Bonita Villa Senior Living

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

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA Serrano was greeted by and discussed the purpose of the visit with Executive Director Amber Rodgers. Today's case management visit is regarding the facilities NCC plan. During today's visit LPA reviewed staff coverage for the "AM" shift, conducted health and safety checks and interacted with staff. One deficiency was cited during today's visit regarding a staff member who did not have a criminal record clearance transfer and was not associated to the facility. An exit interview was conducted with Amber Rodgers whom a copy of this report, LIC809D page, LIC 421BG page, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 11, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Sep 11, 2026

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:(3) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement was not met as evidenced by: Based on LPA observation, file review, and interview, the licensee did not ensure that all staff, prior to employment, transfer their criminal record clearance to the facility, which poses an immediate health, safety, and personal rights risk to 82 out of 82 persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: LIcensee stated that they will transfer S1's criminal record clearance and associate S1 to the facility by POC due date 9/12/26 and will send LPA verification.

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

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA Serrano was greeted by and discussed the purpose of the visit with Executive Director Amber Rodgers. Today's case management visit is regarding the facilities NCC plan. During today's visit LPA reviewed staff coverage for the "AM" shift, conducted health and safety checks and interacted with staff. No deficiencies were cited or observed on this date. An exit interview was conducted with Ambers Rodgers who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Sep 1, 2026

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

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA Serrano was greeted by MedTech Marines Gomez. Med-Tech Beth Sobreo arrived shortly after and LPA discussed the purpose of the visit. Today's case management visit is regarding the facilities NCC plan. During today's visit LPA reviewed staff coverage for the "PM" shift and NOC shift, conducted a health and safety check and interacted with staff. No deficiencies were cited or observed on this date. An exit interview was conducted with Beth Sobreo who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 27, 2026

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

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA Serrano was greeted by Med-Tech Beth Sobreo. Executive Director Amber Rodgers arrived some time after and LPA discussed the purpose of the visit. Today's case management visit is regarding the facilities NCC plan. During today's visit LPA reviewed staff coverage for the overnight and morning hours, conducted health and safety checks on multiple residents and interacted with staff. One deficiency is being cited during today's visit in accordance with California Code of Regulations, Title 22, Division 6 (refer to LIC 809-D). Due to this being a repeat violation a civil penalty was assessed in the amount of $250.00. A plan of correction was jointly developed with the Executive Director. An exit interview was conducted with Executive Director Amber Rodgers who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 21, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87413(a)(1) · Plan of correction due date: Aug 22, 2026

(a) In each facility:(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement was not met as evidenced by; Per LPA observation the facility had 4 staff during NOC shift. The medtech on duty failed to request or advise managment of the need for additional staff. This posed an immediate health and safety risk to 81 of 81 residents in care.the state’s words, verbatim · CDSS document, Aug 21, 2026

Plan of correction: The licensee stated they will conduct a staff inservice by 8/22/26 and will send the itinerary and sign in log to LPA. Will rearrange schedule so that a manager is on site for every shift change.

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

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA Serrano was greeted by Laundry Aide Guadalupe Retes, Med-Tech Beth Sobreo arrived shortly after and LPA discussed the purpose of the visit. Today's case management visit is regarding the facilities NCC plan. During today's visit LPA reviewed staff coverage for the overnight and morning hours, conducted health and safety checks on multiple residents and interacted with staff. No deficiencies were cited or observed on this date. An exit interview was conducted with Beth Sobreo who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 14, 2026

Type of visit: POC

Licensing Program Analysts (LPAs) Arian Golbakhsh and Ramon Serrano conducted an unannounced Plan of Correction (POC) visit regarding two (2) deficiencies that were cited on 8/7/26. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) Amber Rodgers. LPA Jose De La Cruz arrived later during the visit. On 8/7/26 the facility was issued two (2) deficiencies for violations of regulations 87355 and 87468.2. Plans Of Correction (POC) were developed for both deficiencies on 8/7/26 between Community Care Licensing (CCL) and the facility, with a due date of 8/8/26. The Licensee submitted POC items on 8/8/26 for both deficiencies via email. One POC (for cited regulation 87468.2) was determined to be incomplete and as a result, LPA conducted a POC visit to verify correction and to assess a Civil Penalty Violation for Failure to Correct. Per interview with ED, some of the POC items were not submitted with the original email and ED provided them to LPA during the visit. However, POC remained incomplete. A Civil Penalty of $100.00 a day has been assessed from 8/9/26 to 8/10/26 for a total of $200.00 and will continue to accrue at the aforementioned daily rate until the deficiency is cleared. An exit interview was conducted with Executive Director Rodgers to whom a copy of this report, the LIC 421FC, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 10, 2026

Type of visit: POC

Licensing Program Analysts (LPAs) Arian Golbakhsh and Ramon Serrano conducted an unannounced Plan of Correction (POC) visit regarding four (4) deficiencies was cited on 8/6/26. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Amber Rodgers. On 8/6/26 the facility was issued four (4) deficiencies. Plans Of Correction (POC) were developed for all four (4) deficiencies on 8/6/26 between Community Care Licensing (CCL) and the facility, with a due date of 8/7/26. The Licensee was able to submit POC items on 8/7/26 for three (3) of the four (4) deficiencies cited and LPA provided copies of the POC Clearance letters during the visit. The remaining deficiency LPA had not received POC items for was regarding the facility having been unable to furnish staff records for LPA review during regular business hours. As the Licensee failed to submit verifiable POC items by the due date, LPA conducted a POC visit to verify correction and to assess a Civil Penalty Violation for Failure to Correct. Per interview with Executive Director Rodgers, they remain unable to access and provide the requested records for LPA. A Civil Penalty of $100.00 a day has been assessed from 8/7/26 to 8/10/26 for a total of $400.00 and will continue to accrue at the aforementioned daily rate until the deficiency is cleared. An exit interview was conducted with Executive Director Rodgers to whom a copy of this report, the three (3) POC clearance letters, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 10, 2026

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

Licensing Program Analysts (LPA) Ramon Serrano, Arian Golbakhsh, Jose De La Cruz conducted an unannounced Case Management Visit. LPA Serrano was greeted by and met with Executive Director Amber Rodgers, to discuss the purpose of the visit. Today's case management visit is regarding the facilities NCC plan. During today's visit LPA's conducted health and safety checks on multiple residents, interacted with staff and obtained facility records. No deficiencies were cited or observed on this date. An exit interview was conducted with Amber Rodgers who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 10, 2026

Type of visit: Case Management - Health Checks

Licensing Program Analysts (LPAs) Amy Rodgers and Amy Domingo conducted an unannounced Health and Safety Check visit regarding deficiencies that were cited on 8/8/26. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Rhonda James, Med Tech. Amber Rodgers, Executive Director, joined the visit during the tour. On 8/8/26, the facility was issued a deficiency for facility staff not having keys to open the occupied resident rooms. The Licensee corrected this deficiency by providing all shifts' keys to access any occupied resident rooms. The keys are labeled and located in the Med Tech office, and the staff was in-serviced by management on the importance of the keys and their location. A deficiency was cited due to staff being absent from their scheduled shift. The Licensee corrected the deficiency by ensuring that the required number of staff were immediately scheduled and present to provide adequate supervision and maintain the residents’ health and safety. A deficiency was given regarding coverage by a designated substitute. The Licensee corrected the deficiency by providing a list of designated staff responsible for managing the facility in their absence. The management in-serviced the staff on the use of the designated substitute list. A deficiency was given for staff not following the physician's medication order. The Licensee provided the staff a list of residents who have a physician's order to have a meal before medications. The Licensee in-serviced the staff on the importance of following the physician's orders. [Continued on LIC809C) [Continued from LIC809] For today's visit, the deficiencies issued on 8/8/26 per Title 22 Division 6 of the California Code of Regulations, were corrected. An exit interview was conducted with Amber Rodgers, Executive Director, to whom a copy of this report, the corrected POC, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 9, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst's (LPA's) Amy Rodgers and Amy Domingo conducted an unannounced Health and Safety Checks visit regarding a deficiency that was cited on 8/4/26. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit Xitlali Esquivel, Med Tech. The Executive Director, Amber Rodgers and RSD Eva Zuluaga also participated in the meeting. On 8/4/26 the facility was issued a deficiency for accepting and/or retaining bedridden residents without having a fire clearance that allows so. A Plan Of Correction (POC) was developed on 8/4/26 between Community Care Licensing (CCL) and the facility, with a due date of 8/5/26.During today's visit, LPA's conducted a health and safety check with bedridden residents, [See LIC 811 Confidential Name List for a description of select person identifiers used in this report], as identified during the visit conducted 8/4/26. While touring the facility Staff 1 (S1) stated that they do not have keys to open the resident rooms. A deficiency will be given for the facility not providing a safe environment for the residents. A deficiency will be given for staff absent from their scheduled shift. A deficiency will be given regarding coverage by a designated substitute. A deficiency will be given for staff not following physician's medication order. For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. See LIC809-D dated for 8/8/26. A plan of correction was jointly developed with the Executive Director. An exit interview was conducted with Amber Rodgers, Executive Director to whom a copy of this report, the LIC 811, the POC, the LIC 421FC, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.695(f)(2)(A) · Plan of correction due date: Aug 8, 2026

A facility maintains a set of keys for residence rooms, staff are not able to promptly access an occupied resident room.This requirement has not been met as evidenced by: Based on observation and interview, the only caregiver (S1) responsible for 86 residents, did not have key access to 1 of 86 resident rooms. It took approximently seven minutes to obtain the correct key. This poses an immediate health risk to 1 of 98 residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2026

Plan of correction: License agrees to provide direct care staff on all shifts key access to all occupied rooms by the end of the business day today.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87413(a)(1) · Plan of correction due date: Aug 9, 2026

In each facility: when scheduled regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement has not been met as evidence by: Based on observation and interview, On 8/8/26, two of five scheduled caregivers were absent from their scheduled shift and coverage by qualified personnel was not in place for 3. This poses an immediate health risk to 98 of 98 residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2026

Plan of correction: License agrees to provide adequate staffing on all shifts for residents in care by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Aug 9, 2026

87405 Administrator qualifications and duties (a) when the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in section... This requirement has not been met as evidenced by: Based on observation and interview, there was not coverage by a designated substitute for the administror who has the qualifications adequate to be responsible and accountable for nanagement of the facility. This poses an immediate health risk to 98 of 98 residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2026

Plan of correction: Management agrees to submit to the department list of designees responsible for managing the facility in their absence, clarifying who is responsible and when by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87611(e) · Plan of correction due date: Aug 9, 2026

General requirements for allowable..in addition to 87465(a) and 87464(d) the license shall ensure that the resident is cared for in accordance with physician's orders, and the resident's medical needs are met. This requirement has not been met as evidenced by: Based on observation and interview, Staff did not follow the physician's orders for resident's dia This poses an immediate health risk to 1 of 98 residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2026

Plan of correction: Management agrees to provide training for staff to recognize the resident's that need meals prior to medications by POC date.

Type of visit: POC

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit for a Plan of Correction (POC) regarding a deficiency that was cited on 8/4/26. LPA identified herself and was granted entry by receptionist Angel. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Executive Director Amber Rodgers. On 8/4/26 the facility was issued a deficiency for accepting and/or retaining bedridden residents without having a fire clearance that allows to do so. A Plan Of Correction (POC) was developed on 8/4/26 between Community Care Licensing (CCL) and the facility, with a due date of 8/5/26. On 08/06/2026, the Department issued a Civil Penalty Violation for Failure to Correct and submit a verifiable POC items by the due date. During today’s visit LPA Lopez spoke with Executive Director and requested and obtained relevant documents pertinent to this visit. LPA received the facility’s POC documents during the visit. A review of POC documents is warranted prior to the POC clearance. There is no Civil Penalties being assessed during today’s visit. It should be noted that LPA left the facility for approximately one hour. The report was discussed, and an exit interview was conducted with Executive Director Amber Rodgers to whom a copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to the ED at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Aug 7, 2026

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

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced case management visit for a fire clearance plan of correction, delivered investigative findings to complaint control # 08-AS-20260424113831, and, in conjunction, conducted this legal/non-compliance visit for updates. LPA identified herself and was granted entry by receptionist Angel. LPA stated the purpose of the visit and reviewed the basic elements of this visit with Executive Director Amber Rodgers. During today’s visit, LPA Lopez spoke with residents, staff, and outside sources, and requested and obtained relevant documents pertinent to this visit. On 8/7/2026, facility timecards were reviewed, which indicated that one staff member (S1), noted as a medtech, worked in the facility on at least 16 occasions from 7/12/2026 to 7/30/2026. A review of Guardian indicates that S1 was not associated with the facility until 7/31/2026. The remaining staff members who were observed working in the facility today were confirmed cleared and associated with the facility. One Type A citation was issued [see attached LIC 809(d)], and a civil penalty of $100 per day was assessed for a violation of Health and Safety Code § 1569.17. As the staff member was present for five (5) or more days without a clearance transfer, the maximum civil penalty of $500 was issued [see attached LIC 421 BG]. The ED was also advised that a repeat violation of the same regulation within twelve (12) months will result in additional civil penalties of $100 per day, up to a maximum of 30 days ($3,000) per subsequent violation. During the visit, the facility was also cited for insufficient staff [see corresponding report for complaint control number 08-AS-20260424113831. (Continuation on LIC809-C) (Continuation of LIC809) Based on the information obtained during the investigation, additional deficiencies were observed and are being cited and may be viewed on the LIC809-D page of this report. The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with Executive Director Amber Rodgers to whom a copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Aug 7, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355 · Plan of correction due date: Aug 8, 2026

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review… (b) shall prior to working, residing or volunteering in a licensed facility: … (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)… This requirement was not met as evidenced by: Based on record review, the licensee permitted one medication technician (S1) to work in the facility on sixteen occasions from 7/12/26 through 7/30/2026 without first obtaining a background clearance transfer to the facility. This posed an immediate Health, Safety and Personal Rights Risk to 84 persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2026

Plan of correction: ED will review the staff schedule and check to see who is working with residents in care for Saturday – Tuesday and verify they are cleared to work with residents in care, by POC due date 08/08/26. Once ED is cleared to access Guardian, they will verify that all staff are cleared and associated to the facility prior to being scheduled to work by 08/14/2026.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to the facility. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Amber Rodgers. As LPA was conducting interviews with residents and outside sources, it was revealed to LPA that a resident (identified as R1) was not having their care needs met by facility staff. Interview with R1 revealed that staff bring R1 three (3) meals a day, however R1 has not been receiving assistance with eating, which they need. Interviews with two (2) outside source individuals managing R1's care also shared concerns about R1 not receiving needed feeding assistance, often arriving to find R1 hungry. One outside source interviewed corroborated that R1 is physically unable to feed themselves. Another who was interviewed shared that from their understanding, facility services for R1's level of care do not include feeding assistance. File review of R1's Physician's Assessment dated for October 2023 list R1 as able to feed themselves and staff later brought LPA a copy of R1's updated physician assessment dated for June 2026 -- that the facility had received today, which noted R1 as unable to feed themselves. Review of R1's current service plan, dated for July 2026 indicate R1 is independent in feeding. Review of R1's service plan prior to the current one is dated for December 2024 and also noted R1 to be independent in feeding. One type A Deficiency is being cited per California Code of Regulations, Title 22, Division 6 on the attached LIC 809-D for the facility's neglect in meeting R1's feeding assistance needs. This violation was previously cited within a 12 month period on 12/22/2025, constituting for a Repeat Violation Civil Penalty of $1,000.00. An additional Type A deficiency is being cited for the facility not obtaining or requesting an updated medical assessment on an annual basis or as needed with changes in resident condition. This violation was previously cited within a 12 month period on 4/27/2026, constituting for a Repeat Violation Civil Penalty of $1,000.00. [Continued on LIC 809-C] [Continued from LIC 809] Additionally, R1 shared that they have not been receiving routine repositioning as they are bedridden, especially during the night. Per R1, they are a two (2) person assist for repositioning, but there is only one staff member assigned to the area overnight and so the staff will not try. Per review of R1's Physician's Assessment, dated October 2023, R1 does not require continuous bed care or have a history of skin conditions/breakdown. However, per interview with a member of R1's hospice team, R1 has been bedridden since starting hospice services and is currently receiving wound care services for a pressure injury sustained to the coccyx (tailbone area). The facility was able to provide an updated physician's assessment dated for June 2026, and it does indicate R1 of requiring assistance with repositioning and that R1 is noted to have a history of skin condition and breakdown. Review of R1's service plan dated revealed for July 2026 does not address repositioning needs for R1 at all. One type A Deficiency is being cited per California Code of Regulations, Title 22, Division 6 on the attached LIC 809-D for the facility not meeting R1's repositioning needs. This violation was previously cited within a 12 month period on 4/27/2026, constituting for a Repeat Violation Civil Penalty of $1,000.00. While at the facility, LPA also made requests for additional resident and staffing records and the facility was unable to provide them during the duration of LPA's visit. One type A Deficiency is being cited per California Code of Regulations, Title 22, Division 6 on the attached LIC 809-D for the facility not being able to furnish records as required for LPA to review during normal business hours. This violation was previously cited within a 12 month period on 4/15/2026, constituting for a Repeat Violation Civil Penalty of $1,000.00. Four deficiencies were cited during the inspection for a total of $4,000.00. Additional Civil Penalties are under review by the Community Care Licensing Division (CCL) and may be assessed at a later date. An exit interview was conducted with Executive Director Rodgers to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 6, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 7, 2026

87468.2: "In addition to the rights listed in Section 87468.1 [...] residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs [...]." This requirement is not met as evidenced by: Based on interviews and file review, the licensee did not comply with the section cited above in ensuring a resident's needs for feeding assistance were met, which poses an immediate health and safety risk to 1 out of 84 persons in care.the state’s words, verbatim · CDSS document, Aug 6, 2026

Plan of correction: Licensee will conduct a reappraisal/redo the service plan for R1 that addresses and meets their current service needs. Licensee will submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87458(b) · Plan of correction due date: Aug 7, 2026

87458(b): "The licensee shall obtain an updated medical assessment when required by the Department." This requirement is not met as evidenced by: Based on interviews and file review, the licensee did not comply with the section cited above in ensuring an updated medical assessment was obtained as necessary for R1, which posed an immediate health and safety risk to 1 out of 84 persons in care.the state’s words, verbatim · CDSS document, Aug 6, 2026

Plan of correction: Licensee obtained an updated medical assessment for R1. Licensee will conduct review of all resident files to ensure that each has a current/updated medical assessment as needed. Licensee will submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87101(c)(3) · Plan of correction due date: Aug 7, 2026

87101(c)(3): '"Care and Supervision" [...] involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. [...]." This requirement is not met as evidenced by: Based on interviews and file review, the licensee did not comply with the section cited above in ensuring bedridden care and supervision needs for R1 were met as necessary, which posed an immediate health and safety risk to 1 out of 84 persons in care.the state’s words, verbatim · CDSS document, Aug 6, 2026

Plan of correction: Licensee will conduct review of R1's care plan in collaboration with R1's hospice team and update as necessary to reflect current care needs. Additionally, Licensee will coordinate an in-service training with staff on bedridden care. Licensee will submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87412(f) · Plan of correction due date: Aug 7, 2026

87412(f): "All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. [...]." This requirement is not met as evidenced by: Based on interviews and file review, the licensee did not comply with the section cited above in being able to provide staff records for review, which posed an immediate health and safety risk to all persons in care.the state’s words, verbatim · CDSS document, Aug 6, 2026

Plan of correction: Licensee will submit requested staff records to LPA by POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Plan of Correction (POC) visit regarding a deficiency that was cited on 8/4/26. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Business Office Manager Raymie Cruz. Executive Director Amber Rodgers arrived later during the visit. On 8/4/26 the facility was issued a deficiency for accepting and/or retaining bedridden residents without having a fire clearance that allows so. A Plan Of Correction (POC) was developed on 8/4/26 between Community Care Licensing (CCL) and the facility, with a due date of 8/5/26. The Licensee failed to submit verifiable POC items by the due date and as a result, LPA conducted a POC visit to verify correction and to assess a Civil Penalty Violation for Failure to Correct. During today's visit, LPA conducted a health and safety check with bedridden residents R1, R2, and R3 [See LIC 811 Confidential Name List for a description of select person identifiers used in this report], as identified during the visit conducted 8/4/26. Per interview with Executive Director, POC is being worked on, but it is not complete at this time. A Civil Penalty of $100.00 a day has been assessed from 8/5/26 to 8/6/26 for a total of $200.00 and will continue to accrue at the aforementioned daily rate until the deficiency is cleared. An exit interview was conducted with Executive Director Rodgers to whom a copy of this report, the LIC 811, the LIC 421FC, and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 6, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced Case Management visit to the facility to conduct a health and safety check on residents in care. LPA was welcomed by, identified herself to, and discussed the purpose of the visit to Executive Director Amber Rodgers. During today's visit, LPA conducted a health and safety check, reviewed resident records, and interviewed residents. LPA observed Resident #1 (R1) and Resident #2 (R2) to be bedridden. [See LIC 811 Confidential Name List for a description of select person identifiers used in this report.] R2 reported to LPA that they are bedridden. R1 reported that they are unable to reposition in their bed independently. Additionally, staff reported an another bedridden resident at the facility, Resident #3 (R3). For the purposes of a fire clearance, bedridden means a resident who requires assistance with turning or repositioning in bed. The facility does not have a fire clearance that allows for bedridden residents. One deficiency is being cited during today's visit in accordance with California Code of Regulations, Title 22, Division 6 (refer to LIC 809-D). This deficiency constitutes a repeat violation within a 12 month period, as a fire clearance violation was previously cited on 4/15/26, which results in the assessment of a Repeat Zero Tolerance Civil Penalty totalling $1,000 (refer to LIC 421IM). A plan of correction was jointly developed with the Executive Director. An exit interview was conducted with Executive Director Amber Rodgers to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Aug 5, 2026

87202 Fire Clearance (a) All facilities shall maintain a fire clearance… Prior to…retaining any of the following types of persons, the… licensee shall obtain an appropriate fire clearance… (2) Bedridden persons This requirement was not met as evidenced by: Per LPA observations and interviews with residents and staff, 3 out of 81 residents are bedridden, which the facility does not have a fire clearance for. This poses an immediate health and safety risk to 3 of 81 residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: Executive Director agreed to submit the documentation requested by the fire department to determine if a bedridden fire clearance can be granted. Executive Director will copy LPA upon submission by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced case management visit for a Plan of Correction (POC). LPA Serrano identified himself and was granted entry and discussed the purpose of today’s visit with Special Operations Director Kathy Valencia and later met with Memory Care Director Stephanie Iffland. On 4/15/26, the facility was issued a citation, for Fire Clearance, §87202(a)(b), Based on interview and record review, the licensee retained 1 bedridden resident (R1) without an approved fire clearance. This posed an immediate health, safety and personal rights risk. The Licensee agreed to submit an LIC200 bedridden application and facility sketch by plan of correction (POC) date 4/16/26. The LIC200 bedridden application was submitted to the San Diego Regional Office on 4/20/26, as a result a civil penalty was assessed for the period of 4/16/26 through 4/20/26. No new additional deficiencies were observed or cited during today’s visit. An exit interview was conducted and a copy of this report, civil penalties (LIC421IM), along with Licensee Rights (LIC 9058 03/22) were provided to Memory Care Director Stephanie Iffland at the conclusion of the visit. The signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jul 15, 2026

Allegation investigated: Staff illegally evicted a resident in care. Staff did not follow resident's admission agreement.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit and delivered complaint findings. LPA introduced himself and disclosed the purpose of the visit with Executive Director Abraham Botello. The Department’s investigation consisted of interviews with staff, resident and review of records. The Department received information that a resident received an eviction notice dated February 23, 2026, but did not receive it until after the listed date. The reporting party stated the resident should not have received an eviction notice because they believed their rent had been paid. The reporting party also stated the resident did not receive maid or housekeeping services for five weeks, even though such services were included in their admission agreement. The resident identified in these concerns is Resident 1 (R1).The Department interviewed the facility’s Executive Director (ED) regarding the eviction notice and billing concerns. Unsubstantiated The ED stated that R1 had been paying below the current market rate of $2,300 per month and had a long pattern of late or inconsistent payments. The ED stated the facility had been working with R1 for several months to help them address the unpaid balance and had waived several late fees to assist them. The ED explained that once an eviction matter is sent to the facility’s legal team, the process usually takes three to four months, and residents are not required to leave immediately. The ED reported that the facility does not accept cash payments and uses an online payment portal. According to the ED, the portal would be reset so R1 could resume making payments electronically. The ED stated that R1 had been provided with a detailed invoice with a breakdown of charges in the past and that the facility would provide another copy. The Department interviewed R1 in their room. R1 reported that they had recently returned from multiple hospital stays throughout the year due to ongoing medical issues, including surgeries on their knee and foot. R1 said they pay rent on the second Wednesday of each month using their Social Security income, which is their only source of income. R1 stated they originally signed an admission agreement with the facility’s previous owner but never signed a new admission agreement with the current owner. According to R1, in November 2025 they were told they owed $6,400 in past-due rent, but they did not receive a detailed explanation of how the amount was calculated at that time. R1 stated they had difficulty reaching administrative staff for clarification and said a staff member handed them a 30‑day eviction notice without answering any questions. R1 said they had $4,600 available to pay toward their balance but were unable to access the online payment portal, and they were told they could only pay in cash. R1 did not feel comfortable making a large cash payment and wanted clearer information. R1 also stated they were searching for another senior living option with support from their daughter because they felt they could no longer afford the facility’s rates and needed more time to relocate. The Department reviewed facility payment ledgers and invoices dated October 31, 2024 through May 1, 2026. The records showed R1 accumulated a significant outstanding balance beginning in late 2024 due to late or incomplete payments. According to the ledger, the current balance due as of May 1, 2026 is $20,200.00. The Department confirmed that the last payment R1 made was $2,100.00 on October 10, 2025. R1 has not made any payments for rent due from November 1, 2025 through the date of the Department’s review. The Department also reviewed R1’s admission agreement dated November 27, 2020, which listed R1’s monthly rate as $1,495 under the previous operator. On November 19, 2025, the Department received a written copy of a 30 ay eviction notice dated November 13, 2025. The notice stated that R1 owed $6,400 in rent from November 2024 through November 2025 and instructed them to either pay the balance or move out by December 15, 2025. Regarding the housekeeping concern, R1 stated they did not receive maid service for five weeks, even though housekeeping service was part of their admission agreement. The Department reviewed the facility’s housekeeping schedules dated January 22, 2026 through April 4, 2026. The records showed that Housekeeper 1 logged and signed a total of 11 entries documenting that R1’s room was cleaned during this period. The entries showed that services included cleaning the refrigerator, cleaning the microwave, wiping the sink and counter tops, emptying trash cans, cleaning the bathroom, vacuuming, dusting surfaces, and other routine cleaning tasks. This documentation did not support the concern that R1 went five full weeks without receiving housekeeping service. Based on all interviews and document reviews, the Department did not find evidence that the facility unlawfully evicted R1. The eviction notice was provided in writing, included the required information, and the facility stated they were willing to work with R1. The Department also did not find evidence that the facility failed to follow the admission agreement. Billing statements supported the amounts owed, and housekeeping logs showed regular room cleanings during the period in question. While R1 experienced communication difficulties and did not receive timely explanations from staff, this did not constitute a regulatory violation.For these reasons, both allegations—unlawful eviction and failure to follow the admission agreement—are unsubstantiated. The report was discussed, and an exit interview was conducted with Abraham Botello. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Abraham Boello at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Apr 27, 2026 · control 08-AS-20260306114550

Type of visit: Case Management - Incident

LPA Serrano arrived at the facility to deliver a case management investigation report related to a fall experienced by Resident 1 (R1) on 10/20/2025 and concerns regarding the facility’s response, medical assessment practices, supervision, and change in condition procedures. LPA met with Executive Director Abraham Botello and discussed the purpose of the visit. R1 moved into the independent living area on 10/28/2020 and did not require assistance with daily activities at the time of admission. On 10/20/2025, R1 contacted the front desk and requested help after they fell inside their room. Staff 1 (S1) responded and helped R1 up from the floor. S1 stated that R1 reported hitting their head during the fall. S1 reported that R1 appeared to have no visible injuries and reportedly refused medical care. Staff 2 and Staff 3 also responded to the call but did not enter the room or assess R1 for injuries. The Department interviewed the Administrator, who stated they believed R1 had no fall history prior to the 10/20/2025 incident. The Department reviewed R1’s facility records and identified a total of nine falls dating back to January 2024. All but one occurred in R1’s room and were unwitnessed. Three of these falls resulted in hospital transport for serious injuries, including hip injuries. Records also indicated R1 hit their head in at least two prior falls. Additional documentation showed multiple hospital transports for breathing issues and other medical conditions. The only Physician’s Report available was dated 10/1/2020, with no updated assessments on file. The Department conducted a follow-up interview with the Administrator. The Administrator stated they had only been in their role for a few months and were unaware of R1’s fall history. The Department asked whether R1 had been re-evaluated given their repeated falls and clear changes in condition. The Administrator confirmed that no updated medical assessments existed. The Department advised the Administrator that based on the frequency of falls, injuries, and medical needs, R1 should have been considered for a higher level of care such as assisted living. The Administrator agreed. The Department’s review concluded that R1 had not been medically re-evaluated since 10/1/2020, despite multiple falls and significant medical concerns. The facility did not take steps to reduce R1’s fall risk or request a higher level of care. The Department reviewed the facility’s response to R1’s fall on 10/20/2025. S1 reported that R1 stated they hit their head. S2 and S3 responded but did not enter the room or assess R1. S1 1 claimed R1 refused medical treatment. S2 instructed S1 to monitor R1 every hour for any change in condition. The Administrator stated that while the facility has no written policy on suspected head injuries, staff are instructed to call 911 when a resident hits their head or is suspected of hitting their head. S3 confirmed this expectation. The Department interviewed R1. R1 stated they told S1 they hit their head hard and that their head and right side were hurting. R1 stated S1 did not assess them and that they did not refuse medical care. R1 stated they remained in their room for two days in pain until they contacted the front desk again. Facility records show that on 10/22/2025, S3 called 911 after R1 asked for help. The Department reviewed documentation and found no recorded hourly checks between 10/20/2025 and 10/22/2025, despite staff claiming these checks were performed. R1 also reported no staff checked on them during these dates. S3 confirmed that such monitoring should have been documented. Based on the information reviewed, the Department determined that the facility did not provide timely medical attention and did not conduct required monitoring after a reported head injury. The Department concluded that the facility failed to provide care and supervision, failed to observe and document changes in condition, and did not meet Title 22 RCFE requirements. Deficiencies were cited on LIC 809-D. An exit interview was conducted and a copy of this report along with the Licensee's Rights (LIC9058 03/22) was provided to Abraham Botello signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Apr 27, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87101(c)(3) · Plan of correction due date: Apr 28, 2026

"Care and Supervision" means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents...This requirment was not met as evidenced by. The facility did not supervise R1 properly when they reported hitting their head. Staff did not assess R1, did not call 911 for a suspected head injury, and did not complete or document hourly monitoring checks. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Apr 27, 2026

Plan of correction: The facility will retrain all caregivers and Med-Tech staff on fall response, suspected head injury protocol, and required documentation.• Training will be completed by [POC due date].• A copy of the training agenda and staff signatures will be submitted to CCL by 4/28/26

From the deficiency page — Deficiency type: Type A · Section cited: CCR87458(b) · Plan of correction due date: Apr 28, 2026

(b) The licensee shall obtain an updated medical assessment when required by the Department. This requirement was not met as evidenced by; R1’s last medical assessment was dated 10/1/2020. The facility did not obtain updated assessments despite repeated falls, hospitalizations, and changes in condition. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Apr 27, 2026

Plan of correction: • The facility will immediately obtain an updated medical assessment for R1.• The Administrator will implement a tracking system to ensure all residents receive timely updated assessments.• Proof of the updated assessment and tracking system will be provided to CCL by 4/28/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(e)(1) · Plan of correction due date: Apr 28, 2026

(e) The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition... to the attention of the appropriate licensed medical professional... Documentation of such communication shall be added...This requirement was not met as evidenced by; The facility did not conduct reappraisals for R1 despite nine falls, multiple injuries, and hospitalizations, all of which constitute significant changes in condition. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Apr 27, 2026

Plan of correction: The facility will complete a written reappraisal for R1.• The Administrator will create a system to ensure reappraisals are completed after any significant change in condition.• Verification of completion will be submitted to CCL by 4/28/26.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(16) · Plan of correction due date: Apr 28, 2026

Residents in all residential care facilities for the elderly shall have all of the following personal rights:(16) To receive or reject medical care or other services. This requirement was not met as evidenced by. R1 did not receive timely medical evaluation or safe and healthful care after reporting a head injury. Staff failed to provide proper assessment and supervision. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Apr 27, 2026

Plan of correction: The facility will create and implement a written fall and head injury response policy.• All staff will be trained on the new policy.• Proof of policy implementation and staff training will be submitted to CCL by 4/28/26.

Type of visit: Case Management - Deficiencies

On 4/14/2026 LPA Ramon Serrano arrived to the facility to conduct a case-management deficiencies visit. LPA was greeted by Executive Director Abraham Botello and LPA explained the purpose of the visit. On 4/6/2026, the Department conducted a case management visit to follow up on the self-reported death of a Resident (R1) [see 811 confidential names list]. During the visit, records were requested, however, three of the requested records could not be provided to the Department as required. An interview was conducted with the Executive Director (ED) who clarified that three records were not available due to the Resident Services Director (RSD) being out of the facility. The records included R1’s Preplacement Appraisal, LIC602 Physician’s Reports, as well as Caregiver Work Schedules for the months of January, February, and March. On 4/14/2026 the department conducted a review of records that were obtained and identified that R1 was bedridden (R1). Interview conducted with ADM who believed R1 was bedbound. R1’s Needs and Service Plan update for Grooming dated 2/20/2026 was reviewed and indicated “Resident is Bed Bound.” A review of the facility narrative charting notes that on 9/3/2025, it was documented that R1 required repositioning every two hours to prevent bed sores. A review of the facility file was conducted on 4/14/2026 which revealed that the facility was licensed for 145 non-ambulatory residents, and 0 bedridden residents. During today’s visit, a health and safety visit was conducted which revealed that there were four (4) bedridden residents present. Three (3) citations were issued and can be found on the attached LIC 809(D). Per California Health and Safety Code §1569.49 (c)(2)(A), a $500 immediate civil penalty was also assessed for a violation of the facility’s fire clearance [see attached LIC 421-IM]. An exit interview was conducted with Executive Director Abraham Botello, to whom a copy of this report, the LIC809-D page, the LIC421-IM page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Apr 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(b) · Plan of correction due date: Apr 16, 2026

87202 Fire Clearance (a). All facilities shall maintain a fire clearance… Prior to … retaining any of the following types of persons, the… licensee shall notify the licensing agency and obtain an appropriate fire clearance… (2) Bedridden persons This requirement was not met as evidenced by: Based on interview and record review, the licensee retained 1 Residents (R1-) without an approved fire clearance. This posed an immediate Health, Safety and personal rights risk to 1 of 96 Residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Licensee stated they will submit an LIC200/bedridden application and facility sketch to CCL and contact the Fire Department by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87506(a) · Plan of correction due date: Apr 16, 2026

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement was not met as evidenced by: Based on observation and interview, the licensee did not ensure that two records for one resident (R1) were readily available for facility and licensing staff. This posed a potential health safety and personal rights risk to 1 of 96 residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Licensee stated they will submit the requested records by POC due date. Licensee stated in the future they will submit records on the same day or within 24 hrs.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87412(f) · Plan of correction due date: Apr 16, 2026

87412(f)All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement was not met as evidenced by: Based on observation and interview, the licensee did not ensure that staffing schedules for January, February and March of 2026 were readily available for the licensing agency to inspect. This posed a potential health safety and personal rights risk to 1 of 96 residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Licensee provided LPA with staff schedules that were previously requested. Licensee stated in the future they will provide records immediately if not within 24 hrs.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Abraham Botello. Today's visit was in response to an LIC624 Incident Report and an LIC624A Death Report regarding Resident #1 (R1), which Licensee self-submitted to the CCLD San Diego Regional Office (RO); both reports were received on 04/03/2026. [See LIC 811 Confidential Names List for a description of select person identifiers used in this report]. According to these reports: R1 fell at the facility on 03/25/2026, for which they were hospitalized. Then on 03/26/2026, R1 died at the hospital. During today’s visit, LPA performed a brief facility tour and welfare check on remaining clients, finding no immediate safety concerns. LPA collected and/or requested copies of and reviewed pertinent records and interviewed relevant staff. LPA also provided Technical Assistance (TA) / education to Botello regarding CCLD’s Provider Information Notice (PIN) 26-06-ASC, titled, “Calling 9-1-1 in Residential Care Facilities for the Elderly (RCFE).” A physical copy of the PIN was provided to Botello, and an electronic copy of the same was E-mailed to both him and the facility’s Resident Services Director, Richard Tibi. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] The above LIC624 and LIC624A reports were both received at the RO late, meaning not within seven (7) days of either R1’s fall or R1’s subsequent death, respectively, as required by regulation. One (1) deficiency was cited today per California Code of Regulations, Title 22 (refer to the attached LIC809-D page). Since this deficiency was a repeat violation within a twelve (12) month period, a Repeat Violation Civil Penalty of $250 was assessed/charged (refer to the LIC421-FC page). An exit interview was conducted with Executive Director Abraham Botello, to whom a copy of this report, the LIC809-D page, the LIC421-FC page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Apr 6, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 6, 2026

87211 Reporting Requirements: “(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.” This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 94 residents (R1), Licensee did not furnish a written incident and death report to both the licensing agency and the residents’ responsible person within seven days of occurrence. This posed a potential health and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 6, 2026

Plan of correction: As of the date of deficiency issuance, the RO has received a copy of the pertinent LIC624 Incident Report and LIC624A Death Report for R1. During today’s visit, Licensee E-mailed copies of the same to R1’s responsible person. These actions have resolved the violation, and no further Plan of Correction was formed.

Allegation investigated: Staff abandoned resident at hospital Unlawful Eviction

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit and also delivered complaint findings. LPA introduced himself and disclosed the purpose of the visit with Resident Services Director Richard Tibi. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of LPA observations, records review, interviews with staff and outside sources. LPA conducted an investigation into allegations that the facility abandoned Resident 1 (R1) at the hospital and unlawfully evicted them. Information was received indicating that R1 had been medically cleared for discharge from the hospital last week. Transportation was arranged to return R1 to the facility; however, upon contacting the facility, hospital staff were informed that the facility would not accept R1 back. Substantiated Facility staff stated that R1 was now a two person assist, required the use of a restraint, and needed a level of care that the facility does not provide. Hospital personnel indicated that there were no medical orders supporting these claimed changes and that they were prepared to discharge R1 to their home at the facility. LPA interviewed the Resident Services Director (RSD), who confirmed that R1 is not currently residing at the facility. The RSD explained that the facility declined R1’s return due to what they believed was a change in R1’s care needs. According to the RSD, they received direction from the facility’s corporate medical staff, who advised them that R1 required a higher level of care and should not be accepted back. LPA reviewed an email chain between facility management and the Director of Community Nurse Support. The nurse support director stated that the facility did not have adequate staffing to meet R1’s needs. These were described as requiring two person transfer assistance, use of a wheelchair with a hemi tray (considered a restraint because R1 cannot remove it independently due to altered cognition and dementia), and assistance with repositioning, which would classify R1 as bedbound according to the facility’s internal standards. The facility claimed that these needs exceeded the level of care they could safely provide. Through record review and interviews, LPA determined that the facility refused R1’s return without following required eviction procedures. R1 was not given a written 30 day notice, relocation planning assistance, or any of the mandated documentation required by Title 22 and the Health and Safety Code. R1 was medically cleared to return, had an established residence at the facility, and was prepared for discharge; however, the facility’s refusal left R1 at the hospital without a lawful or approved discharge and without a safe relocation plan. The refusal to readmit R1 under these circumstances constitutes unlawful eviction and abandonment. Based on the information obtained, including interviews and documentation reviewed, the allegations of staff abandoning R1 at the hospital and unlawfully evicting them are substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Richard Tibi. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), were provided to Richard Tibi at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Mar 27, 2026 · control 08-AS-20260320163909

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a)(4) · Plan of correction due date: Mar 30, 2026

The licensee may evict a resident for one or more of the reasons listed in Section... Thirty (30) days written notice to the resident is required...If, after admission, it is determined that the resident has a need not previously identified...This requirement was not met as evidenced by: The facility refused to readmit R1 after hospitalization and did not serve any written eviction notice or provide reasons and supporting facts at least 30 days prior to the eviction date. This posed an immediate personal rights risk to 1 of 1 of 91 residents in care.the state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: The licensee shall readmit R1 if and will issue a compliant 30 day eviction notice with reasons, facts, and relocation assistance. Staff will be trained on eviction requirements, and proof of training and policy updates will be submitted to CCL.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1 · Plan of correction due date: Mar 30, 2026

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... This requirement was not met as evidenced by: By refusing R1’s readmission and leaving them at the hospital without a lawful discharge plan or safe relocation, the facility failed to ensure safe, healthful and comfortable accommodations and continuity of care, infringing on R1’s personal rightsthe state’s words, verbatim · CDSS document, Mar 27, 2026

Plan of correction: The licensee will create a readmission/relocation protocol ensuring residents returning from hospitals receive safe placement and proper discharge planning. Staff will receive personal rights training, and documentation of the protocol and training will be submitted to CCL by the due date.

Allegation investigated: Licensee did not provide adequate supervision to resident. Licensee did not meet food service requirement. Licensee did not maintain emergency lighting. Licensee did not provide reasoning/description for rent increase.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit and also delivered complaint findings. LPA introduced himself and disclosed the purpose of the visit with Resident Services Director Richard Tibi. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of LPA observations, records review, interviews with staff, residents and outside sources. On February 23, 2026, LPA conducted an unannounced visit to the facility to investigate the above allegations. LPA interviewed residents and staff, observed the facility, and reviewed records including care plans, physician reports, admission agreements, and staff charting notes.It was clarified that the concern about supervision was not related to a fall caused by lack of supervision, but about the time Resident 1 (R1) remained on the floor after the fall. R1 stated they are independent and staff rarely check on them. Staff charting notes showed that on February 6, 2026, at 9:40 AM, R1’s call pendant was activated. Unsubstantiated Staff responded promptly, knocked several times, and eventually spoke with R1, who insisted they did not press the pendant. Other residents and staff reported that checks are done approximately every two hours for all residents. R1’s care plan dated September 16, 2025, indicated that R1 is independent in bathing, grooming, dressing, meals, toileting, and ambulation. Based on interviews and documentation, there was no evidence that supervision requirements were violated. It was reported that R1 did not eat red meat and sometimes the only alternative is chicken tenders, which was described as overcooked and hard to chew. They also mentioned salads sometimes come without dressing and that food quality varies depending on which chef is working. R1 stated the food is often bland and lacks seasoning, but when the “right chef” is working, meals taste much better. During the visit, R1 called the front desk to order food and was offered herb-grilled fish, garden rice, and vegetables, which they accepted. Staff confirmed R1 is vegetarian and that they communicate this to the kitchen. Staff stated that R1 often requests specific items and is vocal about their preferences. Other residents stated that while food tastes like “cafeteria food,” alternatives are offered if requested. Kitchen staff reported that they can prepare various options for residents, but requests need to be made in advance. Records and interviews show the facility provides options and accommodates special diets. No evidence was found that food service requirements were not met. It was reported that the facility had a power outage from 7:00 PM to 10:00 PM and no emergency lights or flashlights were available. Staff and maintenance interviews confirmed a power outage occurred approximately two weeks ago, lasting between 30 and 60 minutes. The maintenance director stated the outage began around 6:00 PM and the facility does not have a backup generator but does have emergency lighting and illuminated exit signs that activate immediately during a power outage. Staff stated they did their best to assist residents during the outage and that emergency lights were functioning. Based on interviews and observations, there was no evidence to support that emergency lighting was not maintained. R1 stated they were not given a reason for the rent increase. Records show that on September 22, 2022, R1’s representative signed an addendum explaining average monthly fee and level of care increases. On October 20, 2025, the facility issued a written notice explaining that costs had increased due to market conditions, operations, and overall expenses, and therefore rates were adjusted effective February 1, 2026. The notice stated that the facility continually analyzes the market, their operations, and financial strength, and that increases in costs associated with operating the facility and providing quality services led to the adjustment. Documentation supports that the facility provided reasoning for the increase.LPA also interviewed the Resident Services Director (RSD), who stated that R1 is independent and has no additional staff requests on their care plan. RSD noted that R1 has been receiving free meal delivery despite never paying for it and that RSD recently advised R1’s responsible party that meal delivery would need to be paid for going forward, which the responsible party refused. RSD stated that R1’s responsible parties have been demanding and sometimes speak to staff inappropriately. Staff interviews described R1 as vocal and emotional at times, often expressing concerns about management and food quality. Other residents confirmed that staff check on residents regularly and that meal alternatives are available. Based on interviews, observations, and record reviews, all allegations are UNSUBSTANTIATED. This means there is not enough evidence to prove the allegations occurred.An exit interview was conducted with Richard Tibi. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Richard Tibi, whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 08-AS-20260214141208

Allegation investigated: Lack of medical care resulted in serious medical complications

Licensing Program Analyst (LPA) Ramon Serrano spoke with Resident Services Director Richard Tibi via telephone to deliver complaint findings. The Department’s investigation consisted of interviews with staff, residents, outside sources and review of records. It was alleged that Resident 1 (R1) did not receive medical care in a timlely manner, resulting in serious medical complications. On August 1, 2025, R1 tested positive for COVID-19 at the facility and was placed in isolation per protocol. According to Staff 1 (S1), isolation procedures include welfare checks every two hours, meal delivery, and medication administration. Facility charting notes indicate R1 was informed of their condition.On August 2, 2025, at approximately 8:00 AM, facility records show R1 received medication in their room from Staff 2 (S2). Unsubstantiated At approximately 8:45 AM, Outside Source (OS) arrived at the facility and requested R1 be sent to the hospital due to chest pain and ongoing COVID-19 symptoms. OS reported finding R1 on the bathroom floor, stating R1 claimed to have fallen. S1 stated they were unaware of any fall occurring. Facility charting notes from Staff 3 (S3 )documented that OS requested hospital transfer due to chest pain and COVID-19 status. R1 was transported to the emergency department, where medical records indicate they denied chest pain but reported knee pain. Physical examination revealed mild tenderness in the left knee and lung sounds described as rhonchi, which are associated with airway obstruction. R1 was diagnosed with acute COVID-19, dehydration, and acute kidney injury on top of chronic kidney disease. Laboratory results showed elevated creatinine levels, likely due to dehydration. R1 was treated with intravenous fluids and a three-day course of antiviral medication and discharged back to the facility on August 4, 2025. OS agreed to the return because R1 was fearful of change but expressed a preference for palliative care. On October 9, 2025, the Department interviewed S1. S1 confirmed they were familiar with R1 and reiterated that isolation began on August 1, 2025. They stated welfare checks, meals, and medications were provided during isolation. Staff 1 also confirmed that medication was administered on August 2 at 8:00 AM, shortly before OS arrived and requested hospital transfer. Staff 1 reviewed charting notes indicating OS requested hospital transfer due to chest pain and COVID-19 status. Staff 1 stated they were unaware of any fall occurring. On February 12, 2026, the Department interviewed OS, who stated they had numerous complaints about the facility, including staffing shortages, lack of qualified caregivers, and inadequate care practices. They also stated that private caregivers informed them R1 was not receiving showers as frequently as expected. OS provided multiple emails and a letter detailing complaints about care and communication, which were previously sent to CCL. OS later stated that since the incident, the facility hired new staff and new management, which significantly improved care. They confirmed they no longer wish to pursue the complaint further. Based on interviews, facility records, and medical documentation, R1 was isolated and received medication according to facility protocol. Charting discrepancies were noted, including inaccurate documentation of communication with OS. Concerns regarding hydration, isolation, and personal care could not be fully verified. Medical records confirm R1’s complications were primarily related to COVID-19 and underlying health conditions rather than lack of care. Therefore, the allegation that lack of medical care resulted in serious medical complications is unsubstantiated.The report was discussed and an exit interview was conducted with Richard Tibi. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) was provided to Richard Tibi via certified mail.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 08-AS-20250804140626

Allegation investigated: Reporting requirements were not met

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver complaint findings. LPA introduced himself and disclosed the purpose of the visit with Executive Director Abraham Botello. The Department’s investigation consisted of interviews with staff, residents, outside sources and review of records. LPA conducted an investigation into the allegation that reporting requirements were not met. It was reported that Resident 1 (R1) was found by their responsible party (RP) in their room in very poor condition. RP requested that R1 be sent to the hospital. RP stated they were never informed that R1 was sick or contagious.LPA interviewed an outside source (OS) who stated that they visited R1 several months ago and found them sick with COVID in their room. OS reported that the facility never called them to inform them of R1’s condition. Substantiated OS explained that medtechs were calling the wrong number and leaving messages. OS later learned that the medtechs had the correct number but were transposing digits when making calls. OS stated that in the past few months, everything has been fine with the facility and R1. LPA interviewed R1, who stated that facility staff are in regular contact with RP. R1 confirmed that they had COVID some time ago and were sent to the hospital. R1 stated that staff advised RP about the COVID diagnosis. LPA interviewed the Resident Services Director (RSD), who stated that this incident occurred before they were hired. RSD explained that the medtech responsible for communication at the time was terminated and no longer works at the facility. RSD believed RP was informed of R1’s COVID diagnosis. RSD stated that an incident report was never generated or submitted to CCL. LPA interviewed Staff 1 (S1), who stated that they never spoke directly with RP but left a voicemail requesting more disposable undergarments for R1. S1 recalled RP later saying they were never told about R1 having COVID when they came to visit. LPA reviewed R1’s records and noted that R1 has a primary diagnosis of bladder cancer, is listed as having dementia, and their physical health status is documented as poor. Chart notes from March 2025 through October 2025 were reviewed. On August 1, 2025, notes show that R1 tested positive for COVID and that RSD and the Memory Care Director were notified. Later that same day, S1 documented that they informed RP about the need for more disposable undergarments. However, there is no clear documentation showing that RP was informed of R1’s COVID diagnosis. Based on interviews and record review, there is evidence that R1 tested positive for COVID and was hospitalized. RP indicated they were not properly notified and facility staff confirmed that they never spoke directly to RP. An incident report was never submitted to CCL. There is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, chapter 8 is being cited on the attached LIC9099-D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Business Office Manager Raymie Cruz A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) was provided to Raymie Cruz at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 08-AS-20250804140626

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(b) · Plan of correction due date: Mar 9, 2026

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...A written report shall be submitted to the licensing agency and to the person responsible for the resident...Any serious injury as determined by the attending physician...This requirement was not met due to: R1 tested positive for COVID. Facility records show internal staff were notified, but RP was not informed of the diagnosis. CCL did not receive an incident report. Failure to notify RP of a significant change in condition violates reporting requirements and poses a health, safety and personal rights risk.the state’s words, verbatim · CDSS document, Feb 12, 2026

Plan of correction: Licensee stated they will review title 22 regulations on reporting requirements and will conduct a staff training on reporting incidents to both CCL and residents' responsible parties. ED will submit to LPA training log by POC due date.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Licensee did not follow proper eviction protocols for resident in care.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit and also delivered complaint findings. LPA introduced himself and disclosed the purpose of the visit with Executive Director Abraham Botello. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA observations, records review, interviews with staff and outside sources. On January 29, 2026, LPA Serrano investigated a complaint reported to the Community Care Licensing Division (CCLD). The complaint alleged that the facility did not follow proper eviction protocols and that R1’s responsible party (RP) was not given a 30-day notice. It was also alleged that R1 was ultimately removed from the facility by law enforcement. LPA interviewed an outside source (OS) who stated that RP never received a 30-day eviction notice and was never served a court order. OS said that according to San Diego County court records, R1 was served eviction documents in December 2025. Substantiated OS also stated that R1 has dementia and never told RP or other family members about the eviction. LPA reviewed facility records and found that on October 13, 2025, CCL received a copy of a 30-day notice to quit for R1. The notice stated that R1’s residency would end on November 13, 2025, because R1 was not following the facility’s general policies. LPA reviewed R1’s chart notes from October 15, 2024, through July 21, 2025. The notes showed several incidents where R1 was aggressive toward other residents and staff. On October 15, 2024, R1 chased another resident and harassed them because they were reading outside their room. On November 23, 2024, R1 yelled at staff about dinner and chased them. On June 13, 2025, R1 threatened to slap another resident for humming. LPA also reviewed emails between facility management. On September 10, 2025, the facility’s legal team advised management to give R1 an official eviction notice. On October 13, 2025, the Resident Services Director (RSD) emailed that they spoke with RP, who said they were having trouble finding a new placement for R1 but were still actively searching. LPA interviewed RSD, who said they and corporate staff told RP in August and September 2025 that R1 needed to move because of aggression toward other residents. RP said they were looking for a new place. RSD stated they told RP by phone on October 13, 2025, that R1 was being given a 30-day notice. LPA also interviewed outside source 2 (OS2), who said they learned about the eviction on January 22, 2026, when the facility told them R1 needed to be picked up or law enforcement would remove them. OS2 said they knew R1 had issues but never received a 30-day notice by mail or phone. LPA reviewed records and found the facility mailed the 30-day notice to RP by certified mail, but the mail was returned on November 10, 2025, because it could not be delivered. LPA interviewed the Executive Director (ED), who said R1 was officially evicted on January 22, 2026. ED said the notice was sent by certified mail and a court order was posted on R1’s door. ED stated that R1’s family visited during the holidays and would have seen the posted notice. ED stated that although law enforcement arrived at the facility on 1/22/26, they stated that since it was a "civil" matter they could not arrest or transport R1. ED under the advice of law enforcement transported R1 to the hospital and advised hospital staff of the situation. Based on the investigation, LPA determined that the facility had the right to evict R1 because of repeated aggression toward other residents. However, the facility failed to properly inform RP about the eviction. The 30-day notice included important information and resources that RP never received. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during interviews and records review, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Abraham Botello. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), and immediate Civil Penalties were assessed and provided to Abraham Botello at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 08-AS-20260122145349

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468(a)(8) · Plan of correction due date: Jan 30, 2026

(a)Each resident shall have personal rights which include...(8) To have his/her... responsible persons... informed by the facility of activities related to his care or services...This requirement was not met as evidenced by: Based on interviews and records review the licensee did not inform R1's responsible person of the 30 day eviction which is related to R1's care. Failure to comply presented a substantial threat to the mental health and safety of R1.the state’s words, verbatim · CDSS document, Jan 29, 2026

Plan of correction: Licensee stated that they will develop and implement a procedure to properly deliver 30 day notices that can include making calls to families and mailing the notice. Licensee wil submit the new plan/procedure to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ramon Serrano, made an unannounced visit to conduct the required One-Year Inspection. LPA identified himself and discussed the purpose of the visit with Executive Director Abraham Botello. According to the facility’s license, This facility capacity is 145 residents of which all may be non-ambulatory. A tour of the facility was conducted with Maintenance Director which included a sample of resident units, the dining area, common gathering areas, and food storage areas. There is a water feature in the courtyard made inaccessible to residents. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with the required furnishings. Overhead as well bedside lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. Hot water temperature and ambient temperature throughout the facility were at compliant readings. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to clients. Medications were labeled, as required, and stored in locked areas. Per Executive Director, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. LPA file review did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Executive Director Abraham Botello whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 27, 2026

Allegation investigated: Questionable Death Staff did not render services to resident as agreed

Licensing Program Analyst (LPA) Ramon Serrano delivered complaint findings to Executive Director Abraham Botello at the San Diego Regional Office conference room. On June 4, 2024 the Department received a complaint alleging Neglect/Lack of supervision of R1, resulted in Questionable Death. It has also been alleged Staff did not render services to resident as agreed. The Department reviewed incident report (IR) dated May 29, 2024, regarding R1. The IR stated, on May 22, 2024, around 9:00pm, a resident came down to the lobby and informed staff that R1 was on the floor. Staff went upstairs and assessed R1. R1 expressed their hip pain and would shriek when their hips were touched. 911 was contacted. On June 11, 2024, the Department interviewed Rebecca Toves, Executive Director (ED). ED stated R1 moved in on November 17, 2023, in the independent living section and initially had no additional status checks. Substantiated ED stated by December 21, 2023, R1 was re-assessed for assisted living which indicated that R1 required more assistance with daily tasks. ED said the caregivers were reporting that R1 was having difficulty keeping their room clutter free and organized. ED stated R1 had a cat and R1 was unable to keep the cat box clean, and the cats water dish was constantly spilling onto the floor causing a fall risk for R1. ED stated housekeeping was cleaning after the cat and making sure the water dish was not spilled on the floor and cleaning R1’s room because their floors were cluttered and they were worried about R1 falling. ED stated by early March 2024, ED and R1’s family decided to schedule daily housekeeping for R1 since they were unable to keep their room clean, mostly due from mild dementia that was progressive and they continued to decline. It was also revealed that R1’s Designated housekeeper (S1) resigned on May 2, 2024 and no additional housekeeping was assigned to R1. ED stated that they were looking to hire extra staff but at that time no one was cleaning R1’s room up for approximately 19 days leading to R1’s fall, which resulted in a hip fracture. ED stated they were unaware of R1 having any history of falls. ED also said that they were unaware that R1 was on a waiting list for memory care and that they did not follow-up on that. ED said that they were planning to look into what was going on with R, but they had not been able to get to it before R1’s fall, on May 22, 2024. The Department interviewed Resident Care Coordinator, RCC, Stephanie Iffland. RCC said former Residential Service Director (FRSD) Jennifer Brown was working with the family about R1 but abruptly separated from the facility without notes or information regarding the residents. The Department asked RCC with the changes and concerns with R1, why wasn’t R1 re-evaluated, and RCC was unable to answer. RCC admitted that R1 had sustained at least nine (9) falls that they were aware of and felt R1 needed more assistance with their care. RCC also said that housekeeping was being provided daily for R1 but it was not enough because R1 would take everything back out and leave clothes, food, wrappers, and shoes on their bedroom floor. RCC stated the Caregivers also reported that they witnessed R1 eating cat food and urinating in the litter box. RCC said that R1 had a weak knee, many falls and was encouraged to use their pendant for assistance. However, R1 rarely used their pendant and did not ask for assistance. The Department asked RCC if R1 should have been moved to memory care or re-evaluated for possibly a higher level of care. RCC said yes, R1 should have been re-evaluated. The Department asked why didn’t they schedule another housekeeper to clean R1’s room when the last one quit. RCC said they didn’t know what was going on regarding hiring additional housekeepers and that they were not sure why no one reported the condition of R1’s room. The Department interviewed staff (S1). S1 stated R1 kept taking items out and would tell everyone that they needed to organize their room, but left it a mess. S1 said they would offer to help R1 but they would get upset and irritated and refused any help. S1 also stated during the time of the former RSD, a caregiver reported to them that R1 was eating cat food and staff took it away from them. R1 told caregiver that it was okay to eat cat food, and caregiver suspected that R1 was showing signs of dementia or urinary tract infection, but they were also always confused and did not know where they were most of the time. S1 further stated R1 continued to display forgetfulness and at times was unable to find their room and would be found crying in the hallway until a caregiver found them. S1 said R1 had also bad knees, and often complained of pain and had shortness of breath. S1 said they and other MedTech’s notified former FRSD Jennifer Brown about the changes and concerns R1 was displaying by December 2023. S1 said the family agreed to provide daily housekeeping for R1 but there were days that R1 would not allow housekeeping to come in and clean the room. S1 stated FRSD Brown had mentioned that it appeared that R1 displayed signs of dementia, sundowning and was on the waitlist for memory care and staff was conducting status checks throughout the shift and after meals. The Department interviewed Resident Services Director (RSD), Mitchell Shayla Shajun. RSD stated they started working six weeks prior and was picking up where former RSD Jennifer Brown left off. RSD said that Brown did not stay long enough to go over any resident updates or managerial task that needed to be addressed. RSD stated they were recently made aware of R1’s behavior, and staff shared their concerns regarding R1 eating cat food and going to the bathroom everywhere. RSD stated Staff did not bring up these concerns regarding R1 refusing to shower, or having their briefs changed because R1 had a history of UTI’s (urinary tract infections). RSD said they knew about R1’s mobility issues because they were having a lot of falls. RSD admitted to not following up with family because it was until R1’s fall that these concerns were brought to her attention, and that they knew about the last two falls. RSD believed that R1’s change of condition was discussed with family and they had agreed to placing R1 in memory care. However, RSD clarified that they did not follow-up or look into the matter because they were still in training and learning their position. On August 15, 2024, the Department interviewed staff 2 (S2). S2 stated R1’s room was always a mess and malodorous due to the cat box and human and animal feces throughout the studio. S2 also stated caregivers were conducting frequent checks every hour or two to make sure R1 was okay. S2 stated R1 was anxious, depressed and displaying great confusion. S2 stated R1 was unable to care for themself or their cat. S2 said the staff hid the cat food because R1 would eat it and they told the family not to bring cleaning supplies to R1 because they were worried R1 might do something unsafe with them. S2 also explained that staff had requested to turn off the water to R1’s kitchen sink because they would get water all over the floor and was likely to fall. S2 said R1 had a bad knee, weak legs and a cluttered studio no matter how often housekeeping came to clean. S2 believed that all of this contributed to all of R1’s falls, which occurred in their room. On September 16, 2024, the Department interviewed staff 3 (S3). S3 stated they cleaned R1’s room daily, and sometimes three to four times in one day because R1 had a compulsive disorder to move and “organize” their room resulting in unsafe environment. S3 believed R1 needed to be re-assessed and placed in a higher level of care, as they were very confused. Despite R1’s worsening Dementia, R1’s family and facility management were not making any changes or placing them in memory care. S3 also corroborated that R1 had a bad knee, weak legs, and consumed cat food and feces; but no one addressed these concerns. S3 stated R1 refused to shower when they were covered in feces and also did not like changing their briefs when they were soiled. S3 believed that Management should have re-assessed R1. On September 27, 2024, the Department interviewed R1’s Family Member, FM. FM said that they had some concerns about the facility because they believed that they were understaffed and unable to provide the care and services that R1 required. FM stated R1 had been diagnosed with Alzheimer’s seven years prior and that they were moved from a sister facility because they could no longer provide the level of care R1 required. FM stated when they moved R1 into the facility, former Residential Service Director Jennifer Brown said they would be able to accommodate R1. FM stated they checked on R1 once a week and reported R1’s room was dirty and cluttered. FM agreed to pay for daily housekeeping, which went well until the housekeeper left, and the facility was unable to hire additional staff to clean R1’s room. FM believed the facility may have forgotten about the agreement when the new Residential Service Director was hired. The Department reviewed facility records which included R1’s appraisal and care notes from November 18, 2023- May 29, 2024. According to the record, R1 moved in the facility on 11/17/23 and had 10 falls through 05/22/24. One note dated 5/22/2024 stated R1 had sustained a fall and R1 expressed they were in pain. When staff tried to touch R1’s hip, R1 shrieked. They were a bit shaky, and taken to the hospital. R1’s initial appraisal, completed by former Residential Service Director (RSD) Jennifer Brown, noted that R1 required very limited assistance and was noted to be independent. There was no indication of R1 having Dementia or Alzheimer’s, despite their pre-placement appraisal dated 11/16/23 noting that they had dementia, depression and anxiety. Within a few months R1’s behavior had dramatically changed and staff was reporting that R1 was requiring more assistance and more status checks. Even though R1 was issued a pendant for assistance, R1 rarely used it to call for assistance. The staff conducted two-hour status checks on R1 and housekeeping had been upgraded to daily with no additional cost due to the habitual clutter and trash in R1’s room. The staff had notified the family members as to the daily clutter that R1 had in their room and it became difficult to keep their room clean and cluttered free causing a safety risk. Staff reported that R1’s confusion increased and had found R1 eating cat food from the can. During December 2023 a conference was arranged with R1’s FM and family to discuss the concerns regarding the change of condition with R1. The family agreed to move R1 to memory care however there was no availability and R1 was placed on a waiting list. Former Residential Service Director (RSD) Jennifer Brown left their employment and no follow-up regarding R1 moving to memory care was conducted. The new RSD did not address R1’s change of condition and their condition worsened until their fall resulting in a fracture on May 22, 2024. Staff knew R1 was a fall risk and reported this to management, the clutter had been a significant factor to R1’s frequent falls. The facility did not address the falls and implement fall mitigation measures to attempt to prevent R1’s falls. The additional daily housekeeping had ceased due to being understaffed. On May 22, 2024, R1 had an unwitnessed fall in their room. R1 was assessed and displayed pain and discomfort, staff called 911 and R1 was transported to a Hospital. Following admission, the residents family elected to transition R1 to comfort care rather than pursue operative intervention, after goals of care discussion with palliative care and orthopedics. On May 29, 2024, R1 was discharged and family eventually selected board and care for placement with hospice services. R1 passed away on June 1, 2024. There is enough information to support Neglect/Lack of Care and Supervision leading to an unwitnessed fall and sustaining injury. R1’s cause of death was reported by the coroner’s office as complications of left femoral head and neck fracture (a break in the bone at the junction of the femoral head and femoral shaft) due to R1’s fall. R1’s last fall on May 22,2024 was a contributing factor in their death. Therefore, the allegation for neglect/lack of care and supervision contributing to the client’s death is substantiated. Based on interviews and records review, the preponderance of evidence standard has been met therefore the above allegations were SUBSTANTIATED. An immediate civil penalty in the amount of $500 was assessed per Health and Safety Code 1569.49(c)(1), for a violation that the Department determined resulted in an injury of R1. Further Civil Penalties under Health and Safety Code Section 1569.49 are under review by the Department and may be assessed at a later date. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Abraham Botello A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), was provided to Abraham Botello at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 08-AS-20240604154836

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 24, 2025

Additional Personal Rights... (a)In addition to… 87468.1… residents… shall have… the following… rights: (4) to care, supervision… that meet their… needs and are delivered by staff… sufficient in numbers, qualifications, and competency… This requirement was not met as evidenced by Based on interview and record review, the Licensee did not ensure that R1 received care, supervision and services required by their medical condition, resulting in their fall, fracture, and contributing to their death. This posed an immediate Health, Safety, and Personal Rights risk to 1 of 99 persons in care.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: Licensee stated that they will provide a staff training regarding supervision and identifying residents needs and having a staff on call to cover shifts. Licensee will send LPA training itinerary by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303 · Plan of correction due date: Jan 22, 2026

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 evidenced by: Based on interview, the facility did not render housekeeping services to one resident (R1) as agreed. This posed a potential health, safety and personal rights risk to 1 of 99 residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: Licensee stated that maintenance director will conduct room audits and train staff on how to report issues to management. Licensee will send training log/audit by POC due date

Allegation investigated: Lack of supervision resulted in resident on resident abuse

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced visit to deliver complaint investigation findings for an investigation conducted by LPA Carmen Lopez. LPA identified himself and stated the purpose of the visit and reviewed the findings of the complaint with Resident Services Director Richard Tibi. The Department’s investigation consisted of interviews with staff, residents, and outside sources, and records review of relevant documents pertinent to this investigation. On March 28, 2024, it was said that there was a lack of supervision that resulted in resident-on-resident abuse. A review of facility records revealed that a Report of Suspected Dependent Adult/Elder Abuse (SOC341) and an Unusual Incident/Injury Report dated March 22, 2025, documented that Resident #1 (R1) entered Resident #2’s (R2) room without permission, slapped R2 with an open hand, and broke R2’s glasses. Substantiated R1’s physician’s report (LIC602) dated November 9, 2022, indicated that R1 is ambulatory and has an underlying medical condition that is described as a progressive brain disorder leading to memory loss, confusion, language problems, and personality changes, per Google AI overview. The report further stated that R1 required full supervision and assistance with activities of daily living. Their underlying medical condition was described as permanent and severe. R2’s LIC602 further describes their mental condition as confused, disoriented, exhibiting inappropriate behaviors, intermittent aggression, wandering, and sundowning. R1’s preplacement appraisal dated November 28, 2023, noted episodes of confusion and the need for R2 to have special observation and night supervision due to wandering. R2’s LIC602 was also reviewed. R2 was non-ambulatory and is a fall risk. They have an underlying condition that, per AI overview, is described as a condition where cells, tissues, or organs progressively break down and lose function over time, which affects their nervous system. They are also diagnosed with a condition that affects their memory. Their LIC602 further shows that R2 is able to follow instructions, communicate their needs, and store their own medications. Resident interviews were conducted. An interview with R1 was attempted but was unsuccessful due to limited verbal skills; R1 only smiled and did not verbally respond. R2 was interviewed and corroborated the incident, stating that R1 entered their room, ignored verbal redirection, slapped them with an open hand, and knocked their glasses off their face. Staff responded to the incident and contacted law enforcement. Staff interviews were conducted. Staff member S1 corroborated the incident, explaining they had left R2’s room briefly to assist another resident. Upon their return, they found R2 crying and were informed that R1 had entered the room and slapped them. S1 observed R2’s glasses knocked off. S1 reported that R1 has exhibited escalating aggressive behaviors, including attempts to hit caregivers and urinating in random areas. Former Executive Director Rebecca Toves arranged for a one to one caregiver contracted by the VA to assist R1 three times per week following the incident. Interviews with outside sources were also conducted. One outside source stated that staffing at the facility was adequate but limited, remarking that “they can only do so much.” Another outside source confirmed that R1 received VA assistance after the incident. Law enforcement corroborated that they had responded to the facility on multiple occasions for incidents involving R1, including altercations with other residents resulting in minor injuries. R1 was described as frequently getting into altercations and sometimes becoming violent. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff, resident, and outside source interviews, and records review, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D. The report was discussed, a plan of correction was jointly developed, and an exit interview was conducted with RSD Richard Tibi, to whom a copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) were provided at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Dec 22, 2025 · control 08-AS-20240328170333

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jan 26, 2026

To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse… this requirement was not met as evidenced by: Based on interview and records review, facility staff did not protect one resident (R2) from physical abuse by a resident with a known history of aggression (R1), which posed an immediate health, safety and personal rights risk to 2 of 99 residents in care.the state’s words, verbatim · CDSS document, Dec 22, 2025

Plan of correction: Licensee stated they will conduct a staff training regarding resident on resident altercaions to prevent from occuring again. LIcensee will submit signed training log to LPA by POC dated 1/26/25. The LIC9099-D page was amended to correct deficiency type and verbiage.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Resident Services Director Richard Tibi, to discuss the purpose of the visit. Today's visit is in response to the self reported incident involving Resident 1 (R1- see LIC811 Confidential Names List) who eloped from the facility and was found later that same day in La Mesa. An Incident report was submitted to CCLD reporting the following: On 10/03/2025 at approximately 9:30 AM, staff conducted a routine check and discovered that Resident 1 (R1) was not in their room. Staff immediately began searching inside and outside the facility. During the search, a staff member who was on break informed the Executive Director (ED) that they saw R1 a few blocks away from the facility. After about one hour of unsuccessful searching, staff notified R1’s Power of Attorney (POA) and contacted the Sheriff’s Department to report the incident. The Sheriff’s Department initiated a search; however, R1 was not located at that time. At approximately 7:50 PM, a staff member received a call from a Transit Security Officer stating that they had R1 at the trolley station in La Mesa on Spring Street and La Mesa Boulevard. The officer reported that R1 was very intoxicated and had shown them the facility’s business card, stating, “That is where I live.” After receiving this information, staff contacted the ED, who immediately went to pick up R1. R1 returned to the facility around 9:00 PM. The POA was notified, and R1’s primary care physician was also informed. On 12/22/2025, LPA interviewed R1 in the facility’s patio area. R1 was well-groomed and appropriately dressed. R1 stated that prior to the incident, they believed they had a stroke and had gone to the hospital several times to get checked. On the day of the incident, R1 said they intended to visit their spouse and child’s graves at Glen Abbey Cemetery. After visiting, they took a bus and ended up at Fashion Valley Mall. R1 then boarded a trolley, thinking it would take them back to Chula Vista, but they ended up in La Mesa. R1 stated that they told an officer they were lost and showed the officer the facility’s business card. The officer then contacted the facility, and the ED picked R1 up. R1 believes they may have had a stroke that caused confusion that day and stated they were checked out and are doing well now. LPA reviewed R1’s records. According to the physician’s report dated 08/05/2025, R1 has mild cognitive impairment, hypertension, and a history of alcohol use disorder. R1 is not permitted to leave the facility unsupervised and is disoriented to time and date. LPA interviewed Executive Director (ED) who stated that on the date of the incident R1 eloped during lunch service. ED stated that R1 usually sits near the front door of the facility and believes that due to lack of supervision R1 was able to exit the building and walk away from the facility. Based on the information obtained, the facility did not ensure that R1 remained under supervision as required. This poses a potential health and safety risk to residents in care.California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Resident Services Director Richard Tibi. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), was provided to Richard Tibi at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Dec 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Dec 23, 2025

...residents in ... residential care facilities for the elderly shall have all of the following personal rights:To care, supervision... that meet their individual needs and are delivered by staff that are sufficient in numbers... and competency to meet their needs. This requirement was not met as evidenced by: R1 who has mild cognitive impairment and is not permitted to leave the facility unsupervised, was able to leave the facility. R1 was located several hours later by an Officer in La Mesa. The facility did not ensure proper supervision, which posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Dec 22, 2025

Plan of correction: Licensee stated that after the incident R1 was placed on "care plan" and is checked on 3-4 times per shift. The Licensee will also conduct a Staff training on elopement prevention and emergency response. Facility will submit plan to LPA by POC due date. Proof of staff training and updated policies must be submitted to the Department by POC due date.

Allegation investigated: Unlawful Eviction

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to investigate and deliver complaint investigation findings. LPA introduced himself and stated the purpose of the visit with Executive Director Abraham Botello. The Department’s investigation consisted of interviews with staff, resident and review of records. It was alleged that Resident 1 (R1) was being unlawfully evicted. The concern was that R1 was not given proper notice, had not received clear communication about their rent balance, and was being forced to leave without adequate time or support to find alternative housing. On December 17, 2025, LPA Serrano interviewed R1 in their room at the facility. R1 shared that they had recently returned from the hospital the previous Thursday and had been hospitalized multiple times since January 2025 due to ongoing medical issues, including surgeries on their knee and foot. Unsubstantiated LPA interviewed the facility’s Executive Director (ED), who stated that R1 had been paying below the current market rate of $2,300 per month. ED explained that the facility had been working with R1 for several months to resolve the payment issues, including waiving several late fees. However, ED noted that R1’s payments were inconsistent and often late. ED emphasized that they did not want to evict R1 and were willing to continue working with them. ED stated that once a case is referred to the legal team, the eviction process typically takes 3–4 months. ED also clarified that the facility does not accept cash payments from residents and that R1’s payment portal would be reset to allow them to make payments online again. ED confirmed that R1 had previously been given an invoice with a breakdown of charges and stated they would ensure R1 received another copy. Based on interviews with R1 and the Executive Director, as well as a review of billing records and the eviction notice, LPA found that the facility followed proper procedures in issuing the 30-day eviction notice. The facility demonstrated efforts to work with R1 over several months, including waiving fees. Although R1 expressed concerns about communication and the payment process, there was no evidence that the eviction was unlawful. The facility provided documentation supporting the outstanding balance and issued a formal notice with a 30-day timeline, which aligns with regulatory requirements. Based on interviews and records review, there does not exist a preponderance of evidence to prove that licensee unlawfully evicted R1. Therefore, the above allegation is deemed to be unsubstantiated. The report was discussed, and an exit interview was conducted with Abraham Botello. A copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Abraham Boello at the conclusion of the visit. The signature below confirms the receipt of these documents. R1 stated that they pay rent on the second Wednesday of each month using their Social Security income of $2,148, which is their only source of income. R1 explained that they had a signed lease agreement with the previous owner, Atria Bonita, but had never signed a new lease with the current owner, Pacifica Senior Living. In November 2025, R1 was informed by facility staff that they owed $6,400 in past due rent. R1 requested a detailed invoice showing how the charges were calculated but had not received one at the time of the interview. R1 also reported that they had not been able to speak with the Executive Director or other administrative staff about the issue. The only communication they received was from a staff member who handed them a 30-day eviction notice and refused to answer any questions about it. R1 stated they had $4,600 available to pay toward the balance but were unable to access the facility’s online payment portal. They were told they could only pay in cash, which they found concerning and inconvenient. R1 expressed that they could no longer afford to live at the facility and, along with their daughter, were actively searching for a more affordable senior care home. R1 requested additional time to find a suitable place to move. LPA reviewed R1’s billing statements from October 31, 2024, through December 1, 2025. The records showed that R1 had accumulated an outstanding balance of $14,750 between October 2024 and March 2025. R1 made payments that reduced the balance, but as of December 1, 2025, they still owed $8,700. This amount included several late fees. LPA also reviewed R1’s signed admission agreement with Atria Bonita dated November 27, 2020. The agreement listed R1’s monthly rate as $1,495 and included a rate increase history disclosure. On November 19, 2025, CCLD received a copy of a 30-day eviction notice issued by Bonita Villa Senior Living to R1. The notice, dated November 13, 2025, stated that R1 owed $6,400 in unpaid rent from November 2024 through November 2025. The notice informed R1 that they must either pay the full balance or vacate the facility by December 15, 2025.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 08-AS-20251208131410

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Abraham Botello, to discuss the purpose of the visit. Today's visit is in response to the self reported incident involving Resident 1 (R1- see LIC811 Confidential Names List) who was transported to the hospital after a fall, resulting in a fracture. LPA conducted a health and safety check, interacted with staff and obtained facility records. No deficiencies were cited or observed on this date. An exit interview was conducted with Abraham Botello who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Dec 17, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing (CCL). LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director Abraham Botello. CCL received an incident report on November 24th, 2025 in which it was reported that on 11/14/25, a resident (identified as R1) was transported to the hospital during a visit from R1's Home Health provider. Per the report, the Home Health provider --who is a licensed medical professional, noted that an edema in R1's leg had worsened, in addition to a wound on their leg that produced a foul odor. The Home Health provider recommended R1 be taken to the hospital for evaluation and treatment. The report notes that R1 was treated at the hospital for an infection in their leg, and returned to the facility the following day. Per the report, R1's responsible party and primary care provider were notified, and wound care orders for Home Health updated. On 11/24/25, CCL requested additional records for R1 for follow-up, but after no response, LPA conducted the Case Management visit. During today's visit, LPA conducted file review, interviews, and a health and safety visit with R1. No Deficiencies were cited during today's visit. An exit interview was conducted with Executive Director Botello to whom a copy of this report was provided. Their signature below confirms receipt of this document.the state’s words, verbatim · CDSS document, Nov 26, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management visit to deliver an “Order to Licensee/Facility of Immediate Exclusion from Facility” for staff #1 (S1 – see Confidential Names List). LPA Serrano identified himself and stated the purpose of the visit with Executive Director (ED) Abraham Botello. The Department of Social Services, Community Care Licensing Division, orders PACFICA SL CA LLC;PACIFICA BONITA LP; BONITA MGR , to remove S1 from any contact with residents or presence of S1 in all facilities associated. This exclusion letter is in result of an investigation by the California Department of Social Services, a case management investigation of conduct inimical has been found to be substantiated against an employee, by the name of S1. The Department has determined that continued or future contact with residents or presence in any child day care or residential facility licensed by the California Department of Social Services constitutes a threat to the health and safety of the residents in care. During the visit, LPA confirmed that S1 was not present at the facility. LPA was advised by ED that S1 was terminated as of July 23, 2025. LPA provided ED with the exclusion letter. An exit interview was conducted with Executive Director Abraham Botello, to whom a copy of this report, exclusion letter, LIC811 Confidential Names List, and the Licensee/Appeal Rights were provided. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Oct 30, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Abraham Botello, to discuss the purpose of the visit. Today's visit is in response to the self reported incident regarding Resident 1 (R1) who did not receive medical care for approximately two days after sustaining a fracture from a fall, due to refusing medical assistance. LPA interacted with staff and obtained facility records. No deficiencies were cited or observed on this date. An exit interview was conducted with Abraham Botello, who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Oct 30, 2025

Allegation investigated: Lack of supervision resulted in resident being assaulted by another resident.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver complaint findings. LPA introduced himself and disclosed the purpose of the visit with Resident Services Director Richard Tibi. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA observations, records review, interviews with staff and residents. It was alleged that lack of supervision resulted in a resident being assaulted by another resident. It was reported that on July 21, 2025 Resident 1 (R1) attacked Resident 2 (R2) resulting in a laceration on their arm. Review of R1's Physician's report dated October 10, 2024 revealed R1 has mild cognitive impairment and cannot leave the facility unassisted. R1 can be fiercely independent and does not like being restricted. Substantiated LPA reviewed R1's charting notes dated October 15, 2024 through July 21, 2025. On October 15, 2024 R1 "chased" another resident to the lobby area and harassed them due to the resident reading outside of their room, which R1 did not like. On November 23, 2024 R1 was verbally abusive towards staff regarding R1's dinner. R1 chased after staff and yelled at them. On June 13, 2025 R1 became very aggressive with another resident due the other resident "humming." R1 told the resident that R1 would "slap" them in the face if they continued to hum. LPA Interviewed R1 who stated that they have lived at the facility less then a year. R1 stated that although they only have a few friends at the facility, they do know every resident by their face. R1 stated that just prior to speaking with LPA they accidentally sat down next to a resident that they previously had a minor disagreement with. R1 explained that they asked the other resident if they were the one they had a disagreement with earlier in the day. R1 stated that the resident said "yes" and they both laughed. R1 denied having any altercations, disagreements or aggression towards other residents in the past. R1 stated that if they are ever annoyed with another resident they just ignore them and forget about it. LPA interviewed R2 who stated that on the date of the incident they recall arguing with R1. R2 stated that they could not remember what they were arguing about. R2 stated that R1 came up to them and "twisted their arm off" R2 stated that after R1 hit them, R1 had an angry look in their eyes that frightened R2 and R2 thought they were going to come back after them, but they didn't. R2 stated "I just think that R1 is an angry, angry person. R2 stated that R1 has a history of being aggressive and angry with other residents, R2 stated that an incident occurred in the past where R1 became aggressive with another resident but R2 could not recall what exactly happened and who the resident was since it occurred a while back. LPA interviewed Resident 3 (R3) who stated that they witnessed the incident that occurred on July 21, 2025. R3 stated that R1 was talking to them in the lobby area when R1 stopped turned to R2 and stated " we are having a private conversation, I'm talking to my friend." R2 said something and R1 yelled "what did you say?" R3 stated that R1 began to "tussle" with R2. R3 stated that the facility staff then came and separated R1 and R2. R3 stated that R1 has been aggressive with other residents in the past. R3 stated that R1 argued with another resident because they were whistling and it upset R1. LPA interviewed Staff 1 (S1) who stated that they were informed that on the date of the incident R1 became aggressive towards R2. S1 stated that R1 grabbed R2's arm resulting in a arm injury. S1 stated that after the incident R1's family promised that they would provide R1 with a private caregiver. S1 stated that R1's private caregiver was only seen for two to three days and they never returned. S1 stated that after a recent incident of elopement they spoke with R1's responsible party informing them that R1 needed a higher level of care. S1 stated that R1's responsible party is in the process of finding new placement for R1. LPA reviewed a San Diego Sheriff's incident report (SDSIR) dated July 21, 2025. SDSIR indicated that R1 initiated a physical altercation with their neighbor R2 at their shared elderly care facility. SDSIR stated that R1 grabbed R2's forearms, resulting in a severe laceration to R2's right forearm. R2 was transported to a local hospital for medical treatment. Both residents were described as having mental cognitive deterioration. Staff members at the facility described R1 as having cognitive deterioration. Based on the statements collected, the injury to R2's arm, and the totality of the circumstances, R1 was placed on a 5150-hold pending psychiatric evaluation. Had R1 been left at the residential facility, it is believed that R1 would have likely continued being a danger to other residents and staff members. Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during interviews and records review, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Resident Services Director Richard Tibi. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), and immediate Civil Penalties were assessed and provided to Richard Tibi at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Sep 15, 2025 · control 08-AS-20250722163151

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Sep 16, 2025

87466 Observation of the Resident The licensee shall ensure that residents are... observed for changes in physical, mental, emotional and social functioning and that... assistance is provided... This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not assist a resident with a history of aggression, resulting in a resident-on-resident altercation causing injury to 1 resident [R1], posing an immediate health, safety, and personal rights risk to 1 of 114 residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: Licensee stated that they would conduct an online training regarding resident aggression and dementia behaviors. Licensee will submit the training date and outline by 9/16/25. LIcensee stated that R1's POA is in the process of transferring R1 to a higher level of care facility.

Allegation investigated: Unlawful Eviction

On August 29, 2025, Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted a telephone conference with Resident Services Director Richard Tibi to present investigative findings. The Department’s investigation included a facility tour, record review, and interviews with staff and external sources. Allegation: Unlawful Eviction On October 22, 2024, Community Care Licensing (CCL) received a complaint alleging that a resident (R1) had been unlawfully evicted from the facility. Specifically, it was alleged that on October 17, 2024, R1 was transferred to the hospital due to a medical emergency, and that prior to the hospitalization, staff told R1 they needed to vacate their apartment by the end of the month because the facility could no longer meet their needs. (Continue at LIC9099C) Unsubstantiated (continue from LIC9099) Record Review A review of facility and resident records indicated that R1 was capable of making their own decisions. R1 signed an admission agreement on November 25, 2019, and moved into the facility. Records also showed that R1 was receiving financial assistance from an outside source to help cover monthly room and board fees. On October 4, 2024, the facility issued R1 a 30-day termination notice and Notice to Quit due to nonpayment of the basic service rate. The notice stated that the admission agreement would terminate effective November 4, 2024, and that R1 had an outstanding balance of $33,400. This amount represented unpaid residency, care, and service fees from June through September 2024. Billing statements from March through October 2024 and correspondence between R1 and the facility’s business office confirmed that R1 was not current with payments. Handwritten notes from R1 to staff further indicated that R1 was no longer receiving financial support from the outside source and lacked the financial means to continue paying for room and board. R1 had previously been served a 30-day termination notice on September 4, 2024, when they first became delinquent. However, the facility withdrew that notice when R1 attempted partial payments. Those payments were returned due to insufficient funds, which led to the second 30-day termination notice issued on October 4, 2024. Resident Placement Interviews and records showed that on October 21, 2024, R1 was discharged from the hospital to another facility that provided rehabilitation services appropriate for R1’s needs. As of the date of this report, R1 continues to reside at that rehabilitation facility and receive necessary services. (continue to LIC9099C) ((ontinue from LIC9099C) Findings The investigation found no corroborating evidence that R1 was unlawfully evicted from the facility when transported to the hospital by 911 personnel due to a medical emergency. Review of the 30-day termination notice and Notice to Quit was properly served to R1, and it did not indicate any violations of Title 22 regulations. Conclusion Based on the investigation, including record reviews and interviews with staff and external sources—there is insufficient evidence to substantiate the allegation of unlawful eviction. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted with Resident Services Director, Richard Tibi. A copy of this report, LIC811 Confidential List form and the Licensee Appeal Rights (LIC 9058, 03/22) were provided via email at rsd.bonita@bonitavillaseniorliving.com and ed.bonita@bonitavillaseniorlviging.com. An electronic confirmation of receipt was obtained.the state’s words, verbatim · CDSS document, Aug 29, 2025 · control 08-AS-20241022162033

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced Case Management visit to obtain additional information on a self-reported incident. LPA identified herself and was granted entry by receptionist Michelle Gould. LPA met with Abraham Botello, Executive Director, and discussed the purpose of the visit. On 08/25/2025, it was reported that law enforcement investigator arrived at the facility and requested to speak with Executive Director Botello. Executive Director Botello spoke with the investigator regarding incidents of theft that were reported of former staff #1 (S1- see confidential names list) who has since been removed from the facility. The Executive Director had been working with families and law enforcement to obtain additional information regarding the incidents. The incidents had transpired between June 1, 2025, through July 29, 2025. During today’s visit, LPA spoke with Executive Director Botello and requested and obtained relevant documents pertinent to the incidents. LPA Lopez informed Executive Director Botello that, at this time, the case requires additional telephone calls or visits relating to this incident. No deficiencies were cited during this visit. An exit interview was conducted with Executive Director Abraham Botello, to whom a copy of this report, along with the Licensee/Appeal Rights (LIC9058 03/22) were provided to Executive Director Botello, at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Aug 25, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced Case Management visit to deliver an amended report for a visit conducted on 08/08/2025. LPA identified herself and was granted entry by receptionist Michelle Gould. LPA met with Abraham Botello, Executive Director, and discussed the purpose of the visit. During today’s visit, LPA obtained Executive Director's signature on the amended report LIC9099-C and LIC9099-D page dated (08/08/2025), immediate civil penalties were issued along with an amended deficiency on the attached LIC809-D. An exit interview was conducted with Executive Director Abraham Botello, to whom a copy of this report, the amended report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Aug 25, 2025

Allegation investigated: - Lack of supervision resulting in resident-on-resident altercation

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings for a complaint investigation. LPA identified herself and was granted entry by Annmarie Salazar, Resident Service Coordinator (RSC). LPA stated the purpose of the visit and reviewed the findings of the complaint with RSC Salazar. The Department’s investigation consisted of interviews with staff and residents, and records review of relevant documents pertinent to this investigation. On April 03, 2025, it was reported there was a lack of supervision which resulted in resident-on-resident altercation. It was specifically alleged on April 1, 2025, resident #1 (R1) had an altercation with resident #2 (R2) and later reported to the facility staff, who alerted law enforcement. An interview with staff #1 (S1) said they worked as the person in charge that day. They had heard resident #1 (R1) and resident #2 (R2) in an altercation near the elevator outside the dining area. (Continuation on LIC9099-C) Substantiated (Continuation of LIC9099) When S1 went to see what the commotion was regarding, S1 found both R1 and R2 were face-to-face, confronting each other. S1 separated both R1 and R2, and they were directed to their rooms. S1 spoke with R1, who said R2 had hit them with a decorative figurine, which has since been removed. According to S1, they were informed that the incident had started earlier in the day, between R1 and Resident #3 (R3) during an activity. The facility had an activity that included the consumption of wine. According to S1, R1 usually attends this activity with friends, who bring their own alcohol. It had come to S1’s attention that R3 had made a comment to R1 regarding their heritage. According to an interview with R2, they said they had seen R1 argue with another unknown resident at the dining table, prior to leaving the dining area. After they left the dining area, they went to the elevator, and R1 called them an “asshole” and a “motherfucker.” R1 went towards them, with their motorized scooter, and ran into them while at the elevator. R2 then confirmed they retrieved a decorative ceramic figurine and hit R1 in the chin. R1 commenced to yell at them and then took the ceramic figurine with them so they can inform everyone what R2 had hit them with. R2 said that staff #3 (S3) came out of the employee’s lounge, and R2 informed them of the incident. Later, law enforcement came by to obtain statements, and since they defended themselves, they were not in trouble. According to Resident #3 (R3), they had seen R2 pouting in the dining area. When they asked what was wrong, they informed them that they had an incident with R1. Minutes later, R3 then accompanied R2 to their room, where law enforcement was waiting for them to obtain a statement. During this time, R1 passed by their room and did this approximately 3 times to intimidate them, but they were there to protect R2. Interviews were conducted with resident #4 (R4), who said they heard commotion but did not recall details. A review of records revealed that, since 2023, the resident has had numerous documented altercations, inebriations, and acts of aggression toward other residents. Photos revealed the residents’ bruising. R2 had bruising to the inner thigh of their right leg. R1 had bruising to the bottom left side of their chin. The facility provided the resident and the RP with a violation notice of the rules, dated April 3, 2025. While a care conference had been scheduled with R1’s responsible party after the alleged incident, there were no documented attempts by the facility to address R1’s known aggression and/or behavioral expressions over the prior 2 years. LPA reviewed R1’s file again on August 8, 2025, and there were no updated information as to the updates to R1’s care plan. The Department requested law enforcement reports but there were no responsive records for this incident. (Continuation on LIC9099-C) (Continuation of LIC9099-C) Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff and outside source interviews, and records reviewed, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D. The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Abraham Botello, Executive Director. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22), and immediate Civil Penalties were assessed and provided to Executive Director Botello at the conclusion of the visit. The signature below confirms the receipt of these documents. This is an amended version to an original report delivered on 08/08/2025.the state’s words, verbatim · CDSS document, Aug 8, 2025 · control 08-AS-20250403173506

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Aug 22, 2025

87466 Observation of the Resident The licensee shall ensure that residents are... observed for changes in physical, mental, emotional and social functioning and that... assistance is provided... This requirement was not met as evidenced by: Based on interview and record review, the licensee did not assist a resident with a history of aggression, resulting in a resident-on-resident altercation with injuries for 2 residents [R1 and R2], posing an immediate health, safety, and personal rights risk to 2 of 127 residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: The facility plans to schedule a care conference with the family to update R1's plan of care, and aggreed to make a PCP appointment for an updated LIC602. The facility will inform LPA the scheduled dates by POC due date, 08/22/2025. The updated plan of care and LIC602 will be submitted to LPA once they are complete. This is an amended version to an original report delivered on 08/08/2025.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced visit to deliver investigative findings and in conjunction, conducted this case management visit. LPA identified herself and was granted entry by Annmarie Salazar, Resident Service Coordinator. LPA stated the purpose of the visit and reviewed the basic elements of this visit with Executive Director Abraham Botello. During the Department’s investigation of complaint control # 08-AS-20250403173506, there were additional discrepancies found, which are being addressed during today’s visit. During the investigation, which consisted of interviews with staff and residents, and records review of relevant documents, the investigation uncovered that the facility documents for residents needed to be updated. During today’s visit, LPA spoke with the Executive Director Botello and reviewed the following California Code of Regulations: 87208 Plan of Operations, 87458 Medical Assessment, 87101 Definitions, and 87463 Reappraisals. LPA also provided the Executive Director with the Department’s flyer for Important Updates to Dementia Care and Miscellaneous Changes, which took effect January 1, 2025. The flyer had a QR code that directs the recipient to the Department’s website and informs the viewers of updated regulations that impact RCFE facilities. Additionally, the facility did not report the incident that transpired on April 1, 2025, until LPA opened the investigation on April 10, 2025. Based on the information obtained during the investigation, an additional deficiency was observed and cited, and technical advisories were provided which may be reviewed on the LIC809-D and LIC9102TA pages of this report. The report was discussed, and an exit interview was conducted with Executive Director Abraham Botello. A copy of this report, along with Licensee/Appeal Rights (LIC9058 3/22) were provided to Executive Director Botello at the conclusion of the visit. The signature below confirms the receipt of these documents.the state’s words, verbatim · CDSS document, Aug 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Aug 22, 2025

87211 Reporting Requirements: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case... This requirement was not met as evidence by: Based on records review, staff did not submit a written report to the Department within the allotted timeframes for 1 of 127 residents in care, which which posed a potential personal rights risk to 127 of 127 residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: The facility agreed to provide the RSD and the RSC training on Reporting Requirements, and submit the in-service training form to the LPA by POC due date, 08/22/2025.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced Case Management Visit. LPA was greeted by and met with Executive Director Abraham Botello, to discuss the purpose of the visit. Today's visit is in response to the self reported incident regarding Resident 1 recanting an allegation of sexual abuse. LPA interviewed residents and obtained facility records. No deficiencies were cited or observed on this date. An exit interview was conducted with Abraham Botello, who was provided with a copy of this report and Appeal Rights. Their signature confirms receipt of these documents.the state’s words, verbatim · CDSS document, Jul 28, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate complaint investigations and in conjunction conducted this case management visit. LPA Lopez identified herself and was granted entry by Michelle Gould, Concierge. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Dining Services Director, Abraham Botello. On May 12, 2024, the Regional Office received a self reported SOC341 regarding resident #1 (R1) who reported to the facility that on 03/08/2025, staff #1 (S1) had gone onto their room during the night and pulled on their call pendant. According to the SOC341, R1 does suffer from a cognitive condition. Due to the incident, the facility contacted law enforcement who came out to the facility and obtained statements. Additionally, it was reported to the Department that staff #2 (S2) had received an item from resident #2 (R2) which the amount may have been significantly large. During today's visit LPA obtained relevant documents pertinent to these incidents. LPA informed Dining Service Director that there may be follow-up phone calls or visits pertinent to these incidents. No deficiencies were not observed or cited during this CM visit. The report was discussed, and an exit interview was conducted with Dining Service Director Abraham Botello, to whom a copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) were provided at the conclusion of the visit. The signature below confirms the receipt of these documentsthe state’s words, verbatim · CDSS document, Jun 19, 2025

Type of visit: Collateral

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Collateral Visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Rebecca Toves. During today’s visit, LPA conducted staff and residents interviews to aid in an investigation involving a different licensed care facility. During LPA's time at Bonita Villa Senior Living, he observed that the carpet inside Apartment #211, belonging to Resident #1 (R1), was significantly stained/dirty. [See LIC811 Confidential Names List for a description of R1.] Interviews of manager and outside sources aligned to show: The carpet in this apartment is almost five (5) years old. Licensee had earlier constructive knowledge of the staining, and acknowledged the need to remedy it. Licensee had not yet remedied it. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Toves, to whom a copy of this report, the LIC 809-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 8, 2025

87303 Maintenance and Operation: "(a) The facility shall be clean...sanitary and in good repair at all times." This requirement was not met, as evidenced by: Based on manager interview and LPA observation, pertaining to the bedroom of 1 of 126 residents (R1), Licensee did not ensure that the facility was clean, sanitary, and in good repair at all times. This posed a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 8, 2025

Plan of correction: Licensee agreed to use its carpet shampoo machine to thoroughly clean the carpet inside Apartment #211, and once complete, to send LPA a video of the carpet post-cleaning, by the POC due date. In the event the machine is not successful in removing all stains, Licnesee agreed to coordinate with R1's responsible person to make arrangements for the carpet to be replaced with new flooring material, at no additional charge to R1.

Type of visit: Collateral

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Collateral Visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Rebecca Toves. During today’s visit, LPA conducted staff and residents interviews to aid in an investigation involving a different licensed care facility. No deficiencies were observed or cited during today's visit. An exit interview was conducted with Toves, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Apr 2, 2025

Allegation investigated: Staff are not esnuring that residents recieve incontinence care Staff do not ensure the care needs of residents are being met Staff do not ensure residents room is kept in safe, clean, sanitary conditions Staff do not ensure call system alerts are responded to in a timely manner for residents in care

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Dining Services Director Abraham Botello and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff and outside sources. It was reported to CCL that staff are not ensuring that residents receive incontinence care, staff do not ensure the care needs of residents are being met, staff do not ensure that resident rooms is kept in safe, clean, sanitary conditions and staff do not ensure call system alerts are responded to in a timely manner. Unsubstantiated Regarding the allegation that staff are not ensuring that residents receive incontinence care, it was reported that reporting party (RP) has visited a resident (R1) at the facility and has found R1 to be left in soiled clothing. Interview’s with outside sources revealed no concern for lack of incontinence care for residents. Interview’s with residents revealed no concern for resident incontinence care. Interview’s with facility staff revealed no concern for lack of incontinence care. Regarding the allegation that staff do not ensure the care needs of residents are being met, it was reported that RP went to visit R1 and found R1 soiled on the floor. It was reported that a staff was observed exiting R1’s room and did not clean or assist R1 off the floor. Interview’s with residents revealed no concerns for staff not ensuring that their care needs are being met. Interviews with facility staff revealed no concern for staff not meeting resident’s needs. Interviews with outside sources revealed no concerns. Regarding the allegation that staff do not ensure that resident room is kept in safe, clean and sanitary conditions, it was reported that R1’s room has a foul smell of urine and feces and has dirty clothing. LPA conducted unannounced visits and observed R1’s room along with other resident rooms. LPA did not smell any foul odors and did not see anything of hazardous conditions. Interview’s with facility staff revealed no concerns for cleanliness of resident rooms. Interview’s with residents revealed no concerns. Interview’s with outside sources revealed no concerns. Regarding the allegation that staff do not ensure call systems alerts are responded to in a timely manner for residents in care, it was reported that R1 has used their call pendant to alert staff when they have fallen but staff do not come. A review of facility records show when call alerts were activated but are not time stamped when they are cleared. Interview’s with outside sources revealed no concern for response times for call button alerts. Interview’s with residents revealed no concern with response times for call system alerts. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Botello. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Botello whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Feb 26, 2025 · control 08-AS-20240503112011

Allegation investigated: Staff abandoned residents. Staff did not have transportation for resident after hospital visit.

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Dining Services Director Abraham Botello and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff and outside sources. It was reported to CCL that staff abandoned resident and staff did not have transportation for resident after hospital visit. Regarding the allegation, staff abandoned resident, it was reported that resident (R1) was transported to the hospital for unknown reasons. It was reported that hospital contacted the facility to pick up R1 but facility refused. It was reported that R1 was still at the hospital. Unsubstantiated Interview with reporting party (RP) revealed that R1 had started to develop exit seeking behaviors and memory care unit at facility was full. RP said that facility had explained that they were not a locked facility and were not equipped to care for a resident with exit seeking behaviors. RP said that facility staff informed hospital staff of the exit seeking behaviors that R1 was exhibiting and hospital social worker had R1 moved to another facility. Records review revealed that on 4/15/24, a 30 day eviction notice was given to R1 due to R1 needing a higher level of care. Interview’s with facility staff revealed that facility had sent out R1 to the hospital and was in communication with hospital social worker about concerns for the need for a higher level of care. Interview with facility staff revealed that R1’s responsible party had passed away and there was no relatives willing to assist in re-locating R1. Interview with outside source (OS2) revealed that they were aware of the situation and was involved in trying to locate a responsible party for R1. OS2 reported that the facility is at no fault and did all they could. OS2 stated that there was no concern for facility abandoning R1. Regarding the allegation, staff did not have transportation for resident after hospital visit, it was reported that resident (R2) was admitted to the hospital due to chest pain. It was reported that on 5/18/24, R2 was released from hospital but facility did not pick R2 up. It was reported that facility did not have transportation and R2 remained at the hospital and passed away. Interview’s with facility staff revealed that the facility utilizes a van from their other property for transportation services. Staff reported that if van is not available and a resident needs transportation services then facility will pay for an Uber. Staff reported that residents have never been denied transportation. Staff reported that when R2 was at the hospital they were in contact with hospital social worker and was never told that R2 was ready for discharge. Staff reported that R2 passed away at the hospital. Interview with outside source (OS2) revealed that there was no concern for lack of transportation at the facility. Interview’s with other resident’s revealed that residents have returned to the facility via ambulance, facility van or Uber paid for by facility. No concern for lack of transportation from residents. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Botello. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Botello whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 08-AS-20240618085911

Allegation investigated: Staff are charging a resident for services not rendered Staff did not provide resident with a complete admissions agreement

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Dining Services Director Abraham Botello and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff and outside sources. It was reported to CCL that staff are charging resident for services not rendered and staff did not provide resident with a complete admissions agreement. Regarding the allegation, staff are charging a resident for services not rendered, it was reported that reporting party (RP) made arrangements for resident (R1) to move into facility in April 2024. Unsubstantiated R1 became hospitalized prior to move in date and was unable to move in. RP states that they spoke to facility staff about ensuring that room was kept available for R1 and reported that staff assured RP that there would be no additional fees until R1 moved in. In August 2024, R1 moved into facility and RP discovered that facility had been charging the resident monthly rent each month after initial move in date. Interviews with facility staff revealed that once someone signs an admission’s agreement they are taking financial responsibility for the room and rent accrues automatically in the system, while care charges begin when the resident is physically in the facility and is receiving care. Interview with facility staff revealed that no payment was made for rent owed prior to R1 moving in and facility waived all fees upon hearing about the confusion from RP. Interview with reporting party revealed that there was a misunderstanding about billing but stated that issue has been resolved. RP said that no payments were made for back owed charges and stated that facility waived all fees that were assessed prior to R1 moving in. Regarding the allegation, staff did not provide resident with a complete admissions agreement, it was reported that after R1 moved into the facility, they were not given a current admission’s agreement that shows all the fees that will be charged. Records review revealed that a complete admissions agreement was signed and dated 4/30/24. Admissions’ agreement shows that monthly fee for R1 is $2895.00. Admissions agreement states “The Community’s Resident Services Director or his or her designee will evaluate your service needs by assessing your functional capabilities, physical status, mental condition, and social factors”. Records show that care cost was not determined at the time admissions agreement was signed and shows that care cost for R1 started on 11/1/2024. Interview’s with facility staff revealed, that RP had difficulty utilizing the facilities online portal to access all forms and facility staff reached out to assist in this via email. Records review revealed that on 9/27/25, facility staff assisted RP by email providing a username and password for online portal and informed RP that there was no billing for care costs at the time. Records review showed emails between RP, facility staff and facility accounting addressing RP concerns with billing and statements stating that late fees were waived and balance due prior to resident moving in were waived. Interview with RP revealed that they were able to get copies if admissions agreement and was ale to access to only portal. RP reported no concerns. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Botello. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Botello whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 08-AS-20241014122752

Allegation investigated: Staff did not refund authorized representative

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Executive Director Rebecca Toves and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff and outside sources. It was reported to CCL that staff did not refund authorized representative. Unsubstantiated Regarding the allegation, it was reported that reporting party received a bill from facility after resident (R1) moved out. Report says that fees should have been waived. Interviews with facility staff revealed that R1 resided at the facility and no payment was ever made to facility. A review of records revealed that that charges were made for the time that resident resided at the facility and no payments were made. Records review revealed that facility notified reporting party of balance due and there was no indication that balance due would be waived. Facility staff reported that since balance was past due, account was sent to collections. Interview with reporting party (RP) revealed that RP was told by an unknown staff via telephone, that the balance due would be waived due to RP being unsatisfied with facility. RP was unable to provide a name of staff whom they spoke to and was unable to provide any documentation that facility would waive the balance owed. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Botello. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Botello whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 08-AS-20241018110036

Allegation investigated: Licensee did not allow resident to have visitors

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Dining Services Director Abraham Botello and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency. It was reported to CCL that licensee did not allow resident to have visitors. Regarding the allegation, it was reported that a former staff was told they could not visit a resident (R1) at the facility. Interviews with facility staff revealed that no one was denied access to visiting residents at the facility and clarified that former staff can visit as long as they are abiding by facility visitor policy. Unsubstantiated Reporting Party (RP) reported that they became notified that they were not allowed to visit the facility when the resident (R1) called them to inform them that facility management told them that RP was not allowed to visit the facility. RP said that the following day they were contacted by facility management to discuss concerns. RP said the facility accused them of visiting outside of visiting hours, going in staff only areas and not signing in and out of the visitors log. It was agreed that RP was allowed to visit the facility as long as visitor policy was followed. RP denied ever being denied access at the facility and denied ever being turned away at the facility. Interview with outside source/R1’s responsible party (OS2), revealed that they were aware of the situation and stated that the issue had been resolved. OS2 stated that it was unclear if the RP had been denied access to the facility or facility was just suspicious of RP’s motive. Interview with R1 revealed that facility management said that RP was not allowed to visit the facility, although it was unclear if RP would be denied access to the facility or it was asked that RP only visit when abiding by visitor rules. R1 reported that RP has been to visit since this and stated that there have been no other issues with visitors. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Botello. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Botello whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Feb 20, 2025 · control 08-AS-20241127142322

Allegation investigated: Resident call pendant was not in working condition

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced complaint visit to deliver findings in the above-mentioned allegation. LPA met with Executive Director Rebecca Toves and discussed the purpose of the visit. On October 22, 2024, Community Care Licensing (CCL) received a complaint alleging resident call pendant was not in working condition. During investigation, LPA Strong collected pertinent resident records, made observations, and conducted interviews. According to the allegation, on October 19, 2024, Resident 1 (R1) pressed their call pendant and waited for over three hours for assistance in toileting, when it was reported to staff it was found that pendant was not sending signal to staff. On October 30, 2024, LPA Strong conducted a facility inspection and observed multiple residents pressing their pendants. On this date, LPA Strong observed and video recorded two of five resident pendants malfunctioning as the residents were unable to activate the pendant upon pressing it. LPA showed Executive Director the recording of the malfunctioning pendants. Substantiated Based on observations and interviews, a preponderance of evidence exists to support the allegations. Deficiencies are being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Executive Director Rebecca Toves, to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to. LPA Strong reviewed an invoice for the weekend of October 19, 2024, dated October 21, 2024, with charges for parts, labor, and emergency visit. LPA Strong called the facility phone number on October 22, 2024, and October 30, 2024, and the telephone was answered promptly by receptionist. It was also alleged that housekeeping staff assigned to R1’s room were not providing complete room cleaning from regular bathroom maintenance to vacuuming. Interview with staff assigned to R1’s room revealed that they provided extra cleaning care and attention to R1 as R1 had requested more assistance. Records reviewed shows facility room cleaning checklist which includes floor care and general cleaning of bathrooms. Interview with an outside source revealed that staff provide regular room care as noted in residents’ rooms. LPA observed R1’s room on October 30, 2024, which was clean and organized. Lastly it was alleged R1 did not receive assistance with bathing. Records collected revealed staff notes that showed R1 has verbally declined regular scheduled bathing and requested it to be pushed out. Interview with R1 did not reveal any information to corroborate that R1 did not receive bathing assistance. Interview with other resident did not reveal any information to corroborate that residents are not receiving assistance with bathing. Interview with outside source did not reveal other residents do not receive assistance with their scheduled bathing. Based on multiple interviews and record reviews, there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Rebecca Toves to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.the state’s words, verbatim · CDSS document, Feb 13, 2025 · control 08-AS-20241022165133

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(B) · Plan of correction due date: Feb 28, 2025

shall have signal systems which shall meet the following criteria: 1) All facilities licensed for 16 or more a....shall have a signal system which shall: (B)Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met in evidence as: Based on interviews and observations the licensee did not provide a working pendant for 2 of 120 persons in care which posed a potential Health, Safety, or Personal Rights risk to persons in carethe state’s words, verbatim · CDSS document, Feb 13, 2025

Plan of correction: Licensee has already begun daily pendant checks and alarm clearing, Maintanance team has also initiated monthly random checks of pendants to verify working conditions. Adminsitrator stated they are updating the system and getting outside company quotes. Adminsitrator will provide a written letter to LPA to confirm such continous checks.

Allegation investigated: Facility staff did not meet resident's medical needs

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Executive Director Rebecca Toves and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA observation, records review and interviews with facility staff, resident and outside sources. It was alleged that facility staff did not meet Resident 1's (R1) medical needs. It was reported that R1's oxygen tank was not with R1 for several days. LPA interviewed R1 and observed R1's oxygen tank was nearby but R1 was not wearing it. R1 stated that they know they're suppose to be wearing the oxygen all day but they often remove it since R1's nose gets sore. Substantiated LPA asked R1 if the facility staff remind them to put it back on. R1 exclaimed "oh yeah, they remind me all the time." R1 stated that they did not have their oxygen tank when they moved to their temporary room. R1 stated that they could not remember how many days they did not have their oxygen. R1 further stated that the staff probably forgot about it, since R1 never mentioned it to them. LPA interviewed outside agency (OA) who stated that R1 arrived at the emergency room with a low oxygen saturation. OA stated that R1 is required to be on oxygen 24/7.OA stated that the facility was treating R1's room for bed bugs and as a result, R1 was transferred to a different room. OA further stated that staff member 1 (S1) advised OA that R1 was moved to their temporary room without their oxygen tank. S1 further stated that since the room was being treated, staff could not enter the room to retrieve it. OA believes R1 was without their oxygen tank for several days. LPA interviewed R1's responsible party (RP) who stated that R1 has lived at the facility approximately four years. RP stated that R1 is a "pain" and stubborn. RP stated that R1 regularly goes against doctor's orders and refuses to wear compression socks and removes their oxygen regularly. RP stated that R1 will throw staff out of R1's room although they are just trying to help. LPA interviewed S1 who stated that they "do not know what happened" in regards to R1's oxygen tank. S1 stated that R1's oxygen tank was not with R1 prior to being transported to the hospital. S1 explained that R1's room was being treated for bed bugs and facility staff forgot to move R1's oxygen tank to their temporary room. S1 believes that R1 did not have their oxygen on at the time of the move which caused staff to leave the tank in the room. S1 stated that since the room was being treated for bed bugs staff could not enter the room to retrieve the oxygen tank. S1 estimated that R1 was without their oxygen tank for approximately two days. LPA interviewed staff member 2 (S2) who stated that they assisted in clearing out R1's temporary room. S2 stated that they noticed that R1's oxygen tank was not transferred to the room. S2 stated that R1 was without their oxygen for approximately two days. S2 stated that they believe staff simply "forgot to move it out." LPA interviewed Executive Director (ED) who stated that she was not aware of the incident involving R1 and their oxygen tank until today. ED stated that she was out of the office during that time frame and was not advised by staff of the incident. ED further stated that facility staff should be aware of R1's need for oxygen since R1 has an "oxygen sign" posted outside of their door. Based upon the foregoing, the above listed allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and is noted on the attached LIC 9099-D. An exit interview was conducted with Rebecca Toves and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Rebecca Toves whose signature below confirms receipt of documents.the state’s words, verbatim · CDSS document, Jan 28, 2025 · control 08-AS-20250124144319

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87611(e) · Plan of correction due date: Feb 18, 2025

In addition to Sections 87465(a) and 87464(d), the licensee shall ensure that the resident is cared for in accordance with the physicians orders and that the resident's medical needs are met. Based upon staff and outside agency interviews. The facility did not ensure that one out of 128 residents in care (R1) have their medical equipment transferred to their room. This posed a potential health risk to 1 of 1 of 128 persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2025

Plan of correction: Executive Director stated that she will conduct an inserivce training focusing on protocol for transferring residents to temporry rooms. Proof of traning will be provided to Community Care Licensing by the POC due date 2/18/25.

Type of visit: Required - 1 Year

Licensing Program Analyst’s (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Rebecca Toves This facility serves one hundred fourty five, residents 60 and above. Hospice waiver approved for fifteen. During today’s inspection, facility has a census of ninety-six (96) residents. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected a sample of resident bedrooms. The facility was clean, sanitary, and in good repair. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) & first aid kit were present. Required licensing postings were observed in visible areas of the facility. LPA conducted interviews and reviewed staff and resident records/files. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Toves to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 27, 2025

Allegation investigated: Licensee is not ensuring that facility is free of rodents & pests

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Executive Director Rebecca Toves and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, residents and outside agency. It was reported to CCL that Licensee is not ensuring that facility is free of rodent’s & pests. [Continued on LIC 9099-C] Unsubstantiated Regarding the allegation, licensee is not ensuring that facility is free of rodent’s & pests, it was reported that the facility had rats, bedbugs and cockroaches. Interview’s with resident’s revealed no concern for facility having pests. Interview’s with facility staff revealed no accounts of rodents or pests being observed in the facility. Interview with outside source report no knowledge of the facility having issues with rodent/pests. LPA conducted an unannounced visit to the facility and inspected areas in which were reported to have rodents/pests, no rodents/pests were observed. Records review revealed that facility gets serviced semi-monthly through Orkin. Records review revealed that Orkin had been out to the facility on 8/30/2024 to inspect for bed bugs and “no activity was found”. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Toves. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Toves whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Oct 21, 2024 · control 08-AS-20240828163058

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Alyssa Ramirez conducted an unannounced Case management visit. The LPA identified herself and explained the purpose of the visit to Executive Director Rebecca Toves. During today's visit, the LPA secured report signatures and delivered an amended report. An exit interview was conducted with Toves, to whom a copy of this report and the licensee appeal rights (LIC9058) were provided.the state’s words, verbatim · CDSS document, Sep 23, 2024

Allegation investigated: Staff are withholding food from a resident Staff are retaliating against a resident

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Executive Director Rebecca Toves and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency. It was reported to CCL that staff are withholding food from a resident and staff are retaliating against a resident. Regarding the allegation, staff are withholding food from a resident (R1), it was reported that a resident was not being provided their usual food allotment. LPA observations revealed that facility had sufficient food supply. Unsubstantiated Interview’s with staff reported that all residents are fed and no one goes without food. Staff reported that residents can either go to the dining room for meals or can get tray service per resident request. Interview with resident’s revealed that meals are always provided by the facility. Interview with R1 revealed, that facility provides R1 with all meals daily. R1 reported that they have never been denied food by staff at the facility. Regarding the allegation, staff are retaliating against a resident (R1), it was reported that staff were mad at R1 because a staff was let go because of R1 and as a result R1 was not being given typical food allotment. Interview with R1 revealed that they have not had any staff retaliate against them or treat them unfairly. Interview’s with facility staff revealed that R1 had been exhibiting paranoia and had been requested doctor evaluate them. Facility staff reported that R1 had made comments about staff “out to get them”. Facility staff reported that no one was fired and there was a staff that took a long vacation and returned to the facility. Interview’s with residents revealed that no one has experienced retaliation from staff. Interview’s with outside sources revealed no concerns. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Toves. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Toves whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Sep 13, 2024 · control 08-AS-20240721221122

Allegation investigated: Resident eloped from the facility due to lack of care and supervision Staff did not follow reporting requirements

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Resident Service Director Shayla Mitchelland discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency. It was reported to CCL that resident (R1) eloped from the facility due to lack of care and supervision and staff did not follow reporting requirements. [Continued on LIC 9099-C] Unsubstantiated [Continued from LIC 9099] Regarding the allegation, resident (R1) eloped from the facility due to lack of care and supervision, it was reported that R1 left the facility unattended and sustained a scratch to the arm due to a fall. It was reported that R1 was located but continues to elope from the property. Records review revealed that R1 has a diagnosis of Dementia and is unable to leave the facility unassisted. Records review revealed that facility issued a 30-day notice to R1 due to R1 requiring a higher level of care for exit seeking behaviors. Interviews with staff revealed that R1 has began exhibiting exit seeking behaviors but has never been out of staff sight. Staff report that they will follow R1 when R1 exits the facility and will redirect to come back. Staff reported an incident where R1 was observed with a scratch to the arm but was unable to determine where/how R1 sustained the scratch. No reports of anyone observing R1 off facility property. Staff reported no concerns for lack of supervision. Interview with R1 reported that they have never been out of the facility unassisted and reported that staff will accompany if they want to go for a walk. R1 reported having no concern for lack of supervision and reported that staff are “helpful”. R1 stated they do not recall an incident where they fell and sustained a scratch to the arm. Interview with outside source revealed no concern for the facility. Regarding the allegation, staff did not follow reporting requirements, it was alleged that facility staff were instructed my management not to report an incident where resident was AWOL (absent without leave) from facility. Interview’s with staff revealed that staff have never been instructed by management not to report something. Facility staff reported that there was some confusion amongst staff about what is considered a reportable AWOL and what is not. Facility reported that staff were re-trained on AWOL procedures, and it was made clear that once a resident is not being supervised by a staff member it is considered an AWOL. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Mitchell. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Mitchell whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Aug 8, 2024 · control 08-AS-20240209104244

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Executive Director Rebecca Toves and discussed the purpose of the visit. Community Care Licensing received an incident report on 6/19/2024 in which it was reported that Resident #1 (R1) went absent without official leave (AWOL) from the facility on 6/13/2024. Staff was driving to the facility and circled the perimeters per usual route. Staff noticed that back gate was ajar and located R1 walking towards the facility. Facility staff were notified of gate being open per alarm on walkies. Staff failed to check back gate and clear alarm. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. Deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plan of Correction was jointly developed with the Toves. An exit interview was conducted with Sano, to whom a copy of this report, the LIC 809-D and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visitthe state’s words, verbatim · CDSS document, Jun 21, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.317 · Plan of correction due date: Jul 21, 2024

1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall…develop and comply with an absentee notification plan…The plan shall include…a requirement that an administrator of the facility, or his or her designee, inform the resident’s authorized representative when that resident is missing from the facility…and the circumstances in which [they] shall notify local law enforcement.” This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 117 residents (R1), the licensee did not comply with its absentee notification plan. This posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 21, 2024

Plan of correction: Executive Director will ensure that a staff training on elopment procedures is conducted and will email sign in sheet to LPA by POC due date.

Allegation investigated: Facility in disrepair

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced visit to deliver investigative findings. LPA was granted entry into the facility and met with Executive Director Rebecca Toves to whom LPA explained the purpose of the visit. Community Care Licensing (CCL) has investigated the above listed complaint allegation. The investigation consisted of LPA direct observation, records review and interviews with staff and residents. It was alleged that the facility was in disrepair. It was reported to CCL that Resident 1 (R1)(an LIC 811 Confidential Names List was provided to the facility representative to identify the resident) had a broken window. It was also reported that residents have broken toilets and clogged sinks throughout the facility. LPA visit to the facility on May 30, 2024 revealed a broken window in R1's room. LPA interviewed R1 on May 30, 2024 and June 18, 2024. R1 was not able to state how or when the window in R1's bedroom was broken. R1 stated that R1 was informed by facility staff that the window was broken. Unsubstantiated Records review dated May 28, 2024 revealed online communication with a glass repair company regarding the replacement of R1's window. An invoice dated May 31, 2024 revealed the window was scheduled to be repaired on June 5, 2024. LPA direct observation on June 18, 2024 revealed R1's window was repaired and there were no unresolved maintenance issues in R1's room. During LPA's visit to the facility on May 30, 2024, LPA visited three (random) resident rooms and inspected the sinks, toilets and bathtubs. LPA did not encounter any clogged sinks, bathtubs or broken toilets. LPA found all of the sinks, tubs and toilets to be functioning as normal. Interview with Executive Director (ED) revealed R1 threw something at R1's bedroom window causing it to "spider" but not completely shatter on approximately May 26, 2024. ED stated that she has been in contact with several glass repair companies. ED stated that the facility had been without a maintenance worker for approximately one month. ED stated that during that time period they received maintenance staff assistance from their "sister facility" and from "corporate." ED stated that they currently have a maintenance applicant that has been hired and passed the background check. ED further stated that this new maintenance worker will start after he has gone through the on-boarding process. Based upon the foregoing, the above listed allegation is unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegation is not valid. An exit interview was conducted with Rebecca Toves. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Rebecca Toves whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Jun 18, 2024 · control 08-AS-20240529112342

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management visit to amend report for missing signatures. No deficiencies were issued during this visit. An exit interview was conducted with Business Manager Ana Solis copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Apr 4, 2024

Allegation investigated: Staff did not assist residents with care needs Facility had incomplete files for residents Staff falsified documents

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Rebecca Toves On January 12, 2024, Community Care Licensing (CCL) received a complaint alleging facility staff do not assist residents with care needs, facility has incomplete files for residents and staff falsified documents. During investigation, LPA Ramirez reviewed records, toured the facility and conducted interviews of staff, residents and outside sources. It was alleged that facility staff did not assist residents with care needs. LPA’s interviews with residents revealed no concern for staff not assisting with care needs. Interviews with facility staff revealed conflicting statements about particular staff not doing their duties and revealed that other staff will take over those duties to ensure that residents are cared for. Outside Source reported no concerns for the facility. [Continued on 9099-C] Unsubstantiated [Continued from 9099] It was alleged that facility had incomplete files for residents. LPA conducted file reviews and did not see any incomplete files. LPA received conflicting statements from staff about whether or not they have seen incomplete resident files. One staff reported seeing incomplete files but was unable to provide names of residents with incomplete files. Outside source reported no concerns for the facility. It was alleged that facility staff falsified documents. LPA conducted file reviews and files reviewed were complete and consistent with all paperwork in the file. Physician’s names and signatures matched all documents. Interviews with facility staff did not avail any concerns for falsified documents. Outside source reported no concerns for the facility. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Executive Director Rebecca Toves. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Toves whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Apr 2, 2024 · control 08-AS-20240112092031

Allegation investigated: Facility staff leave residents in soiled bedding

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Rebecca Toves On January 18, 2024, Community Care Licensing (CCL) received a complaint alleging facility staff leave residents in soiled bedding. During investigation, LPA Ramirez reviewed records, toured the facility and conducted interviews of staff, residents and outside sources. It was alleged that facility staff leave residents in soiled bedding. Interviews with facility staff revealed that there have been concerns for staff leaving residents in soiled bedding. LPA conducted records review and verified that a staff member had received a progressive disciplinary action form for an incident where a resident was left soiled during a night shift. [Continued on 9099-C] Substantiated [Continued from 9099] Based on evidence obtained, the preponderance of evidence standard was met, therefore, the allegation was Substantiated. The deficiency was cited in accordance with California Code of Regulations, Title 22, and listed on the LIC 9099D. A plan of correction was jointly formulated with Executive Director Rebecca Toves. An exit interview was conducted with Toves, to whom a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058) were provided.the state’s words, verbatim · CDSS document, Apr 2, 2024 · control 08-AS-20240118142103

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)2 · Plan of correction due date: May 2, 2024

Managed Incontinence - Licensee shall be responsible for ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Facility records show that residents often wake up with soiled diapers and linen.the state’s words, verbatim · CDSS document, Apr 2, 2024

Plan of correction: Administrator shall retrain staff on proper incontinence care and hold them responsible for complying with these requirements. A copy of this training shall be provided to CCL by POC date indicating the date, topic, and attendees.

Allegation investigated: Facility does not have an adequate food supply

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced visit to deliver findings in the above complaint allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Rebecca Toves On February 5, 2024, Community Care Licensing (CCL) received a complaint alleging that facility does not have adequate food supply. During investigation, LPA Ramirez reviewed records, toured the facility and conducted interviews of staff, residents and outside sources. [Continued on 9099-C] Unsubstantiated It was alleged that facility does not have adequate food supply specifically referencing an incident where facility ran out of milk. LPA interviews with facility staff revealed that there was an incident where they ran out of milk due to a shift in resident demand for milk as a beverage at meal times. Facility staff reported that there are always multiple beverage options at meals including water, coffee, soft drinks and tea. Facility staff stated that they have increased their milk supply since the incident. Facility staff denied any concerns for lack of food supply at the facility. Interviews with residents revealed no concerns for facility lacking food. LPA toured facility kitchen and observed food supply to be adequate. Outside Source reported no concerns for the facility. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. No deficiencies were cited today. An exit interview was conducted with Executive Director Rebecca Toves. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Toves whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Apr 2, 2024 · control 08-AS-20240205162825

Type of visit: Case Management - Other

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced Case management visit. The LPA identified himself, and explained the purpose of the visit to Executive Director Rebecca Toves. During today's visit, the LPA secured report signatures and delivered an amended report. An exit interview was conducted with Toves, to whom a copy of this report and the licensee appeal rights (LIC9058) were provided.the state’s words, verbatim · CDSS document, Mar 6, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced case management visit to review a plan of correction. The LPA introduced herself and disclosed the purpose of the visit to Executive Director Rebecca Toves. During the visit the LPA confirmed and secured documentation to clear Plan of Corrections (POC) cited on 2/2/2024. POC's letters were provided to the Executive Director confirming the POC's were completed. An exit interview was conducted with Executive Director Toves. A copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) were provided to the facility at the conclusion of the visit. The signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Mar 4, 2024

Allegation investigated: Facility retained resident not appropriate for facility Facility had uncleared staff

Licensing Program Analyst (LPA) Renita Hall conducted an unannounced visit to open a complaint and deliver findings. LPA was allowed entry by Ana Solis, Business Office Manager. The interview was later joined by Rebecca Toves, Executive Director. LPA identified herself and disclosed the purpose of the visit and elements of the findings to the Business Office Manager and the Executive Director. On February 22, 2024, the Department received allegations that a resident residing in the facility was not appropriate for the level of care provided by the facility. Additionally, there were claims that the facility had uncleared staff working with residents. This investigation report aims to address these allegations and determine the validity of the claims. The LPA conducted interviews with staff members and outside sources. A review of the resident's medical records and care plans and toured the facility {Continued on 9099C}amended report at 12:22 pm to include additional Resident (R2) Unsubstantiated 1. Resident Appropriateness: After reviewing the resident's medical records and care plans, it was determined that the resident was appropriate for the level of care provided by the facility. The resident's needs were being met, and there were no indications that the resident required a higher level of care before hospitalization. It was determined before release from the hospital that the resident needed a higher level of care. The family member did not want the resident to go to a Skilled Nursing Facility (SNF). As of February 22, 2024, the resident is no longer residing at the facility. The family member retrieved the resident's belongings. The resident was hospitalized on February 14, 2024, directly from an appointment with dialysis. Resident 2 (R2) was deemed appropriate for the facility at Level 1 based on the assessment conducted before move-in to the facility. R2 was diagnosed with aphasia s/p stroke, which caused communication limitations for R2. The staff interviewed did not deem R2's behavior as "aggressive" but as frustration due to limited communication. 2. Staff Clearance: All staff members working with residents had undergone the necessary background checks and clearance processes as per the facility's policies and procedures. No uncleared staff members were working with residents at the time of the investigation. Based on the findings of the investigation, the allegations that the facility retained a resident who was not appropriate for the level of care provided and had uncleared staff working with residents are unsubstantiated. A finding that is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Rebecca Toves, Executive Director. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Executive Director and her signature on this report confirms receipt of the Licensee Rights.the state’s words, verbatim · CDSS document, Feb 28, 2024 · control 08-AS-20240222151847

Type of visit: POC

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced case management visit to review a plan of correction. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Rebecca Toves. During the visit the LPA confirmed and secured documentation to clear a Plan of Correction (POC) cited on 2/21/24. A POC letter was provided to the Executive Director confirming the POC was completed.. An exit interview was conducted with Executive Director Toves. A copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) were provided to the facility at the conclusion of the visit. The signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Feb 23, 2024

Allegation investigated: Staff did not assist resident with transportation to medical appointments

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Memory Care Director Jeralyn Markiewicz. Throughout the investigation, the Department secured pertinent records and conducted interviews with external and internal sources, including staff and residents. It was alleged the facility did not assist residents with transportation to medical appointments. It was reported to the Department that the facility advertised transportation, but the facility did not transport residents to medical appointments. Interviews revealed the facility had a transportation vehicle but did not have a qualified driver for several months. The transportation vehicle required a staff member to have a commercial drivers license. Due to this the facility had decreased their transportation schedule from Tuesday and Thursdays to only providing transportation on Thursday. The facility would request a vehicle from a sister facility, offer the clients Uber services, or suggest the use of public transportation. Substantiated Additional interviews revealed the facility may, or may not cover the Uber bill, and some medical appointments were missed due to the lack of transportation service at the facility. A review of the facility’s website and admission agreement corroborated the facility had advertised transportation and agreed to provide such service. An interview with the facility’s Executive Director confirmed the facility was responsible for scheduling and providing transportation to medical appointments. Based on evidence obtained, the preponderance of evidence standard was met, therefore, the allegation was Substantiated. The deficiency was cited in accordance with California Code of Regulations, Title 22, and listed on the LIC 9099D. A plan of correction was jointly formulated with Memory Care Director Jeralyn Markiewicz. An exit interview was conducted with Markiewicz, to whom a copy of this report, LIC 9099D and Licensee/Appeals Rights (LIC 9058) were provided. Based on the evidence obtained at the facility, there was not a preponderance of evidence to prove the alleged violation occurred. The allegation was unsubstantiated. An exit interview was conducted with Markiewicz, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058) were provided.the state’s words, verbatim · CDSS document, Feb 21, 2024 · control 08-AS-20240103143529

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Feb 21, 2024

87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement was not met as evidenced by: Based on review of records and interviews, the licensee did not make arrangements to ensure transportation to medical appointments, which posed a potential health, safety, and personal rights risk to 130 of 130 in care.the state’s words, verbatim · CDSS document, Feb 21, 2024

Plan of correction: Memory Care Director (MCD) agreed to hire a driver as soon as possible. Director will coordinate with staff, residents, and sister facility to arrange transportation medical appointments. MCD agreed to provide the LPA proof of facility advertising for a driver, by 02/22/24.

Type of visit: Case Management - Annual Continuation

Licensing Program Analysts (LPA) Amy Rodgers, made an unannounced visit to conduct the required One-Year Inspection to ensure substantial compliance with Title 22 regulations. LPA Rodgers was granted entry into the facility Executive Director Rebecca Toves, after identifying herself and stating the purpose of the inspection. This facility serves one hundred fourty five, residents 60 and above. Hospice waiver approved for fifteen. A tour of the facility was conducted which included a sample of resident units, the dining area, common gathering areas, and food storage areas. There is a water features in the courtyard made inaccessible to residents. Each resident had clean and sufficient bed linens. All residents’ rooms were equipped with the required furnishings. Overhead as well bedside lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Showers were equipped with grab bars. Hot water temperature in residents’ bathrooms were compliant. The facility is operating in accordance with their fire clearance. The smoke and carbon monoxide alarms were present in each building. Emergency lighting, and facility telephone were all working. First aid kit(s) were complete and readily accessible in the medical rooms. Required licensing postings were observed in visible areas of the facility. PPE supplies are onsite. Indoor passageways were free from obstructions. Food supply is replenished frequently by outside vendors. Food was observed to be properly labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted. Centrally stored medications were properly stored and locked in medication carts. Medications were labeled and kept in compliance with label instructions. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Resident records were reviewed and confirmed compliant. Administrator’s certification is current. LPA reviewed the theft and loss policy and procedures. LPAs conducted a review of In-service training procedures. LPA interviewed Executive Director Toves as well as staff and was assured transportation procedures as well as outside medical and dental assistance procedure are compliant. There are two large common rooms used for dining and activities. At the time of visit, LPA observed a few residents participating in a small group activity. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. Staff records review verified that all staff records were not complete and compliant. During today’s visit, LPA file review and staff interview, for 6 of 6 care staff (S1-S6) licensee did not have the required First Aid and/or Cardio Pulmonary Resuscitation (CPR) certificates , which posed a potential safety risk to persons in care. Facility has a two-day supply of perishable food and did not have a seven-day supply of nonperishable food items. Some food supplies were kept in in an locked storage area. During today’s visit, LPA observed storeroom with very limited food supplies. Therefore, did not meet the required one week of nonperishable ‘supplies, which posed a potential health and safety risk to persons in care. During today’s visit LPA toured residents’ rooms and observed some showers did not have non-skid mats or non-skid strips. This poses a safety risk to persons in care. An exit interview was conducted with Executive Director Tover to whom copies of this report, Licensee/Appeal Rights (LIC9058 03/22), and 809-D’s were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 2, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Rodgers conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Rebecca Toves. During today’s visit, LPAs briefly toured the facility, reviewed staff and resident records, and interviewed staff and residents. No deficiencies were cited during today’s visit. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection. An exit interview was conducted with the Executive Director Toves, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Jan 30, 2024

Allegation investigated: Staff did not follow universal precautions Staff are not isolating residents with infectious diseases

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Executive Director Rebecca Toves and discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegations. The investigation consisted of records review, interviews with facility staff, clients and outside agency. It was reported to CCL that staff do not follow universal precautions for COVID and staff are not isolating residents with infectious diseases. [Continued on LIC 9099-C] Unsubstantiated [Continued from LIC 9099] LPA’s interview with Executive Director and Resident Services Director revealed that there was a COVID outbreak in the facility with approximately sixteen (16) residents affected. They reported that the facility has a COVID mitigation plan and it was followed. They reported that residents who tested positive for COVID were asked to isolate for five (5) days and if after five days if the resident still had symptoms they were asked to continue to isolate until they have no symptoms. They stated that signage was placed outside positive resident’s doors and PPE was left outside the bedrooms. Positive residents all had a designated caregiver who monitored their symptoms. During the outbreak there was no communal dining, and they utilized cart service for meals. All staff, physician’s and responsible parties were notified of the outbreak and the change in dining services. Interviews with facility staff revealed that staff were aware of the outbreak and protocol’s were followed. Staff reported that positive residents isolated, all parties were notified, and PPE was provided. LPA reviewed facility records, including facilities’ COVID mitigation plan and COVID positive residents daily notes that showed that facility followed COVID protocols. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met and the allegations are not valid. An exit interview was conducted with Executive Director Rebecca Toves. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Executive Director Rebecca Toves whose signature below verifies receipt of these rights.the state’s words, verbatim · CDSS document, Dec 27, 2023 · control 08-AS-20231106122214

Allegation investigated: Facility staff did not ensure that resident room notification is working properly.

Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced complaint visit to deliver findings on the above allegation. LPA met with Executive Director Rebecca Toves and we discussed the purpose of the visit and elements of the complaint. Community Care Licensing (CCL) has investigated the above allegation. The investigation consisted of LPA direct observation and interviews with facility staff and residents. It was reported to CCL that Resident 1's (R1) (an LIC 811 Confidential Names List was provided to the facility representative to identify the resident.) call pendent was broken and R1 was unable to get staff's assistance. LPA visited the facility on November 1, 2023. LPA escorted by facility staff went to R1's room. Facility staff pressed R1's pendant button and a red light blinked. Facility staff advised LPA that the blinking light meant the pendant button was working. LPA was then escorted to the Pendant button control room to verify on the computer that the pendant button was activated. Substantiated Facility staff was unable to retrieve the pendant information via computer so facility staff asked a caregiver to press R1's pendant button so we could hear it over the speaker. Several minutes passed and facility staff advised LPA that R1's pendent button was not working. Facility staff replaced R1's pendant button and LPA was able to hear via radio/speaker that R1's pendant button was functional and working. Facility staff advised LPA that the call button system in the facility was old and has issues at times. Based upon the foregoing, the above listed allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. Deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and is noted on the attached LIC 9099-D. An exit interview was conducted with Rebecca Toves and a copy of this report and Licensee/Appeal Rights (LIC9058, 3/22) were provided to Rebecca Toves whose signature below confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 27, 2023 · control 08-AS-20231027120157

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1) · Plan of correction due date: Dec 8, 2023

Facilities shall have signal systems...All facilities licensed for 16 or more...shall have a signal system which shall:Operate from each resident's living unit.Transmit a visual and/or auditory signal to a central staffed location...loud enough to summon staff. This requirement was not met as evidenced by: Based on LPA direct observation the licensee did not have a functional signal system for R1 [1] of [1] of 109 persons in care which posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 27, 2023

Plan of correction: Licensee agreed to do "pendant checks" every week and will conduct a managment training regarding pendant system and will provide proof of training to LPA by POC due date of 12/8/23

Allegation investigated: Staff inappropriately touched resident

Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced complaint visit to deliver investigative findings. LPA met with Jenifer Brown, Resident Services Director, and shared findings. The Department investigated the above-listed complaint allegation. The investigation consisted of observations, a review of relevant records, and interviews with facility staff, and outside sources. On October 5, 2023, Community Care Licensing (CCL) received a complaint alleging that a facility staff (S1) inappropriately touched a resident (R1), [an LIC 811 Confidential Names List was provided to staff to identify the resident and staff]. On September 19, 2023, R1 communicated that S1 had touched their “private area” inappropriately. Facility staff immediately reported the incident to law enforcement. (continue at LIC9099C) Unsubstantiated Continue from LIC 9099 A review of law enforcement incident report indicated that they were not able to establish mistreatment or abuse of R1 based on the information provided. A detailed review of R1’s medical records and service care plan indicated that R1 had a diagnosis of dementia and was prescribed medication to suppress pain and erratic behaviors. Statements obtained by law enforcement, outside sources, and staff regarding the alleged incident during interviews with R1 were inconsistent due to their dementia. During a visit to the facility conducted on October 10, 2023, R1 was not available for an interview. A review of camera footage during the time frame of the alleged incident, seen by outside sources and facility staff did not show any questionable or suspicious activity. The video footage as reported by outside sources and facility staff showed S1 performing incontinence care to R1, as required in R1’s service care plan. The video footage was not available for review during the investigation. A review of S1’s personnel records did not indicate any disciplinary actions or misconduct. During interviews, S1 denied the allegation and stated that they were conducting routine incontinence care following normal procedures as part of their job responsibilities. After the incident, as an extra precautionary measure, facility staff instituted two-person assist for R1 when conducting incontinence care. Based on record reviews and interviews with staff and outside sources, there was insufficient evidence to support the allegation that S1 inappropriately touched R1. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Resident Services Director, Jenifer Brown, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 08-AS-20231005114844

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Garcia-Centeno opened a complaint investigation and in conjunction conducted a case management visit to the facility to ensure the safety and welfare of the residents in care. LPA Garcia-Centeno identified herself and stated the purpose and reviewed basic elements of the case management visit with Business Office Manager, Rebecca Toves. LPA reviewed infection control procedures to ensure the health and safety of the residents in care. In addition, LPA requested facility staff to complete the reporting requirements to Community Care Licensing regarding the active COVID-19 outbreak. An exit interview was conducted with Business Office Manager, Rebecca Toves and a copy of this report along with the Licensee Appeal Rights (LIC9058 03/22) were provided at the completion of the visit.the state’s words, verbatim · CDSS document, Oct 10, 2023