Bonhomie III - Lena Drive

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required Annual visit and met with caregiver Maria Lorena Hernando. During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and observed there to be locked drawers for cleaning supplies and sharp objects. LPA oberved there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the first aid kit and found it to be complete. LPA toured 4 out of 4 resident bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPA tested the smoke detectors in the hallways and resident bedrooms and found them to function properly when tested. LPA tested the carbon monoxide detector and it functioned properly when tested. LPA toured three out of three resident bathrooms and observed each bathroom to have working lights, available soap, and hand drying machines. LPA measured the water temperatures in the bathroom sinks and observed them to range from 107 F to 112 F. LPA toured the outside area and found the outdoor exit to be clear of obstructions. LPA reviewed five out of five resident records, including Centrally Stored Medication and Destruction Records, and found them to be complete. LPA reviewed five staff records and found them to be complete. The Emergency Disaster Drill Log indicates the last drill was conducted on 07/14/2026. See LIC809-C page for more information. Page 1 of 2. LPA Marrufo requests that the following facility records be updated and copies sent to the department by 08/19/2026: LIC500 Personnel Report LIC308 Designation of Administrative Responsibility LIC400 Affidavit Regarding Client/Cash Resources LIC610E Emergency Disaster Plan No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Caregiver Maria Lorena Hernando and a copy of this report was provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, Aug 12, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with staff Maria Lorena Hernando. The purpose of the visit was to follow up on a report that the facility had notified an unauthorized family member of the death of resident R1. During visit, LPA Marrufo interviewed staff S1. During interview, S1 stated to recall the day that R1 deceased, which was on 03/09/2026. S1 stated that when R1 deceased at the facility, either S1 or another staff notified R1's Family Member FM1 that R1 had deceased. S1 stated R1's hospice nurse also notified FM1 of R1's passing. S1 stated that prior to R1's passing, FM1 had instructed the facility not to notify any other member of R1's family of R1's passing. S1 stated that the day after R1 deceased, R1's other family member, FM2, arrived at the facility to visit R1. S1 stated that FM2 looked for R1 in his/her bedroom, but R1 was gone. S1 stated FM2 asked what had happened to R1 and S1 told FM2 to contact FM1 for information about R1. S1 stated FM2 became visibly angry, frustrated, and upset. S1 stated neither he/she nor any other staff told FM2 that R1 had deceased. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Maria Lorena Hernando and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 26, 2026

Allegation investigated: Staff did not keep resident’s personal information confidential.

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced initial complaint investigation visit and met with Gladys Smart, Administrator (ADM). During visit, LPA obtained copies of resident records, interviewed ADM and staff S1, and observed resident R1 and R1's bedroom. LPA also observed R2's bedroom. During visit, LPA Marrufo observed that resident R1's bedroom had a posting on a wall near R1's bed. The posting had the name of R1's hospice agency and the hospice agency's telephone number. LPA toured the facility and also observed R2's bedroom had a posting with R2's hospice name and telephone number posted near R2's bed. See LIC9099-C page for more information. Page 1 of 2. Substantiated R1's resident record contained an Advanced Health Care Directive identifying R1's family member, FM1, as R1's medical Power of Attorney (POA). During visit, S1 stated that R1's family member, FM2, had visited R1. S1 stated FM2 wanted to have R1 taken to the hospital, but S1 stated to have told FM2 that R1 is on hospice and only the hospice agency can decide to take R1 to the hospital. S1 stated to have provided FM2 with the name of R1's hospice agency and the hospice agency's telephone number. S1 stated the name and phone number of R1's hospice agency were shown on the posting on the wall near R1's bed. S1 stated to have sent a text to FM1 on 02/01/2026 around 11:00 AM telling FM1 that S1 had given FM2 the name and telephone number of R1's hospice agency. Based on records review, interviews and observations, there is preponderance of evidence to prove the alleged violation did occur. Therefore, the allegation is substantiated. See LIC9099-D for a deficiency cited as per the California Code of Regulations, Title 22. This report was reviewed with Administrator Gladys Smart and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, Feb 11, 2026 · control 26-AS-20260203142643

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Feb 12, 2026

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, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met as evidenced by: Licensee did not ensure that residents R1 and R2's hospice agency information remained confidential, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 11, 2026

Plan of correction: Licensee agrees to submit a plan of correction to the department by 02/12/2026 stating how the licensee will ensure that all residents' records and personal information remain confidential, including removing personal information from view in residents' bedrooms and training staff on not giving away confidential information to unauthorized persons. Once training is complete, the licensee agrees to submit copies of training records, including names of staff trained, training dates, training topic(s), and names and qualifications of trainers to the department.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year Visit and met with Administrator Gladys Smart. During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA Marrufo reviewed the first aid kit and found it to be complete. LPA toured four out of four resident bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPA tested the smoke detectors in the hallways and each resident bedroom. All smoke detectors functioned properly when tested. LPA tested one out of one carbon monoxide detectors and it functioned properly when tested. LPA toured two out of two resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks measured at 117 F and 119 F. LPA toured the outside area. The outside area exit was clear of obstructions. LPA reviewed six out of six resident records, including Centrally Stored Medication and Destruction Records, and found them to be complete. LPA reviewed six staff records and found them to be complete. The Emergency Disaster Drill Log indicates the last drill was conducted on 06/03/2025. This report was reviewed with Administrator Gladys Smart and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 8, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Gladys Smart. LPA observed 5 residents and 2 staff in the facility.3 residents files and 3 staff files were reviewed. One staff was observed not associated with the facility. LPA toured the facility inside and out with ADM. License, ADM certificate, and personal rights posters were observed in the facility. Living room, kitchen, dinning room and three restrooms were inspected. The window glass of one of the restroom was observed broken. Grab bars and non skid mats were observed in the bathrooms. Two single resident bedrooms, two resident shared bedrooms, and laundry room were inspected. Two staff live-in rooms were observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet were observed locked. Cleaning product closet was observed unlocked. ADM add lock and locked the cleaning product closet before LPA finished the inspection. Room temperature was at 73 degree F, and hot water temperature was at 106 degree F in facility. The temperature of the freezer was at -10 degree F and the temperature of the refrigerator was at 40 degree F. First aid box, flash light, and night lights were observed in the facility. The last time the facility conducted the emergency drill is on 6/4/2024. Fire extinguisher was serviced on 06/18/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways. Deficiencies noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature.the state’s words, verbatim · CDSS document, Aug 23, 2024

Allegation investigated: Resident eloped from the facility. Facility did not have awake night staff for hospice residents. Facility dinner meals have been reduced in both quantity and quality. Residents are losing weight. Residents who requires feeding had to wait for attention due to only one staff assisting during meals. Facility staff left residents without supervision.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Administrator (ADM) Gladys Smart. On 03/13/2023, the Department received a complaint with the above allegations. On 03/14/2023, the Department conducted an initial investigation visit. LPAs requested the following documents: resident physician report, appraisal needs and service plan, incident reports, menu, schedule of staff and staff training documents. On 9/22/2023, the Department delivered the investigation findings for the allegations that staff neglected a resident who had difficulty swallowing who became unresponsive and subsequently died, and A resident did not have a doctor's order for a pureed diet. Continue on LIC9099-C. Page 1 of 4. Unsubstantiated Resident eloped from the facility: Facility staff left residents without supervision. On 06/14/2023, the Department interviewed 3 residents. 3 out of 3 residents stated there are no issues or concerns for the facility. On 01/19/2024, the Department interviewed 3 residents. 3 out of 3 residents stated the facility never left residents unattended, and the facility always has staff in the facility. The Department interviewed 2 staff (S2, S3). 2 out of 2 stated the facility always has staff in the facility, and never left residents unattended. S2 stated he/she never saw or heard any resident eloped from the facility. The Department interviewed Administrator (ADM). ADM denied there was any resident eloped from the facility. ADM stated the facility has staff 24 hours a day. ADM stated staff sometimes took residents to backyard for fresh air, but never left residents unattended. The Department did not received any incident report or cross report that the facility resident eloped from the facility. Based on the interviews, the facility never left residents unattended, and there was no resident eloped from the facility. Facility resident were never left without supervision. Facility did not have awake night staff for hospice residents: On 1/19/2024, the Department interviewed 3 residents. 1 out of 3 residents stated the facility has staff 24 hours a day. 1 out of 3 residents stated that the staff helped him/her to go to restroom at night. The Department interviewed ADM and 2 staff. 3 out of 3 staff confirmed the facility has an awake staff at night shift. Reviewing the facility staff schedule. the facility always has a staff on duty at night shift. Based on the interviews with residents and staff, and documents, the facility has an awake staff at night shift. Continue on LIC9099-C. Page 2 of 4. Facility dinner meals have been reduced in both quantity and quality: On 1/9/2024, the Department interviewed 3 residents. 3 out 3 residents stated the facility provides enough food for the meals, and they can request more if they want. 1 out of 3 residents stated if he/she does not like the food that the facility provides, he can request to change. The Department interviewed ADM and 2 staff (S2, S3). 3 out of 3 staff stated the facility provides plenty of food for the meals, and the residents can request second round of food if they want more. S2 stated the facility prepares the food based on the residents' preference, they cook the food which the residents like. ADM stated the home provides the residents with their plates. ADM stated the home provides vegetables, carbohydrates and protein with quality. ADM stated there are two staff during the meals time to help residents for meals. ADM provided the facility food menus. Based on the interviews with residents and staff, there is no evidence the facility dinner meals have been reduced in quantity and quality. Residents are losing weight: on 1/9/2024, the Department interviewed ADM and 2 staff . Both staff stated if any resident lost weight they will report to ADM, doctor and family. ADM stated he/she will report to doctor and family if resident lost weight. There are two staff during the meal time, and the staff will help to feed the residents. ADM stated he/she did not find resident lost weight significantly except resident R1. R1 was on hospice care and had swallowing difficulty problem. ADM stated according to the hospice doctor instruction, if R1 refuses to eat or coughing, then staff to stop feeding R1 because of safety issue. ADM stated the doctor was ware of R1 losing weight. ADM stated the facility staff followed the doctor's instruction to feed and take care of R1. ADM provided other residents weight records. ADM stated the doctor issued a doctor order to provide R1 pureed food because R1's losing weight and having difficult of swallowing. Based on interviews and records reviewed, there was no evidence to indicate that the facility had fault causing resident losing weight. Continue on LIC9099-C. Page 3 of 4. Residents who requires feeding had to wait for attention due to only one staff assisting during meals: On 1/9/2024, the Department interviewed ADM and 2 staff. 3 out of 3 staff stated there are always 2 staff during the meal time to help residents for meals, residents do not need wait for eating. Resident R4 stated residents do not need to wait, the staff help right away. Reviewing the facility staff schedule, there are always two staff during the breakfast, lunch and dinner time. Based on interviews and record reviewed, resident who needs feeding assistance does not need to wait for meals. Based on observations, documents review, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegation did or did not occur. No citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. A copy of this report was provided to ADM. Page 4.the state’s words, verbatim · CDSS document, Feb 20, 2024 · control 26-AS-20230313112753