because resident broke toilet. Investigation consisted of LPA interviewed five (5) residents, five (5) staff, and witness #1 (W1). Interview with residents revealed that four (4) out of five (5) denied being physically or verbally harassed by staff. Two (2) out of four (4) residents denied being harassed by staff because of their race and all stated that they were happy to be at the facility. LPA observed during R1 interview that R1 becomes combative when discussing allegations. R1 accused LPA of harassing R1 as well. In addition, the interview with W1 described a similar experience when placement agency staff tried to meet with R1 to discuss services and, as 07/18/2025, placement agency staff has not been able to speak with R1. Interviews with staff revealed that five (5) out of five (5) staff denied the allegation above. Staff described administration reminders during staff meetings to be always nice and respectful to residents. Three (3) out of five (5) staff denied entering R1’s room or removing or damaging R1’s belongings. Based upon the investigation, residents, staff interviews, witness interview, and LPA observations, the facility staff was not found to be harassing residents in care. Report continues on page 9099C... Regarding allegation: Facility is not allowing resident payment options for monthly rent. It is alleged that the facility does not allow resident payment options for monthly rent and that facility refuses payment in the form of money orders. It is also alleged that the Administrator requests payment in cash. Investigation consisted of LPA interviewed five (5) residents, five (5) staff, and document review. LPA review of admission agreement revealed that agreement states that rent payment can be made in the form of checks and/or money orders under the section of “Payment Provisions.” Administrator stated that even though the admission agreement does not state that cash is accepted, the cash option is also available for private pay residents. Administrator stated that residents have payment options for monthly rent. Interview with four (4) out of five (5) residents revealed that none have had any issues with making the monthly rent payments. All four stated that they are not aware of how payments are made since rent payments are directly made by SSI or other social service agencies. Interviews with staff revealed that four (4) out of five (5) staff are not aware of how payments are made to administration. Based upon the investigation, residents, staff interviews, witness interview, and document review, the facility does offer payment options in the form of check, money order and cash. Regarding allegation: Facility is in disrepair It is alleged that the facility and a resident's room are in disrepair. Resident alleges that the lock to resident's room is broken, there are holes that are not patched on the wall, there are wall holes from nails that have not been patched, pest dropping, mattress cover is torn and burned, and floor molding is loose. Investigation consisted of LPA interviews with five (5) residents, five (5) staff, physical plant tour, and document review. LPA observed during the physical plant tour that there were no health and safety risks in residents’ rooms and/or common areas. LPA observed a water leak under the sink of a resident’s room that was reported to the administrator. LPA observed that R1’s room had various nail holes on walls, unpainted wall patch, torn and cigarette burn mattress covers, and dirty floor molding. Report continues on page 9099C... Interviews with four (4) of out five (5) residents revealed that none have observed any issues with their rooms or common areas. All residents stated that staff maintenance quickly responds when issues are reported for repairs in their rooms. A resident stated that administration keeps up the facility. Interviews with staff revealed that five (5) out of five (5) staff denied the allegation above. Five (5) out of five (5) staff stated that repairs to R1’s room is not possible since R1 refuses to provide access to room. Administrator contemporaneous notes indicate that on 4/23/25, R1 refused to allow electrician to R1 room. On 4/7/25, R1 indicated that no one was allowed in the room and R1 would do own cleaning and changing of the bed linen and sheets. S2 stated that from day one, R1 requested that S2 not enter R1’s room. Staff described administration responding quickly to requests for repairs. Staff described an instance where a toilet tank broke inside a resident’s room, and it was repaired the same day. On another instance, windows screens fell off from the dining room but were immediately repaired. LPA reviewed maintenance logs for facility and observed repair request since November 2023. An interview with maintenance staff (S3) revealed that S3 is responsible for repairing minor jobs throughout the facility. However, if a job requires a professional service, administration places call for repair services. Administrator provided invoices for recent repairs made by commercial contractors. R1 allowed maintenance staff (S3) to come to R1’s room with LPA to take note of repairs needed to be done in R1’s room, R1 immediately started accusing S3 to be the problem and harassing R1. LPA explained that S3 needed to take notes for repairs and repairs would be scheduled. Based upon investigation, residents, staff interviews, document review and observations, the facility does not appear to be in disrepair and does not pose any health and safety risk. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held with Dana Ordonez. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 18, 2025 · control 28-AS-20250611135715

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Cindy Morales, Med Tech for the facility, and explained the purpose of the visit. Administrator Dana Ordonez arrived shortly thereafter. There are forty-four (44) residents residing within the facility. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a two story building located in a residential neighborhood. It is licensed for a capacity of forty-five (45) residents, six (6) of whom may be bedridden, all may be non-ambulatory, and a hospice waiver approved for twenty (20) residents. The facility consists of basement area which contains the facility’s storage area, kitchen, and laundry room. The first floor contains a reception area, a dining room, a storage room for linens and towels, and resident bedrooms. The second floor contains an activity room, a storage for linens and towels, and additional resident bedrooms. There twenty (24) resident bedrooms in total, LPA toured eight (8) of the rooms and measured the hot water temperatures for all the rooms, which all met the required 105 – 120 Degree Fahrenheit range. Carbon Monoxide detectors and signal systems in the resident rooms were operational. The facility was observed to be in good repair. ·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has multiple fully charged fire extinguishers kept throughout the facility. Operational Requirements: · Care and supervision to meet the clients’ needs was observed. Staffing: · Twenty-four (24) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Six (6) staff files were reviewed for criminal background clearance and training. · All six (6) staff records reviewed have a health screening with a Tuberculosis clearance, and five (5) staff have First Aid/CPR trainings that are active. · Staff did not have the required twenty (20) hours of required annual retraining on the topics of dementia care, hospice care, postural supports, and restricted health conditions. · The administrator’s certificate expires on 5/19/2026. Resident Rights/Information: · Physician orders were reviewed for six (6) resident files. · Medications were also reviewed for six (6) residents. · Review of the Medication Administration Records (MARs) revealed that 2 residents either had missing initials on their log or were being logged for taking medication when they had not been taking the medication. Resident Records/Incident Reports: · Six (6) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. ·One (1) resident does not have their physician’s report on file. · Two (2) residents did not have the pre-admission appraisal documented in their file. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. Disaster Preparedness: · Emergency and Disaster Plan (LIC610E) was posted in the facility. · The last emergency and disaster drill was conducted on 4/21/2025. Planned Activities: · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs · There is one (1) resident that currently has bed rails that extend the length of their bed, however they are not on hospice. · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit is documented on the LIC809D pages. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 10, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Alma Gonzalez conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. LPA met with Administrator Dana Ordonez. An application was submitted to CCLD for a Change of Ownership of a Residential Care Facility for the Elderly, ages 60 years and older. The fire clearance has been approved for a capacity of 45 residents, 39 ambulatory and 6 bedridden. Bedrooms #101-103 and #105 are approved for bedridden. The hospice waiver is approved for 20 residents. Infection Control: The licensee has developed an Infection Control Plan and designated a lead staff to conduct training. Facility has sufficient PPE supplies and will provide on-going training to staff on infection control. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 3 residents residing at the facility. Structure/Physical Plant: The facility is a three-level facility which includes: Street level: Kitchen, food storage area, laundry room and parking area. First level: Lobby, dining room, 2 storage rooms, community restroom, office, 9 resident bedrooms (each with a bathroom or a shared bathroom), and a medication room. Second level: Dining room, 15 resident bedrooms (each with a bathroom or a shared bathroom). Outdoor facility was observed in good repair. No large bodies of water were observed. Water temperature was measure in each resident's bathroom and tested between 106 - 120 degrees F., which is within Title 22 regulations. Facility ha a sprinkle fire system and carbon monoxide detectors were observed in each room. Skid strips/mats and grab bars were observed in resident bathrooms. Cleaning supplies and other cleaning agents/ toxins were locked and inaccessible to residents. All common areas were observed in good repair, with sufficient furniture. Facility is following infection control protocols throughout the facility. (CONTINUED ON LIC 809C) Food Service: There is a sufficient food supply of 2 day perishable and at least a week of non-perishable food maintained at the facility. Commercial kitchen is kept clean and sanitary. All the appliances were in working order. Sufficient amount of tableware, dishes, and utensils are observed. The knives and sharps are stored and locked in a cabinet. Refrigerator(s) temperature was observed under 40 degrees F., and freezer(s) temperature was observed under 0 (zero) degrees F. All rooms have sufficient lighting, furniture, and bedding. Staff and Residents files: Staff and Residents files are stored and maintained in the facility office. Resident Rights/Information: Resident rights, Resident councils, and complaint posters are posted in a prominent area. Planned Activities: The facility has sufficient space to accommodate indoor and outdoor activities. Incidental Medical and Dental: Medications are centrally stored and locked inside medication room. The first aid kit contains all the required supplies along with the current first aid manual. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. Physical plant was cleared. Facility met the physical plant requirements as required per California Code of Regulations Title 22 Division 6. Component III was also completed at the time of the visit and all required documents for Licensing were discussed. A copy of this report will be shared with Central Applications Bureau (CAB).If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application. Exit interview conducted and a copy of this report was provided to Administrator Dana Ordonez.the state’s words, verbatim · CDSS document, Jun 18, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Change of Ownership Capacity: 45 Census (if any clients in care): 45 COMP II Participants: Dana Ordonez, Leah Dalope Interview Method: Telephone interview On March 13, 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 the understanding of the California Code Title 22 Regulations. 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. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Mar 13, 2024