Brittany House

Allegation investigated: Resident sustained an unstageable pressure injury due to staff neglect/lack of supervision.

On 08/04/2026 at 08:25, the department conducted an subsequent visit at this facility to deliver the complaint findings for the allegation above. During today’s visit, LPA met with Esperanza Naaktgeboren (Administrator) and explained the purpose of the visit. On 12/02/2025, at 8:55am, the department initiated an unannounced complaint investigation for the allegations listed above. During the initial visit, the department met with Joel Niblett (Administrator) and the purpose of the visit was explained. The department interviewed with Staff (S1-S7) on 12/05/2026 between the hours of 9:21am - 3:00pm, on 12/03/2025 with Administrator (A1) at 10:57am & on 08/04/2026 between the hours of 8:31am - 940am Residents (R2- R10). LPA also requested and received the documents: Staff Roster (dated 11/17/2025), Client Roster (received on 12/02/2025), Resident #1 (R1's) documents such as LIC 601 Identification & Emergency Form (not dated), LIC 602: Physician Report (dated 09/09/2025), Service Plan (dated 09/17/2025), Admission Agreement (dated 09/2025), Medication List (printed 09/06/2025), continues on LIC 9099-C Substantiated Outside Agency Service Documentation (dated 09/13/2025 & 11/21/2025), Resident Assessment (dated 09/17/2025), OMNI Wound Physicians (date of service 11/21/2025), Outside Agency(Omni Wound Physicians) /Service Documentation (dated 11/21/2025) and UCI Lakewood Medical Records (dated 11/21/2025) The investigation revealed the following: Allegation:Resident sustained an unstageable pressure injury due to staff neglect/lack of supervision It was alleged that the facility failed to provide adequate care and supervision to a resident, resulting in the development of a significant medical condition identified an unstageable sacral wound on a resident who has a history of Alzheimer’s and dementia. On 12/03/2025 at 10:57am, the Department interview the former administrator (A1) in regards to the allegation. A1 stated he did not know the resident’s skin-check schedule, did not recall any pressure-injury prevention procedures, did not know when the pressure injury was first observed, and was unaware of any documentation or repositioning logs. A1 repeatedly stated information was “unknown to me,” indicating no direct knowledge of the resident’s wound, monitoring, or care practices. On 12/02/2025 between the hours of 9:27am - 3:10pm, the department conducted 8 staff regarding the allegation. 3 out of 7 staff confirmed the allegation and stated R1's pressure injury was bleeding and required hospital transfer. S1 reported notifying the LVN several times and stated not being trained for wound care. S2 stated the wound was first observed by another caregiver and that hospice did not respond quickly. S2 explained that the facility cleaned around the wound and covered it with gauze before sending the resident to the hospital. S6 stated repeatedly reported the wound and that Home Health never came to assess it. S6 also stated the medtech did not monitor the wound closely and that documentation between medtechs was often missing. 5 out of 7 staff did not confirm nor deny the allegation and mentioned general care routines such as daily body checks and repositioning is documented. None of 5 staff who did not confirm nor deny the allegation had direct knowledge of the R1's pressure injury. On 08/04/2026 between the hours of 8:31am - 9:40am, the Department conducted interviews 10 residents in regards to the allegation. 6 out of 10 residents denied the allegation and stated that stated that staff are responsive, attentive, perform skin checks, and assist with comfort and repositioning when needed. These residents reported staff respond quickly to call-lights, assist with turning or repositioning, check skin regularly, and help when pain or discomfort occurs. 4 out of 10 residents did not confirm nor deny the allegation and stated they are mostly independent with repositioning, occasionally experience delays in receiving assistance, and or were unsure how often staff assist with movement or skin checks. On 07/26/2026 between the hours of 2:00pm - 3:00pm, the department conducted a records review and observed the following: R1 was admitted to UCI Health – Lakewood on 11/27/2025 after being transferred from Brittany House due to a sacral wound present for approximately one week, with drainage, worsening erythema, and wound pain. Prior to hospitalization, the resident was evaluated by OMNI Wound Physicians on 11/21/2025, where the sacrococcygeal wound was identified and categorized as a Stage 4 pressure ulcer. OMNI documented pre-debridement wound measurements of 4.5 cm × 3.0 cm × 0.3 cm, and post-debridement measurements of 4.6 cm × 3.1 cm × 0.4 cm, with a total debrided area of 7.13 cm². OMNI ordered Santyl ointment, silicone bordered foam dressings, an alternating pressure pad/low air loss mattress, and off-loading/turning every 2 hours. Upon hospital admission on 11/27/2025, the wound was documented as an unstageable sacral pressure injury due to slough, thick eschar, and necrotic tissue, measuring approximately 5.0 cm × 4.5 cm. The wound had progressed to acute hematogenous osteomyelitis of the sacrum (left S2) and sepsis, with positive blood cultures for Staphylococcus epidermidis and wound cultures growing Proteus mirabilis. The resident underwent three debridements: one by OMNI on 11/21/2025, one at UCI Health on 11/29/2025, and a surgical excisional debridement down to fascia/necrotic tissue on 12/05/2025 by General Surgery. The resident required broad-spectrum IV antibiotics, nutritional supplementation, and placement on an air-fluidized Envella bed with a Q2-hour turning protocol. Records further indicated the resident’s family was not notified by Brittany House that a sacral wound had developed. Additionally, the resident’s LIC 602A, completed on 09/09/2025, indicated no history of skin breakdown, and documented the resident as ambulatory, able to independently transfer, and not requiring continuous bed care. The hospital documentation stating the resident had been bedbound for approximately nine months prior to admission. R1 was discharged on 12/13/2025 to Cerritos Vista Skilled Nursing Facility with a Wound VAC in place. Also, effective as of 12/13/2025, R1 is no longer a resident at the facility. Based on interviews and records reviewed facility staff failed to ensure R1 received proper wound care such as repositing which resulted in the resident developing a stage 4 pressure injury that required medical intervention. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000). An immediate $500 civil penalty assessed. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Esperanza Naaktgeboren (Administrator) and a copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Aug 4, 2026 · control 11-AS-20251201153121

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Aug 5, 2026

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: Based on interviews and records review facility staff failed to reposition R1 as required by residents Home Health which resulted in the R1 developing a stage 4 pressure injury. This poses an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: Licensee shall ensure all staff receiving training on personal rights, provisions for providing care and supervision and resident care plans. License shall submit proof of training by POC due date. Email proof to LPA Brown at Zina.Brown@dss.ca.gov An immediate $500 civil penalty assessed.

Type of visit: Case Management - Deficiencies

On 08/04/2026, at 12:30pm, Licensing Program Analyst, LPA Zina Brown conducted a Case Management for complaint Control Number 11-AS-20251201153121. LPA met with Esperanza Naaktgeboren, Administrator as the purpose of the visit was explained. ** Please be advised: when the Department initiated this investigation for complaint Control Number 11-AS-20251201153121., Joel Niblett was serving as the facility’s Administrator The department conducted interviews on 12/03/2025 with Administrator (A1) at 10:57am, on 12/05/2026, with Staff (S1-S7) between the hours of 9:21am - 3:00pm, and on 08/04/2026 between the hours of 8:31am - 940am with Residents (R2- R11). LPA conducted an initial unannounced complaint investigation on 12/05/2026 in regards to a resident sustained an unstageable pressure injury due to staff neglect/lack of supervision. Based on records review the facility retained Resident 1 (R1), who had a unstageable pressure injury which is prohibited by title 22 regulations. The facility failed to submit an exception request from the department to retain R1. Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D with civil penalty assessed. Exit interview conducted with Esperanza Naaktgeboren (Administrator), and copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Aug 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Aug 5, 2026

Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on records review and interviews conducted the facility failed to request an exception from Licensing when R1 developed a Stage 4 pressure injury, which is a prohibited health condition. This poses an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: Licensee shall ensure staff receive training on prohibited health conditions and submit proof of the training to the department by POC due date. Email proof to LPA Brown at Zina.Brown@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Aug 5, 2026

Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on records review and interviews conducted the facility failed to request an exception from Licensing when R1 developed a Stage 4 pressure injury, which is a prohibited health condition. This poses an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: Licensee shall ensure staff receive training on prohibited health conditions and submit proof of the training to the department by POC due date. Email proof to LPA Brown at Zina.Brown@dss.ca.gov

Allegation investigated: Inadequate food services Facility water system is in disrepair Staff do not ensure that residents' showering needs are met while in care

On 7/21/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Executive Director, Esperanza Naaktgeboren and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 7/21/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, weekly Menu for July 19 - 25, Alternative Menu, Alternative Menu selection options, Invoice from Ironwood Plumbing, Water Temperature Recordings for June and July 2026, Outside Agency/Services Documentation, shower schedules, list of special diets and food allergies. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 6 (S1 – S6), and Resident 1 – Resident 6 (R1-R6). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Inadequate food services It is being alleged that there aren’t alternative food options available for residents in care. On 7/21/26, LPA Felisa Shirley observed and requested copy of the Alternative Menu of food options offered to residents in care. LPA Shirley also observed the selection options handouts for the Alternative Menu. Per the selection options, the handouts request resident’s name, room number, date and instructions to circle their preferred alternate option if desired. On 7/21/26, LPA Shirley interviewed S3, the Maintenance Assistant, who stated that a vending machine was brought to the facility to provide snacks to the residents who desire additional snacks. LPA interviewed facilities Dietician Manager, S4 on 7/21/26 and they stated that they’ve established rotating menus to accommodate each resident. During this interview, S4 indicated peanut products were temporarily removed from the menu to accommodate the dietary needs of a resident with a peanut allergy and to help ensure a safe dining environment. S4 also offered that during their recent menu review, they evaluated their food service policies to ensure that they are offering a fair variety to all residents. During the monthly Resident Council meeting they announced that they have decided to bring peanut products back to the menu. Staff would be working closely with residents to ensure safe alternatives are in place for the residents in care. Per the interview with S4 on 7/21/26, a water pitcher and an ice chest are available in each resident unit to support hydration. In addition, staff routinely offer water to residents in their rooms throughout the day to help ensure adequate hydration. LPA interviewed staff 1 – staff 6 (S1 – S6). Of those interviewed 5 out of 6 denied the allegation. One confirmed the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 6 out of 6 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Inadequate food services,” therefore, the allegation is unsubstantiated. Allegation: Facility water system is in disrepair It is being alleged that the facility’s water system does not support resident care needs. On 7/21/26, LPA Shirley observed an invoice from Ironwood Plumbing dated 7/21/26. LPA Shirley also received a copy of the Con'd on 9099-C Water Temperature Recordings for June and July 2026. The recorded water temperatures met the regulatory minimum and maximum temperature requirements. Water temperatures are checked weekly in different locations. Per interview with S3 on 7/21/26, since 7/13/26, while the Maintenance Manager has been on vacation, the Maintenance Assistant, S3 has been overseeing maintenance operations. During this time, the domestic hot water temperature has been dropping overnight. To ensure residents are able to shower as scheduled, S3 has been resetting the water heater temperature each morning and monitoring throughout the day. Per interview with the Executive Director, S1, once given notice of problem with the hot water, a technician was called and scheduled to come to the facility on 7/21/26. Upon review of the invoice from Ironwood Plumbing dated, 7/21/26, a part was replaced and the water heater is up and running at this time. LPA interviewed staff 1 – staff 6 (S1 – S6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 6 out of 6 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Facility water system is in disrepair,” therefore, the allegation is unsubstantiated. Allegation: Staff do not ensure that residents' showering needs are met while in care It is being alleged that R6 isn’t able to have showers as scheduled by home health due to water temperature issues. On 7/21/26 LPA Shirley received copy of Outside Agency/Services Documentation from Caring Cove Home Health (CCHH) dated, 6/27/26. CCHH sends a Technician to Brittany House every Wednesday and Saturday to give shower services to R6. On 7/21/26 LPA Shirley called to verify R6’s service history. LPA Shirley was informed that the last service was completed on Saturday, 7/18/26, and the next scheduled service is tomorrow, Wednesday, 7/22/26. The Representative Annie verified service with the technician which stated that they did not report any issues with the water during previous service appointments. LPA interviewed staff 1 – staff 6 (S1 – S6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 6 out of 6 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure that residents’ showering needs are being me while in care,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Executive Director, Esperanza Naaktgeboren.the state’s words, verbatim · CDSS document, Jul 21, 2026 · control 11-AS-20260714094134

Allegation investigated: Staff did not seek timely medical attention for a resident.

On 07/14/26, the department conducted an unannounced subsequent complaint visit to further investigate the allegations listed above. The department met with Esperanza Naaktgeboren, Administrator, and the purpose of the visit was explained. The department was granted entry to the facility. The investigation consisted of the following: On 04/28/26 the department obtained the following documents: staff roster, resident roster, 24 Hour Communication Log dated: 04/13/26, an Unusual Incident/Injury Report (SIR) dated: 04/16/26, and a copy of the Physician’s Orders for residents #1-#10 (R1-R10). Additionally, the department conducted interviews with staff #1-#6 (S1-S6) and R2-R4 and attempted to interview R1. On 07/14/26, the department conducted interviews with R5-R10. Additionally, the department conducted a tour of the facility. Continued on LIC9099-C Substantiated The investigation revealed the following: For the allegation: Staff did not seek timely medical attention for a resident. It is alleged that staff failed to obtain prompt medical care for a resident who experienced a fall, waiting until the following day to seek medical attention. On 04/28/26 and 07/14/26, the department conducted interviews with S1-S6 and attempted to interview S7 but was unable to as they are no longer working at the facility. Of those interviewed, 6 out of 6 staff corroborated the allegation. An interview with S1 revealed that on 04/13/26, R1 sustained an unwitnessed fall during the night. Morning staff observed a skin tear and bruising and reported the injuries to the Med-Tech and LVN; however, the LVN did not immediately assess the resident. S1 stated that after R1 continued complaining of pain, another LVN evaluated R1 and arranged transport to the hospital, where they resident was diagnosed with a fractured femur. S1 said that they investigated and found that the delay in assessment by the LVN contributed to a delay in medical treatment for R1. On 04/28/26 and 07/14/26, the department conducted interviews with R2-R10 and attempted to interview R1 but was unable to because they passed away on 04/25/26. Of those interviewed, 9 out 9 residents could not corroborate the allegation. On 04/28/26 and 07/14/26, the department conducted a review of records. The department reviewed a Special Incident Report (SIR) dated: 04/16/26 that reported that on 04/13/26, R1 sustained an unwitnessed fall. SIR reported that on 04/13/26 around 7:00 am, staff observed a skin tear on R1’s left elbow area, and discoloration on their left elbow and left hip. SIR further reports that the caregiver reported R1’s condition to the Med-Tech, and LVN. It states that the LVN assessed R1 around noon and treated the skin tear and noted the discoloration. It further reports that at approximately 3:00 pm, caregivers reported R1’s change of condition to the PM LVN, and R1 was sent out to Long Beach Medical Center. On 04/14/26 the facility was notified that R1 had a fracture and required surgery. The department reviewed the 24 Hour Communication Lod (dated: 04/13/26) which documented that during the AM shift it was noted that R1 was complaining of hip pain. It was also noted that staff observed a bruise like mark on R1's hip, and that R1 was unable to walk or stand up. It further notes that S2 and S7 were made aware at 7:20 AM. It was noted that on the PM shift, R1 was sent out by emergency services at 5:30 PM.Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be found to be substantiated. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D.An exit interview was conducted, and a copy of this report, along with appeal rights was provided to Esperaza Naaktgeboren. The investigation revealed the following: Allegation: Staff are restraining resident. It is being alleged that staff blocked a resident with chairs. On 04/28/26 and 07/14/26, the department conducted interviews with S1-S6 and attempted to interview S7 but was unable to as they are no longer working at the facility. Of those interviewed, 6 out of 6 staff denied the allegation. 6 out of 6 staff said they treat residents with dignity and respect. On 04/28/26 and 07/14/26, the department conducted interviews with R2-R10 and attempted to interview R1 but was unable to because they passed away on 04/25/26. Of those interviewed, 9 out of 9 residents could not corroborate the allegation. 9 out of 9 residents said staff treat them with dignity and respect. Based on observation, records reviewed, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been unsubstantiated. For the allegation: Staff do not provide privacy for residents. It is being alleged that staff leave the residents’ doors open when changing them. On 04/28/26 and 07/14/26, the department conducted interviews with S1-S6 and attempted to interview S7 but was unable to as they are no longer working at the facility. Of those interviewed, 6 out of 6 staff denied the allegation. 6 of 6 staff reported that residents are afforded privacy during changes. On 04/28/26 and 07/14/26, the department conducted interviews with R2-R10 and attempted to interview R1 but was unable to because they passed away on 04/25/26. Of those interviewed, 9 out of 9 residents could not corroborate the allegation. 9 out of 9 residents said staff treat them with dignity and respect. Based on observation, records reviewed, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been unsubstantiated. For the allegation: Staff leave residents in soiled briefs for an extended period of time. It is being alleged that residents are left in soiled/soaked briefs for an extended period of time. On 04/28/26 and 07/14/26, the department conducted interviews with S1-S6 and attempted to interview S7 but was unable to as they are no longer working at the facility. Of those interviewed, 6 out of 6 denied the allegation. 6 of 6 staff reported that residents are changed every 2 hours and as needed. On 04/28/26 and 07/14/26, the department conducted interviews with R2-R10 and attempted to interview R1 but was unable to because they passed away on 04/25/26. Of those interviewed, 9 out of 9 residents could not corroborate the allegation. Based on observation, records reviewed, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been unsubstantiated. For the allegation: Staff do not keep accurate resident records. It is being alleged that resident files are incomplete and unorganized. It is also being alleged that there is no signed medication list on file for med-techs to reference when administering medications. On 04/28/26 and 07/14/26, the department conducted interviews with S1-S6 and attempted to interview S7 but was unable to as they are no longer working at the facility. Of those interviewed, 6 out of 6 staff denied the allegation. On 04/28/26 and 07/14/26, the department conducted interviews with R2-R10 and attempted to interview R1 but was unable to because they passed away on 04/25/26. Of those interviewed, 9 out of 9 residents could not corroborate the allegation. 9 out of 9 residents said they receive their medication on time and as prescribed. 9 out of 9 residents said they are satisfied with the services being provided to them. On 07/14/26, the department inspected the medication room and observed the storage, preparation, administration, and documentation of medications in compliance with Title 22 Regulations. The department found that the medications are maintained in an orderly and accurate manner. A review of Medication Administration Records (MAR) is complete and correct. Based on observation, records reviewed, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Esperaza Naaktgeboren.the state’s words, verbatim · CDSS document, Jul 14, 2026 · control 11-AS-20260420101450

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jul 21, 2026

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental..., that appropriate assistance is provided when such observation reveals unmet needs... This requirement was not met as evidence by: Based on interviews, and records reviewed, (R1) suffered an unwitnessed fall and a change of condition was not observed for decline in health condition. This violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 14, 2026

Plan of correction: Licensee shall provide staff with training on observation of the residents, and the importance of seeking medical attention in a timely manner. Licensee will provide copies of training materials and sign in sheet to the department by POC due date 07/21/26, via email to Elvira.Gonzalez@dss.ca.gov

Type of visit: Case Management - Other

On 6/25/26 Licensing Program Analyst (LPA) Felisa Shirley conducted a Case Management visit to follow up on the incident report regarding Resident #1 (R1). LPA was greeted by Esperanza Naaktgeboren, Executive Director. LPA spoke with Esperanza and explained the purpose of the visit was to gather information regarding the incident report received 6/15/26, surrounding (R1). The Officer on Duty received a copy of an incident report from the facility listed above that reported the assault of (R1) on 6/13/26 around 2 pm. The incident report stated that approximately around 2 pm on 6/13/26 (R1) was just finishing showering, when there was a knock on the door. R1 went to the door wrapped in a bath towel. When she opened the door, staff S1 was there requesting to pick up an isolation cart. During this encounter, S1 allegedly touched R1’s bilateral breast area. Long Beach Police Department was called, no one came out for report. Report receipt was given on 6/13/26, 26-25903 for sexual battery. S1 was suspended and the last date he worked was 6/13/26, separation date was 6/17/26. S1 was called on 6/22/26 to come into the office on 6/23/26 at 12pm. S1 was terminated, he refused to sign documents as they were not in Spanish and S1 did not accept final paycheck. The following documents were requested: · Incident Report, 6/13/26 · Separation Notice · Facility Internal Communication Con'd on 809-C · Identification and Emergency Information · Physician’s Report · Resident Assessment · Service Plan No deficiencies were cited during this visit. An exit interview was conducted with the Executive Director, Esperanza Naaktgeboren and a hard copy was provided.the state’s words, verbatim · CDSS document, Jun 25, 2026

Allegation investigated: Staff caused injury to a resident in care.

On 6/3/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Esperanza Naaktgeboren and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 10/2/25 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, 24 Hour Communication Logs, Incident reports, Identification and Emergency Information, Physician’s Report, Service Plan, Dental Visit docs, Preplacement Appraisal, and Hospitalization list. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-6 (S1 – S6), and Resident -1 – Resident -6 (R1-R6). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff caused injury to a resident in care. It is being reported that R1 was observed with a bruise on their right forearm and stated that staff were abusing him. On 6/3/26, LPA Felisa Shirley reviewed Special Incident Reports for the months of March, April and May 2026 and did not observe any reports of injury to residents by staff members. During review of Special Incident Reports on 6/3/26, LPA Shirley observed an incident dated, 5/19/26 stating R1 had some discoloration to his right forearm. On 6/3/26, LPA Shirley reviewed the 24-Hour Communication Log dated 5/18/26, stating R1 was upset because he was being transferred to another room. The review of 24-Hour Communication Log also revealed that R1 had bruises on 5/19/26 and the Med-Tech was notified. On 6/3/26, LPA Shirley observed a large dark burgundy bruise on R1’s right forearm. During interviews on 6/3/26, R1 stated 3 to 4 staff workers were pulling his arms while dragging him on the floor preventing him from going home. Per interview with S1, R1 was transported to Long Beach Memorial, non-emergency transport on 5/19/26, and R1 returned to the facility the same day and R1 did not have discharge paperwork. LPA Shirley observed a yellow “Fall Risk” wristband on R1’s wrist. Per review of R1’s Physician Report dated 10/2/25, R1 was not noted as being a fall risk. Per review of R1’s Service Plan dated 3/2/26, R1 was not assessed as being a fall risk. Per interview with S1, R1 will be assessed for frequent falls. Per interview with S2 on 6/3/26, R1 became aggressive on 5/18/26 after learning that he was being transferred to another room and unit. S2 stated R1 threw himself onto the floor, kept hitting his arms on the railings and refused to get up. S4 and S5 stated during interviews on 6/3/26, R1 was very aggressive, swinging his arms and hitting both arms on the floor and moving his body refusing to get up from the floor. Per interview with S2 on 6/3/26, S2 placed his hands under R1’s armpits and shoulders to lift R1 up into the wheelchair to continue to transfer R1 to his new unit and room. Per interview with S1 on 6/3/26, R1 did not have the bruise on his arm on 5/18/26, the day before the room transfer. It was also reported that R2 was working for free labor, as the facility is short staffed and needs the help. It was reported that the reporting party thought that R2 was a staff member until it was realized that he was a resident. Per interview with R2 on 6/3/26, no one has ever ask him to perform duties for the facility nor the residents that reside inside the facility. R2 stated that he likes to help out and be appreciated. He see’s the duties that needs to be done and he does it. When someone ask, who swept that floor, I would say that I did it and it’s no problem. Con'd on 9099-C LPA interviewed staff 1 – staff 6 (S1 – S6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 6 out of 6 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff caused injury to a resident in care,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Executive Director, Esperanza Naaktgeboren.the state’s words, verbatim · CDSS document, Jun 3, 2026 · control 11-AS-20260528014815

Allegation investigated: Staff did not ensure resident's privacy was protected.

On 06/02/2026 between 08:00AM – 04:50 PM the Department reconducted an initial complaint visit to the facility listed above. LPA met with Administrator Esperanza Naaktgeboren and the purpose of the visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: On 04/17/2026 between 08:00AM – 04:50 PM the Department requested, reviewed and obtained the following documents: Resident Roster, Personnel Report 04/14/26, Brittany House Family and Visitor Log dated 04/02/26-04/15/26, Brittany Health Care LLC Daily Census 04/17/26, Face Sheet and Emergency Information R3, R6, R7, R8, R9, R10, Addendums, Residents rights, House Rules, Unusual Incident report. the Department interviewed Staff #1-#6 (S1-S6) and Resident#2-#10 (R2-R10). CONTINUED ON LIC9099-C Unsubstantiated An attempt to interview R1 was made but it was confirmed by the reporting party via an interview that (R1) never resided in the facility. Allegation: Staff did not ensure resident's privacy was protected. It is alleged that the facility fails to protect residents’ privacy by allowing staff to film and photograph residents without their consent and post the images online for profit, in violation of resident rights. On 04/17/2026, between 8:00 AM and 4:50 PM, the Department conducted an interview with, Administrative, staff member Esperanza Naaktgeboren (S1). S1 stated she is the Executive Director and is responsible for ensuring compliance with HIPAA and resident rights. When asked about the facility’s policy on photographing or recording residents, S1 reported that residents sign a consent form upon admission for identification purposes on their face sheet. S1 stated that any photos or videos require a signed consent form from the resident or responsible party, and that the facility does not authorize photo or video recording beyond necessary identification. S1 reported awareness of one incident in which a caregiver took a photo of a cup and a resident on a Hoyer lift to show her. S1 denied personally taking any photos or videos of residents and denied any knowledge of resident images or videos being shared outside the facility, including on social media. On 04/17/2026 the Department interviewed Staff #1-#6 (S1-S6). Out of those interviewed 6 out of 6 staff interviewed denied the allegation. The department conducted interviews with Residents #2- #10 (R2-R10). Out of those interviewed 9 out of 9 residents denied the allegation.On 04/17/2026, between 8:00 AM and 4:50 PM, the Department requested, obtained and reviewed the resident roster and it showed that R1 was never a resident residing at the facility. The Department requested a copy of the Admission Agreement for R1; however, the facility was unable to provide one because R1 never resided at the facility. The Department also reviewed videos provided by the reporting party, which were alleged to show R1 being filmed inside the facility. Upon review, the Department confirmed that the facility shown in the videos was not the facility against which the allegation was made. No documentation was or could be obtained indicating or confirming that R1 had ever been admitted to or resided in the facility. Based on the information obtained, the allegation is unsubstantiated. Based on the information gathered, interviews conducted,and an analysis of records reviewed, the department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with the Marketing Director Marcus Falani and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 11-AS-20260410163410

Allegation investigated: Staff did not provide resident with proper notification prior to rate increase. Staff did not follow proper eviction procedures.

**This report supersedes the previous report dated 10/09/25 but is used to clarify findings* On 05/26/2026 at approximately 09:30 AM Licensing Program Analyst (LPA) Troy Watson conducted a subsequent complaint visit to deliver findings. LPA Watson met with the Administrator Esperanza Naaktegboren, and the purpose of today’s visit was explained. LPA was given access to the facility. The investigation consisted of the following: On 10/09/2025 between 08:20 AM – 04:59 PM, the Department requested, reviewed, and obtained copies of the Personnel Report dated 09/25/2025, Resident Roster, Admission Agreement dated 07/15/24, Facility Sketch, Medical Assessment dated 10/01/25, Emailed Correspondence dated 09/08/25, and an Account Balance Sheet dated 10/10/25. CONTINUED ON LIC9099-C Substantiated On 04/24/26, the Department obtained the Aging Report dated 12/2025, Face Sheet, and Emergency Information dated 07/17/24 for R1. On 10/09/2025, LPA Watson conducted interviews with Resident #1 – Resident #12 (R1–R12) and Staff #1 – Staff #7 (S1–S7). The investigation revealed the following: Allegation: Staff did not provide residents with proper notification prior to rate increase. It is alleged that R1 was not provided with the required advance notification of rate increases, leaving R1 uninformed of changes to the terms of their rental agreement. On 10/09/2025 between 08:20 AM – 04:59 PM, the Department interviewed Administrator Joel Niblett (S1). During the interview, S1 was asked when the most recent rate increase went into effect for the residents at Brittany House. S1 stated that the most recent rental rate increase, for Brittany House went into effect after residents were given advance notice by email communication. The Department requested documented proof of the rate increase notification from the facility, residents, and R1’s conservatorship; however, the Department was unable to obtain any email or written notification showing that the facility provided residents with advance notice of the rate increase that affected their monthly rental rates. On 10/09/2025 between 08:20 AM – 04:59 PM, the Department conducted interviews with Staff #1–#7 (S1–S7). Out of those interviewed, 7 out of 7 staff denied the above allegation. On 10/09/2025 between 08:20 AM – 04:59 PM, the Department conducted interviews with residents (R1–R12). Out of those interviewed, 12 out of 12 residents denied the above allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be Substantiated. Per California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and a citation was issued (ref. LIC 9099D). Exit interview was conducted, appeal rights explained, and a copy of this report was provided to Administrator Esperanza Naaktegboren.the state’s words, verbatim · CDSS document, May 26, 2026 · control 11-AS-20251001083704

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655(a)(b) · Plan of correction due date: May 7, 2026

If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days' prior written notice.This requirement is not met as evidenced by: Based on interviews conducted and records reviewed the licensee failed to give the responsible party 90 days notice of a rate increase including details of the reason for the increase. This poses a potiential personal rights issue to the residents in care.the state’s words, verbatim · CDSS document, May 26, 2026

Plan of correction: POC was cleared on 05/06/2026.

Allegation investigated: Staff do not provide adequate supervision resulting in residents eloping

On 05/15/26 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint visit at the facility. LPA was met by staff nine, Esperanza Naaktgeboren - Executive Director (S9), and the purpose of the visit was explained. Investigation consisted of the following: On 05/15/26 California Department of Social Services (CDSS) came to provide updated findings to the facility. This report supersedes any previous report. On 03/20/26 CDSS delivered findings to facility. On 10/02/25 CDSS collected staff and resident roster(s), two (2) resident admissions agreement and seven (7) special incident report(s) (LIC624) for the month of August first, 2025 (08/01/25) through September tenth, 2025 (09/10/2025), along with timesheets of the following dates: September twenty-nineth, 2025 (09/29/2025) through October second, 2025 (10/02/2025) and interviewed eight (8) staff members (S1-S8), four (4) residents (R1-R4) and three witnesses (W1-W3). One (1) staff denied LPA's interview (S4) and one (1) resident was not available for interview due to current physical condition (R2). Report continues, please see LIC9099-C. Substantiated The investigation revealed the following: Regarding the allegation "Staff do not provide adequate supervision resulting in residents eloping", it is being alleged that the facility is very understaffed which resulted in resident(s) eloping from the facility. Record reviews revealed that on 09/10/25 a resident was found by first responders, unassisted, out in the community. CDSS Interviews revealed that one (1) staff denied CDSS interviews, three (3) out of eight (8) staff disagreed with the allegation, while four (4) out of eight (8) staff agreed with the allegation. One (1) out of four (4) residents denied CDSS interviews, one (1) out of four (4) residents disagreed with the allegation, while two (2) out of four (4) residents agreed with the allegation. Interviews with witnesses have revealed that one (1) out of three (3) witnesses have disagreed with the allegation, while two (2) out of three (3) witnesses have agreed with the allegation. S1 has stated, “A lot of staff called out in unison”. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. Based on record reviews and interviews conducted, the licensee failed to provide adequate resident supervision by staff. There has been one (1) deficiency cited during today’s inspection. An exit interview was conducted with Esperanza Naaktgeboren - Executive Director (S9), and a copy of this report has been provided.the state’s words, verbatim · CDSS document, May 15, 2026 · control 11-AS-20250923103558

Allegation investigated: Staff did not provide adequate supervision to residents, resulting in resident being injured by another resident Licensee does not ensure adequate staffing to meet the needs of residents Staff did not keep resident's room clean Staff did not ensure resident was bathed

On 5/13/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Executive Director, Esperanza Naaktgeboren and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 5/13/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Special Incident Reports, HouseKeeping Schedule, Resident Shower Schedule, April Staff Schedule, Unusual Incident/ Injury Reports, Information and Emergency Information, Physicians Report, Resident Assessment and Admission Agreement, Caregiver Daily Flow Sheet, and 24-Hour Communication log. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 6 (S1 – S6), and Resident 2 – Resident 8 (R2-R8) LPA Felisa Shirley attempted to interview R1. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not provide adequate supervision to residents, resulting in resident being injured by another resident It is being reported that R1 was injured by another resident on 4/10/26. On 5/13/26, LPA Felisa Shirley reviewed the Unusual Incident/Injury Report, dated 4/10/26 reporting a small argument between R1 and another resident over a remote control for the television and R1 was injured by another resident. Per the incident report, dated 4/10/26, staff spoke to R1’s family member and was advised that R1’s behaviors can cause conflict with other residents. On 5/13/26, LPA Shirley reviewed R1’s Resident Assessment, dated 2/27/26. Per assessment, R1 has behavioral challenges and has inappropriate behaviors more than once a day. On 5/13/26, LPA Shirley toured this facility and went directly to R1’s room and observed R1 arguing with their assigned roommate. LPA attempted to convience R1 to leave the room for an interview. R1 did not leave. R1 refused to respond to LPA Shirley as R1 kept shouting in Spanish to her roommate. LPA interviewed staff 1 – staff 6(S1 – S6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 2 – resident 8 (R2 – R8). Of those who interviewed 7 out of 7 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not provide adequate supervision to residents, resulting in resident being injured by another resident,” therefore, the allegation is unsubstantiated. Allegation: Licensee does not ensure adequate staffing to meet the needs of residents It is being reported that a family member stated that it appears that Unit Five goes without supervision for hours. Family member stated that on 4/11/26 at 2:30pm, staff were not available in Unit Five. On 5/13/26, LPA Shirley reviewed staff’s April work schedule. During review of the schedule on 5/13/26, LPA observed that there are 3 work shifts. Per interview with S2 on 5/13/26, the work shifts are morning shift 6:30am to 2:30pm, evening shift 2:30pm to 10:30pm and Noc Shift 10:30pm to 6:30am. Per interview with S2, there are 2 caregivers per shift. On 5/13/26, LPA toured this facility at 2:25pm and observed a shift change within the unit. LPA Shirley observed that 2 caregivers were leaving and 2 caregivers were beginning their shift. LPA interviewed staff 1 – staff 6(S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 2 – resident 8 (R2 – R8). Of those who interviewed 7 out of 7 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Licensee does not ensure adequate staffing to meet the needs of residents,” therefore, the allegation is unsubstantiated. Con'd on 9099-C Allegation: Staff did not keep resident's room clean It is being reported that a family member visited R1 on 4/11/26 and stated that it appeared that R1’s room had not been cleaned for some time. On 5/13/26, LPA Shirley reviewed the HouseKeeping Schedule and observed that all rooms are cleaned daily. The Housekeeping schedule begins at 6:30am thru 3pm, Monday thru Friday. On 5/13/26, the Maintenance Supervisor, stated that the schedule is the same for the weekends. Per interview on 5/13/26, S4 stated that all rooms are cleaned daily. On 5/13/26 at 11am, LPA Shirley conducted a tour of this facility and went directly to R1’s room and observed that the room was clean. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 2 – resident 8 (R2 – R8). Of those who interviewed 5 out of 7 denied the allegation. One agreed and 1 was not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not keep resident’s room clean,” therefore, the allegation is unsubstantiated. Allegation: Staff did not ensure resident was bathed It is being reported that on 4/11/26, a family member of R1 stated that she requested a staff member to bath R1 because it appeared that R1 had not been bathed. On 5/13/26, LPA Felisa Shirley reviewed R1’s shower schedule and observed that R1 is scheduled to be showered 2 times per week, on Tuesdays and Saturdays. LPA notes that 4/11/26 was on a Saturday. On 5/13/26 observed the staff’s 24-hour communication log for 4/11/26. Per the log, R1 refused to be showered. Per interview with S2 on 5/13/26, R1 hardly ever agrees to a shower. LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 2 – resident 8 (R2 – R8). Of those who interviewed 4 out of 7 denied the allegation. Three residents stated that they shower independently. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not ensure resident was bathed,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to Esperanza Naaktgeboren, Executive Director.the state’s words, verbatim · CDSS document, May 13, 2026 · control 11-AS-20260504144843

Allegation investigated: Licensee does not prevent residents and staff from smoking inside the facility Staff does not ensure food is of good quality and quantity Staff does not ensure emergency signal system is in good repair

***This report supersedes the original report delivered on 01/22/2026. On 5/7/2026, LPA arrived at the facility to deliver the corrected 9099, providing clarification on the original report issued on 01/22/2026 *** On 01/22/2026, at 8:30AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to investigate and deliver findings for the alleged allegations. LPA identified herself and met Carlos Hernandez and Marcus Falanai who were informed of the purpose of the visit. The investigation consisted of the following: On 1/22/2026 at 9:00AM LPA Allen conducted interviews with Residents 1-9 (R1-R9) and Staff Members 1-9 (S1-S9). LPA also conducted a tour of the facility that included the kitchen, Unit 1, 2,3, 4 and 5 the outside patio in Unit 3 and Unit 4 sections and tested Emergency call buttons. Unsubstantiated The investigation revealed the following: #1 Allegation: Licensee does not prevent residents and staff from smoking inside the facility The interviews conducted with Residents 1-9 (R1-R9) were asked does the licensee prevents residents and staff from smoking inside the facility and 1 out of 9 residents stated they have smoked cigarettes in their room in the past, but management have spoken to them about following the house rules and they haven’t smoked in their room since. R2-R9 stated they have smelled cigarettes and marijuana lingering after residents have been smoking outside, but they have not personally seen any staff member or residents smoking inside the facility at any time. Residents also mentioned that there is a designated patio area for smoking in unit 3 and unit 4 which is used by the residents. Interviews were also conducted with staff members 1-9 (S1-S9) and 2 out of 9 staff members stated there was a resident smoking in their room (R9) in the past and house rules were discussed with them and since their discussion R9 has not been seen smoking in their room, nor have there been reports of R9 smoking inside the facility/room. The interviews with staff members 3-9 (S3-S9) stated they have heard rumors of smoking in residents room, but they have not personally seen them smoking inside the facility in the past or currently. Additionally, staff mentioned that residents have a designated smoking area outside of the facility in unit 3 and unit 4. #2 Allegation: Staff does not ensure food is of good quality and quantity The interviews conducted with Residents 1-9 (R1-R9) were asked about the food being of good quality and quantity and 9 out of 9 residents stated the food was okay and could use more seasoning on it but it’s eatable and if additional servings are requested it is provided or alternative options are available. The interviews conducted with staff members 1-9 (S1-S9) were asked does the staff ensure food is of good quality and 9 out of 9 staff members stated that the food in their opinion is of good quality and at times some residents complain about small portions, but a request for seconds can be made and provided if available. When asked, are there other options available, all 9 staff members said yes. #3 Allegation: Staff does not ensure emergency signal system is in good repair The interviews conducted with Residents 1-9 (R1-R9) were asked about the emergency signal system being in good repair and 9 out of 9 residents stated that the system works but it takes staff a long time to respond. When asked how long it takes for staff to respond, all 9 said it could be 15-30 minutes When asked does their call system works, all 9 said yes. Interviews were also conducted with staff members 1-9 (S1-S9) and 9 out of 9 staff members stated to their knowledge the emergency signal system in all residents’ rooms were/are in good repair. All 9 staff members stated that residents had not informed them that the system was out at any time. During the tour of the facility LPA did not observe any staff or residents smoking inside of the facility and LPA did not smell any signs of Marijuana or cigarettes being smoked inside of the facility. LPA did observe residents going and coming outside from the designated smoking area in unit 3 and unit 4. LPA also toured the kitchen and LPA observed that there were menus available for review. There were a 7-day supply of non-perishables and a 5-day supply of perishable food. LPA also observed breakfast being served scrambled eggs with vegetables, toast, and raisin brain that was listed on the menu. LPA also tested the call system in rooms 204,209,212, and 216 and all buttons were in working order. Based on interviews, documents reviewed and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided to Joel Niblett- Administrator at conclusion of the visit with appeal rights. This report was signed by Marcus Falanai- Marketing Director.the state’s words, verbatim · CDSS document, May 7, 2026 · control 11-AS-20260114110524

Allegation investigated: Staff did not follow proper eviction procedures.

**This report does not supersede the previous report dated 10/09/25 but is used to clarify findings* On 05/01/2026 at approximately 10:40 AM Licensing Program Analyst (LPA) Troy Watson conducted a subsequent complaint visit to deliver findings. LPA Watson met with the Administrator Esperanza Naaktegboren, and the purpose of today’s visit was explained. LPA was given access to the facility. The investigation consisted of the following: On10/09/2025 between 08:20 AM – 04:59 PM, the Department requested, reviewed, and obtained copies of the Personnel Report dated 09/25/2025, Resident Roster, Admission Agreement dated 07/15/24, Facility Sketch, Medical Assessment dated 10/01/25, Emailed Correspondence dated 09/08/25, and an Account Balance Sheet dated 10/10/25. CONTINUED ON LIC9099-C Unsubstantiated On 04/24/26, the Department obtained the Aging Report dated 12/2025, Face Sheet, and Emergency Information dated 07/17/24 for R1. On 10/09/2025, LPA Watson conducted interviews with Resident #1 – Resident #12 (R1–R12) and Staff #1 – Staff #7 (S1–S7). The investigation revealed the following: Allegation: Staff did not follow proper eviction procedures It is alleged that Resident #1 (R1) was not provided with the proper paperwork regarding eviction procedures and that the facility failed to follow the required eviction process. On 10/09/2025, the Department conducted an interview with Administrator Joel Niblett (S1). S1 stated that he never formally filed or issued an eviction notice to Resident #1 (R1) or to R1’s Power of Attorney (POA). On 04/23/2026, the Department obtained and reviewed an email correspondence dated 11/04/2025, emailed from S1 and forwarded to facility staff, stating that the facility did not give an eviction notice to R1. The Department also requested from R1’s POA paperwork showing that an eviction had been filed against R1. R1’s POA was unable to provide a formal eviction notice given to them by the facility. On 10/09/2025 between 08:20 AM – 04:59 PM, the Department conducted interviews with Staff #1–#7 (S1–S7). Out of those interviewed, 7 out of 7 staff denied the above allegation. On 10/09/2025 between 08:20 AM – 04:59 PM, the Department conducted interviews with residents (R1–R12). Out of those interviewed, 12 out of 12 residents denied the above allegation. Based on record reviews, staff and client interviews and observations there is insufficient evidence to support the allegation: “Staff did not follow proper eviction procedures” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted, appeal rights explained, and a copy of this report was provided to Administrator Esperanza Naaktegboren.the state’s words, verbatim · CDSS document, May 1, 2026 · control 11-AS-20251001083704

Allegation investigated: Staff did not provide residents with proper notification prior to rate increase.

**This report does not supersede the previous report dated 10/09/25 but is used to clarify findings* On 05/01/2026 at approximately 08:11 AM Licensing Program Analyst (LPA) Troy Watson conducted a subsequent complaint visit to deliver findings.LPA Watson met with the Administrator Esperanza Naaktegboren, and the purpose of today’s visit was explained. LPA was given access to the facility. The investigation consisted of the following: On 10/09/2025 between 08:20 AM – 04:59 PM, the Department requested, reviewed, and obtained copies of the Personnel Report dated 09/25/2025, Resident Roster, Admission Agreement dated 07/15/24, Facility Sketch, Medical Assessment dated 10/01/25, Emailed Correspondence dated 09/08/25, and an Account Balance Sheet dated 10/10/25. CONTINUED ON LIC9099-C Substantiated On 04/24/26, the Department obtained the Aging Report dated 12/2025, Face Sheet, and Emergency Information dated 07/17/24 for R1. On 10/09/2025, LPA Watson conducted interviews with Resident #1 – Resident #12 (R1–R12) and Staff #1 – Staff #7 (S1–S7). The investigation revealed the following: Allegation: Staff did not provide residents with proper notification prior to rate increase. It is alleged that R1 was not provided with the required advance notification of rate increases, leaving R1 uninformed of changes to the terms of their rental agreement. On 10/09/2025 between 08:20 AM – 04:59 PM, the Department interviewed Administrator Joel Niblett (S1). During the interview, S1 was asked when the most recent rate increase went into effect for the residents at Brittany House. S1 stated that the most recent rental rate increase, for Brittany House went into effect after residents were given advance notice by email communication. The Department requested documented proof of the rate increase notification from the facility, residents, and R1’s conservatorship; however, the Department was unable to obtain any email or written notification showing that the facility provided residents with advance notice of the rate increase that affected their monthly rental rates. On 10/09/2025 between 08:20 AM – 04:59 PM, the Department conducted interviews with Staff #1–#7 (S1–S7). Out of those interviewed, 7 out of 7 staff denied the above allegation. On 10/09/2025 between 08:20 AM – 04:59 PM, the Department conducted interviews with residents (R1–R12). Out of those interviewed, 12 out of 12 residents denied the above allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above mentioned allegation is found to be Substantiated. Per California Code of Regulations (Title 22, Division 6, Chapter 8), the above mentioned deficiency was observed, and a citation was issued (ref. LIC 9099D). Exit interview was conducted, appeal rights explained, and a copy of this report was provided to Administrator Esperanza Naaktegboren.the state’s words, verbatim · CDSS document, May 1, 2026 · control 11-AS-20251001083704

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.655(a)(b) · Plan of correction due date: May 7, 2026

If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days' prior written notice.This requirement is not met as evidenced by: Based on interviews conducted and records reviewed the licensee failed to give the responsible party 90 days notice of a rate increase including details of the reason for the increase. This poses a potiential personal rights issue to the residents in care.the state’s words, verbatim · CDSS document, May 1, 2026

Plan of correction: Licensee shall review the Health and safety code regarding rate increases and rescind the rate increase notice. Licensee may re-issue a correct notice that is in-complaiance with Health and Safety Code 1569.655. License to sumbit documents to LPA by POC due date 05/07/2026.

Allegation investigated: Staff did not dispense residents’ medication as prescribed.

**The report supersedes the delivered reported on 02/23/2026 to include additional information to the findings** On 04/22/2026 at 09:25am, Licensing Program Analyst (LPA) Zina Brown conducted an subsequent investigation complaint visit at this facility to deliver the findings for the allegation list above. During today's visit, the Department met with Esperanza Naaktgeboren (Adminstrator) and explained the purpose of the visit. The investigation consisted of the following: On 01/14/2026 & 02/23/2026, the Department interviewed Administrator (A1) and Staff (S1-S10) and Residents (R1-R10) received the following documents: Resident Roster (received 01/12/2026), Staff Roster (dated 10/13/2025), and Resident 1 (R1)'s documents such as: LIC 601: Identification and Emergency Form (dated 05/05/2025), LIC 602: Physician Report, LIC 603: Preplacement Appraisal Information (not dated), LIC 625: Appraisal Needs and Service Plan, Admission Agreement (dated 05/05/2025), Medication Administration Record (10/2025 - 01/2026), LIC 621 Client/Resident Personal Property Valuable (not dated), Personal Property Theft & Loss Policy, Housekeeping Policy, Monthly Menu (Dec 2025 - Feb 2026), Laundry Schedule, & Food Handler Certificate of Completion. Substantiated The investigation revealed the following: Allegation: Staff did not dispense residents' medication as prescribed. It was alleged that facility staff failed to dispense residents' medications as prescribed, as multiple prescribed medications appeared unused for extended periods, and residents experienced untreated medical conditions and panic attacks despite active medication orders. On 01/14/2026 at 3:05pm, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated medtechs provide medications to residents. A1 stated the facility contacts the pharmacy for refills when a resident's medication runs out or needs to be refilled. A1 stated medtechs follow the prescription order when a resident requests a PRN medication like Ativan. A1 stated medications are documented both electronically and manually when administered to residents. On 01/14/2026 between the hours of 11:05am - 1:33pm, the Department conducted 7 interviews with staff in regards to the allegation. 1 of 7 staff confirmed the allegation and stated sometimes the residents are not getting their medication as prescribed. 3 of 7 staff denied the allegation and stated medtechs provide medications to residents and document using QuickMar or a laptop, and medtechs follow the prescription order for PRN medications like Ativan. 3 of 7 staff were unaware of the allegation and stated they are not medtechs so they do not administer medications, but they notify the medtech when a resident requests PRN medication. On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm -1:37pm, the Department conducted 10 resident interviews in regards to the allegation. 3 of 10 residents confirmed the allegation and stated they do not get their medicine every day when they are supposed to, sometimes staff do not give them medicine, and they have asked for medicine and not gotten it. 1 of 10 resident did not confirm nor deny the allegation and stated they try to get medicine but sometimes forget. 6 of 10 residents denied the allegation and stated they get their medicine every day when they are supposed to, staff give them medicine when needed, and staff put cream or ointment on their skin when it itches. Investigation findings continue on LIC 9099-C On 02/20/2026 between the hours of 3:38pm - 3:50pm, the Department conducted a record review and observed the following: From October 2025 through January 14, 2026, the Department observed a failure to dispense medications as prescribed. The "Exceptions" and "Pass Notes" logs documented hundreds of missed doses, primarily attributed to a persistent pattern of "Resident Refusal." Many of these refusals occurred because staff failed to administer medication when the resident was asleep, with staff documenting that they "didn't wanna wake up" the resident or that the resident believed "sleep is more important." The Medication Administrator Record showed the failed to maintain an adequate supply of medication, with numerous entries citing medications as "pending delivery," "awaiting RX refill," or "not in cart" for consecutive days. Per the resident's primary diagnoses of Heart Failure and Chest Pain, medications like Furosemide, Bisoprolol, and Losartan—as well as psychiatric medications like Sertraline for anxiety—were routinely omitted for weeks at a time. Substantiated: Based on the Department observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Esperanza Naaktgeboren (Adminstrator) and a copy of this report was provided with Appeal Rights. The investigation revealed the following: Allegation: Staff did not assist resident with care needs in a timely manner. It was alleged that facility staff failed to assist a resident with care needs in a timely manner, as the resident reportedly experienced severe pain and panic without staff assistance, resulting in emergency medical services being contacted by a family member. On 01/14/2026 at 3:05pm, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated residents ask caregivers for help and use the call system when they need assistance. A1 stated the response time when a resident requests assistance is promptly and as needed. A1 stated to see the schedule for the number of staff on duty during different shifts to respond to residents. A1 stated the facility calls 911 as needed for both medical and emotional emergencies when a resident experiences such situations. On 01/14/2026 between the hours of 11:05am -1:33pm, the Department conducted 7 interviews with staff in regards to the allegation. 1 of 7 staff confirmed the allegation and stated sometimes residents have to wait for assistance for hours. 1 of 7 staff did not confirm nor deny the allegation and stated residents may have to wait for assistance if there is an emergency in two different units, but staff would communicate to check on the other resident. 5 of 7 staff denied the allegation and stated residents call for assistance by using the call light or yelling out loud, response time is usually right away or within 5-10 minutes, and staff call 911 or notify the medtech/LVN for medical or emotional emergencies. On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm -1:37pm, the Department conducted 10 resident interviews in regards to the allegation. 2 of 10 residents confirmed the allegation and stated staff do not come quickly when they need help. 1 of 10 resident did not confirm nor deny the allegation and stated they have had to called for help. 7 of 10 residents denied the allegation and stated staff come quickly when they need help and or they find someone to help them if they feel pain or scared. On 02/23/2026 between the hours of 2:37pm - 3:02pm, the Department conducted a call light test and observed the following: In Room 310, the Department pulled the call light which is the old system at 2:37pm and waited for ten minutes and noticed that at 2:47pm staff did not come to answer the call light. In Room 104, the Department pulled the call light at 3:01pm & staff responded at 3:02pm. In Room 105, the Department pulled the call light at 3:06pm & responded at 3:06pm. Overall during the call light test, in one of the rooms such as Room 310 demonstrated a response time (from 2:37pm - 2:47pm) that was not immediate, while the remaining rooms showed prompt response times within one minute (from 3:01pm - 3:02pm). Based on records review, interviews, and observations, the Department did not find sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff did not safeguard resident's personal belongings. It was alleged that facility staff failed to safeguard a resident's personal belongings, as valuable jewelry and personal items were reported missing and possibly replaced without authorization. On 01/14/2026 at 3:05pm, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated the facility has an inventory list and monitors resident belongings as procedures in place to protect residents' personal belongings. A1 stated valuable items are documented on an inventory list and an in-house safe is provided as needed. A1 stated the facility attempts to help find missing items if a resident reports missing property. A1 stated staff have access to residents' rooms. On 01/14/2026 between the hours of 11:05am -1:33pm, the Department conducted 8 interviews with staff in regards to the allegation. 2 of 8 staff confirmed the allegation and stated half of the residents' items are missing, due to some of the residents wander at night and take other residents' personal belongings, and it is hard to protect residents' personal belongings. 1 of 8 staff did not confirm nor deny the allegation and stated valuable items are documented in communication documentation to inform the nighttime care staff, and the facility purchased drawers that have locks. 5 of 8 staff denied the allegation and stated caregivers have to label residents' belongings with the resident's full name, valuables are locked and documented in a log book, and staff notify supervisors when a resident reports missing property. Staff also stated caregivers, medtech, LVN, supervisors, housekeeping, maintenance, directors, and family have access to residents' rooms. On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm - 1:37pm, the Department conducted 10 resident interviews in regards to the allegation. 3 of 10 residents confirmed the allegation and stated they have had jewelry or special items in their room, that have gone missing from their room. 7 of 10 residents denied the allegation and stated they do not have jewelry or special items in their room, nor has anything gone missing from their room, and they themselves or their family help them keep track of their things. The investigation findings continue on LIC 9099-C On 02/20/2026 between the hours of 3:38pm - 3:50pm, the Department conducted a record review and observed the following: The department did not receive a LIC 624 Unusual Incident/Injury Report from the facility in regards to Resident 1 (R1)'s personal belongings such as valuable jewelry and personal items reported missing. According to Brittany House's Personal Property Theft & Loss Property policy, it states: "We do not have a safe or other means of safely securing valuables. They are encouraged to use their own private banking institution to provide this service. We shall provide a lock for the resident's bedside drawer or cabinet upon request of and at the expense of the resident, the resident's family, or authorized representative." "Upon admission, all residents will be requested to appropriately label all clothing and personal items. Residents will be requested to keep fine jewelry and other items of value in a safe deposit box at their banking institution. No items of value will be entrusted to the facility for safekeeping and no cash or other moneys will be entrusted to the facility." Residents are advised that when they notice a personal item is missing, they are to notify the Administrator or other staff members on duty immediately. The staff will conduct a thorough search for the missing item or items. If the personal belongings cannot be found, an estimate of their value will be assessed. Also, upon further review, the LIC 621 Client/Resident Personal Property & Valuables for Resident 1 (R1) only has the resident's name handwritten but no Personal Property/Valuables Entrusted to Facility are written nor listed on the LIC 621. Based on records review, interviews, and observations, the Department did not find sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff did not ensure adequate laundry services were provided to resident. It was alleged that facility staff failed to ensure adequate laundry services, as the resident's clothing, bedding, and pajamas were frequently observed to be dirty and soiled. On 01/14/2026 at 3:05pm, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated residents' bed linens are changed as needed and on a regular basis. A1 stated residents' clothes are laundered daily. A1 stated the laundry schedule for the facility is AM daily laundry from 6:30am -3:00pm. A1 stated the facility replaces bedding or clothing if a resident's bedding or clothing becomes soiled. On 01/14/2026 between the hours of 11:05am -1:33pm, the Department conducted 9 interviews with staff in regards to the allegation. 1 of 9 staff confirmed the allegation and stated sometimes if clothes are not clean that means they are not washed, and sometimes if the bed is wet on both sides after it is flipped over. 1 of 9 staff did not confirm nor deny the allegation and stated sometimes if residents have feces or blood in their clothes, it is not in a separated bag. 7 of 9 staff denied the allegation and stated bed linens are changed every day, every other day, or when residents shower, or whenever they are dirty, and soiled bedding and clothing are changed immediately and placed in a separate area to be washed. On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm -1:37pm, the Department conducted 10 resident interviews in regards to the allegation. 1 of 10 resident did not confirm nor deny the allegation and stated clothes and sheets are clean but sometimes there is a lot of dust which might mean they are not washed well. 9 of 10 residents denied the allegation and stated their clothes and sheets are clean and provided daily, every other day, weekly, or whenever they ask. On 01/21/2026 at 10:34am, the Department conducted a random room inspection in Room 114 and observed staff removing the bed linen and providing the resident with clean bedding. On 02/20/2026 between the hours of 4:20pm - 4:30pm, the Department conducted a records review and observed the following: Based on Brittany House Housekeeping Policy under the routine section, it states routine housekeeping functions are performed to maintain the required standard of cleanliness throughout the facility premises. This encompasses cleaning of residents' rooms, baths, halls, corridors, dining rooms, lounges, offices, storerooms, utility rooms, workshops, restrooms, and any other areas frequented by personnel, as well as the laundering of personal items, bed linens, housekeeping items, and dining linens. Per the "Laundry Schedule" for Brittany House that divides staff into two groups (Group 1 and Group 2) to manage the pickup, separation, washing, drying, and folding of linen and clothing, the schedule begins at 6:30am and concludes with a mandatory work area clean-up between 2:40pm and 3:00pm. Per the "To Remember" section of the document, the department noted that the last round for picking up soiled linen and clothing is at 2:30pm, and staff are required to maintain and sign off on both a daily washer/dryer room cleaning log. Furthermore, the facility policy dictates that all linen closets must remain stocked at all times throughout the shift. Based on records review, interviews, and observations, the Department did not find sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff did not ensure adequate food services were provided to residents. It was alleged that facility staff failed to ensure adequate food services, as residents reportedly received insufficient meals, limited food options, and beverages were not consistently provided. On 01/14/2026 at 3:05pm, LPA interviewed A1 regarding the allegation. A1 was aware of the allegation and stated a resident across the hall from A1's office has complained about food quantity. A1 stated nutritious meals are provided to residents daily. A1 confirmed beverages are served with every meal. A1 stated cooks prepare the meals using standardized menus. A1 stated the facility accommodates residents' dietary preferences and needs on an individual basis. On 01/14/2026 between the hours of 11:05am -1:33pm, the Department conducted 7 interviews with staff in regards to the allegation. 3 of 7 staff confirmed the allegation and stated residents and family members have complained about food quality or quantity, and the same meals are provided over and over again. 4 of 7 staff denied the allegation and stated 3 meals and 2-3 snacks are provided daily, beverages are served with every meal, kitchen staff prepare the meals using menus created by corporate or standardized menus, and dietary preferences and needs are accommodated using index cards or name tags for each plate. On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm - 1:37pm, the Department conducted 10 resident interviews in regards to the allegation. 3 of 10 residents confirmed the allegation and stated the food is bad with no taste, bland and the same daily with no change, they do not get enough food, and beverages are only provided sometimes with meals. 1 of 10 resident did not confirm nor deny the allegation and stated the food is okay and not terrible. 6 of 10 residents denied the allegation and stated they like the food, it is okay or good, they get different types of meals daily including protein, carbs, vegetables, baked and fried foods, beverages are served with every meal, and they get enough food and or can ask for more food if still hungry. On 02/20/2026 between the hours of 4:20pm -4:30pm, the Department conducted a records review and observed the following: The facility provided "Good For Your Health Menus" spanning from December 1, 2025, through March 1, 2026. A review of these records indicates a rotating meal cycle consisting of three daily meals—breakfast, lunch, and dinner—each containing multiple food groups including proteins, vegetables, starches, and desserts. Specifically, breakfast menus documented a variety of beverage options, including cranberry, apple, orange, pineapple, and grape juices. Every menu page reviewed contains a standing directive stating, "Milk and Beverage Offered with Every Meal,". The records further show a wide variety of food options, including specialized holiday meals such as Roast Beef with Savory Thyme Sauce and Rich Cheesecake for Christmas Day, Ham with Pineapple Sauce for New Year's Day, and Pork Chops with Creamy Garlic Sauce for Valentine's Day. Based on records review, interviews, and observations, the Department did not find sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Esperanza Naaktgeboren (Adminstrator) and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 11-AS-20260107161546

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(d) · Plan of correction due date: May 11, 2026

Incidental Medical & Dental Care if the resident is unable to determine their own medication cannot communicate symptoms clearly. . . (3) The date, time, dosage taken, and resident's response shall be documented and maintained in the resident's facility record. This requirement is not met by: Based on observation, interviews and records review: From 10/2025 - 01/14/2026, critical medications for R1's primary diagnoses of Heart Failure, Chest Pain, and anxiety—including Furosemide, Bisoprolol, Losartan, and Sertraline—were routinely omitted for weeks at a time.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: The facility will ensure all medtechs complete the weekly medtech log before end of shift to document all medication administrations, refusals, and exceptions. The Administrator or designee will conduct audit logs on a weekly bases The administrator and or designee will submit proof of the weekly medtech logs completion for Monday 4/27 - Monday 5/11 by the plan of correction due date and email proof to LPA Brown at Zina.Brown@dss.ca.gov

Allegation investigated: Unlawful eviction. Staff demanded resident’s entire SSI check.

On 04/15/26 at approximately 8:00 AM, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced complaint visit. LPA met with Administrator Esperanza Naaktgeboren and explained the purpose of the visit. The investigation consisted of the following: On 04/15/26, LPA Anguiano toured the facility, interviewed eleven residents (R1–R11) and five staff members (S1–S5). LPA also reviewed facility records including resident roster, staff roster, Aging Report, discharge records, and admission agreements for residents. The investigation revealed the following: Regarding the allegation “Facility is evicting residents,” It is being alleged that residents are being forced to leave the facility. Interviews conducted with (R1–R11) revealed the following: 7 out of 11 residents denied being told to leave the facility. 2 out of 11 residents reported hearing about residents leaving but did not experience it directly. Please see LIC9099-C for report continuation. Unsubstantiated (R1) reported feeling pressured to leave the facility and stated he was told to leave; however, he later clarified that his move-out was voluntary and not an eviction. Staff interviews (S1–S5) indicated that no evictions have been carried out. Records review revealed the following: A signed move-out document confirmed that (R1) discharged from the facility. No eviction notices or documentation supporting forced eviction were provided or observed. Based on the evidence gathered, interviews conducted, observations, and records reviewed, although the allegation “Facility is evicting residents” may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. Regarding the allegation “Facility is requiring residents to pay their full SSI check,” It is being alleged that residents are required to pay their full Social Security Income (SSI). Interviews conducted revealed the following: 7 out of 11 residents denied being required to pay their full SSI. 2 out of 11 residents reported hearing about such incidents but did not experience it directly. 1 out of 11 residents reported paying with their SSI check and did not express concerns. (R1) reported that staff requested full SSI check; however also stated that no funds were taken. Staff interviews (S1–S5) indicated that residents are informed of payment expectations at the time of admission. Records review revealed the following: Admission agreements reviewed reflected consistent monthly rates across residents. The aging report showed consistent charges in alignment with those agreements. Records reviewed indicated that residents agreed to payment terms at the time of admission. Based on the evidence gathered, interviews conducted, observations, and records reviewed, although the allegation “Facility is requiring residents to pay their full SSI” may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. No deficiencies were cited in todays visit an an exit interview was conducted, and a copy of this complaint report was provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 15, 2026 · control 11-AS-20260407093925

Allegation investigated: Facility does not have sufficient staffing to provide care to residents.

This report supersedes the report created 12/22/25 and the findings will remain unchanged. On 4/9/2026 at approximately 2:00 PM, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met Esperanza Naaktgeboren/Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrators Interview (A#1), Residents Interviews (R#1-R#6) and Staff Interview (S#1-S#5). LPA obtained and reviewed the following documents: Resident Roster dated: 9/26/25, Staff Roster dated: 9/25/25, copies of (R#1 and R#4) Physicians Report for Residential Care Facilities for the Elderly or LIC 602 various dates, copies of (R#1-R#4) Admissions Agreement various dates, copies of (R#1-R#4) Identification and Emergency Information or LIC 601 various dates, copies of (R#1-R#4) Appraisal/Needs and Services Plan or LIC 625 various dates, and a copy of facility Call-off Tracking Log for the month of September 2025. Evaluation Report continues LIC 9099-C Unsubstantiated This report supersedes the report created 12/22/25 and the findings will remain unchanged. Investigation Revealed the Following: Allegation: Facility does not have sufficient staffing to provide care to residents. The details of the complaint alleged that it was observed that there are not enough staff during regular hours. On October 21, 2025, at 1:00 p.m., Licensing Program Analyst (LPA) Iniguez obtained and reviewed the facility’s Call-off Tracking Log for September 29–30, 2025 and October 1–3, 2025. The department found that the facility schedules on average approximately (33) care staff per day. The facility experiences on average, approximately (5) staff callouts, and this results in an average of approximately (28) staff per shift are available to provide care and supervision. On December 22, 2025, at 10:00 a.m., LPA Iniguez obtained and reviewed Functional Capabilities Assessments (LIC 9172) for 56 residents and found their care needs range from independent to requiring assistance. Based on the daily staffing schedules (Dated) reviewed, the department found (9) caregivers, (3) medication technicians, and (1) LVN are working the AM shift. The department found (8) caregivers, (3) medication technicians, and (1) LVN are working during the PM shift. The department found (7) caregivers and (1) medication technician working during the overnight shift. The department found sufficient staffing to support the needs of the residents are present for each shift. On September 26, 2025, at approximately 10:00 a.m., during an Interview with the facility Administrator (A#1), he stated that we have sufficient staff to provide care and supervision for the memory care residents. However, there are days when we experience a high number of callouts from facility staff. Evaluation Report continues LIC 9099-C This report supersedes the report created 12/22/25 and the findings will remain unchanged. This situation often requires some employees to work overtime and double shifts. Additionally, (A#1) mentioned that when there are call-outs, the remaining facility staff members covering for those absent are expected to meet the needs of the residents in their care. (A#1) also expressed that when staff members call out, he does not believe there is an immediate danger to the residents. On September 26, 2025, at approximately 11:00 AM, during an interview with residents (R#1-R#6), (6) out of (6) stated that the facility does not have enough staff to take care of them and the rest of the residents in care. On September 26, 2025, at approximately 12:00 PM, during an interview with facility staff (S#1-S#6), (5) out of (6) stated that the facility does not have enough staff to provide care to residents. In addition, (6) out of (6) facility staff said that they feel the residents are not in immediate danger due to staffing issues; however, this can potentially become a problem since sometimes there are (1) caregiver per (20) residents with different care needs. During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Esperanza Naaktgeboren/Administrator.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 11-AS-20250919104757

Allegation investigated: Staff do not provide adequate supervision resulting in residents eloping

On 03/20/26 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint visit at the facility. LPA was met by staff nine, Esperanza Naaktgeboren - Executive Director (S9), and the purpose of the visit was explained. Investigation consisted of the following: On 03/20/26 LPA delivered findings to facility. On 10/02/25 LPA collected staff and resident roster(s), two (2) resident admissions agreement and seven (7) special incident report(s) (LIC624) for the month of September first, 2025 (09/01/25) through September tenth, 2025 (09/10/2025), along with timesheets of the following dates: September twenty-nineth, 2025 (09/29/2025) through October second, 2025 (10/02/2025) and interviewed eight (8) staff members (S1-S8), five (5) residents (R1-R5) and three witnesses (W1-W3). One (1) staff denied LPA's interview (S4) and one (1) resident was not available for interview due to current physical condition (R2). Report continues, please see LIC9099-C. Substantiated The investigation revealed the following: Regarding the allegation "Staff do not provide adequate supervision resulting in residents eloping", it is being alleged that the facility is very understaffed. Record reviews revealed that there are about 90 staff associated at the facility. S1 has stated "There's been a spike in people calling out.". LPA's Interviews revealed that eight (8) out of thirteen (13) interviews have agreed with the allegation (W1/2/3, R3 & S5 through S8). Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. An exit interview was conducted with Esperanza Naaktgeboren - Executive Director (S9), and a copy of facilities’ appeal rights and this report has been provided.the state’s words, verbatim · CDSS document, Mar 20, 2026 · control 11-AS-20250923103558

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87413(a)(1) · Plan of correction due date: Apr 3, 2026

87413 Personnel - Operations (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 is not met as evidenced by: Based on interview and record review the licensee did not ensure that one (1) resident, resident 9 (R9), would not elope from the facility, which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Mar 20, 2026

Plan of correction: The facility shall retrain staff on supervision of residents in care along with elopement strategies. S9 and LPA have agreed that S9 will submit training paperwork and the number of staff who have attended to LPA at MARIO.LEON@DSS.CA.GOV on or prior to the POC due date.

Allegation investigated: Staff did not dispense residents’ medication as prescribed. Staff did not assist resident with care needs in a timely manner

On 02/23/2026 at 12:58pm, Licensing Program Analyst (LPA) Zina Brown conducted an subsequent investigation complaint visit at this facility to deliver the findings for the allegations listed above. LPA met with Amy Kaplli (Wellness Director and explained the purpose of the visit. The investigation consisted of the following: On 01/14/2026 & 02/23/2026, LPA interviewed Administrator (A1) and Staff (S1-S10) and Residents (R1-R10) received the following documents: Resident Roster (received 01/12/2026), Staff Roster (dated 10/13/2025), and Resident 1 (R1)'s documents such as: LIC 601: Identification and Emergency Form (dated 05/05/2025), LIC 602: Physician Report, LIC 603: Preplacement Appraisal Information (not dated), LIC 625: Appraisal Needs and Service Plan, Admission Agreement (dated 05/05/2025), Medication Administration Record (October 2025 - Janaury 2026), LIC 621 Client/Resident Personal Property Valuable (not dated), Personal Property Theft & Loss Policy, Housekeeping Policy, Monthly Menu (Dec 2025 - Feb 2026), Laundry Schedule, and Food Handler Certificate of Completion. Substantiated The investigation revealed the following: Allegation: Staff did not dispense residents' medication as prescribed. It was alleged that facility staff failed to dispense residents' medications as prescribed, as multiple prescribed medications appeared unused for extended periods, and residents experienced untreated medical conditions and panic attacks despite active medication orders. On 01/14/2026 at 3:05pm, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated medtechs provide medications to residents. A1 stated the facility contacts the pharmacy for refills when a resident's medication runs out or needs to be refilled. A1 stated medtechs follow the prescription order when a resident requests a PRN medication like Ativan. A1 stated medications are documented both electronically and manually when administered to residents. On 01/14/2026 between the hours of 11:05am -1:33pm, LPA conducted 7 interviews with staff in regards to the allegation. 1 of 7 staff confirmed the allegation and stated sometimes the residents are not getting their medication as prescribed. 3 of 7 staff denied the allegation and stated medtechs provide medications to residents and document using QuickMar or a laptop, and medtechs follow the prescription order for PRN medications like Ativan. 3 of 7 staff were unaware of the allegation and stated they are not medtechs so they do not administer medications, but they notify the medtech when a resident requests PRN medication. On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm -1:37pm, LPA conducted 10 resident interviews in regards to the allegation. 3 of 10 residents confirmed the allegation and stated they do not get their medicine every day when they are supposed to, sometimes staff do not give them medicine, and they have asked for medicine and not gotten it. 1 of 10 resident did not confirm nor deny the allegation and stated they try to get medicine but sometimes forget. 6 of 10 residents denied the allegation and stated they get their medicine every day when they are supposed to, staff give them medicine when needed, and staff put cream or ointment on their skin when it itches. On 02/20/2026 between the hours of 3:38pm - 3:50pm, LPA conducted a record review and observed the following: From October 2025 through January 14, 2026, LPA observed a failure to dispense medications as prescribed. The "Exceptions" and "Pass Notes" logs documented hundreds of missed doses, primarily attributed to a persistent pattern of "Resident Refusal." Many of these refusals occurred because staff failed to administer medication when the resident was asleep, with staff documenting that they "didn't wanna wake up" the resident or that the resident believed "sleep is more important." The Medication Administrator Record showed the failed to maintain an adequate supply of medication, with numerous entries citing medications as "pending delivery," "awaiting RX refill," or "not in cart" for consecutive days. Per the resident's primary diagnoses of Heart Failure and Chest Pain, medications like Furosemide, Bisoprolol, and Losartan—as well as psychiatric medications like Sertraline for anxiety—were routinely omitted for weeks at a time. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights. Allegation: Staff did not assist resident with care needs in a timely manner. It was alleged that facility staff failed to assist a resident with care needs in a timely manner, as the resident reportedly experienced severe pain and panic without staff assistance, resulting in emergency medical services being contacted by a family member. On 01/14/2026 at 3:05pm, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated residents ask caregivers for help and use the call system when they need assistance. A1 stated the response time when a resident requests assistance is promptly and as needed. A1 stated to see the schedule for the number of staff on duty during different shifts to respond to residents. A1 stated the facility calls 911 as needed for both medical and emotional emergencies when a resident experiences such situations. On 01/14/2026 between the hours of 11:05am -1:33pm, LPA conducted 7 interviews with staff in regards to the allegation. 1 of 7 staff confirmed the allegation and stated sometimes residents have to wait for assistance for hours. 1 of 7 staff did not confirm nor deny the allegation and stated residents may have to wait for assistance if there is an emergency in two different units, but staff would communicate to check on the other resident. 5 of 7 staff denied the allegation and stated residents call for assistance by using the call light or yelling out loud, response time is usually right away or within 5-10 minutes, and staff call 911 or notify the medtech/LVN for medical or emotional emergencies. On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm -1:37pm, LPA conducted 10 resident interviews in regards to the allegation. 2 of 10 residents confirmed the allegation and stated staff do not come quickly when they need help. 1 of 10 resident did not confirm nor deny the allegation and stated they have had to called for help. 7 of 10 residents denied the allegation and stated staff come quickly when they need help and or they find someone to help them if they feel pain or scared. On 02/23/2026 between the hours of, LPA conducted a call light test and observed the following: In Room 310, LPA pulled the call light which is the old system at 2:37pm and waited for ten minutes and noticed that at 2:47pm staff did not come to answer the call light. In Room 104, LPA pulled the call light at 3:01pm & staff responded at 3:02pm. In Room 105, LPA pulled the call light at 3:06pm and staff responded at 3:06pm. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Amy Kaplli (Wellness Director and a copy of this report was provided with appeal rights. The investigation revealed the following: Allegation: Staff did not safeguard resident's personal belongings. It was alleged that facility staff failed to safeguard a resident's personal belongings, as valuable jewelry and personal items were reported missing and possibly replaced without authorization. On 01/14/2026 at 3:05pm, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated the facility has an inventory list and monitors resident belongings as procedures in place to protect residents' personal belongings. A1 stated valuable items are documented on an inventory list and an in-house safe is provided as needed. A1 stated the facility attempts to help find missing items if a resident reports missing property. A1 stated staff have access to residents' rooms. On 01/14/2026 between the hours of 11:05am -1:33pm, LPA conducted 8 interviews with staff in regards to the allegation. 2 of 8 staff confirmed the allegation and stated half of the residents' items are missing, due to some of the residents wander at night and take other residents' personal belongings, and it is hard to protect residents' personal belongings. 1 of 8 staff did not confirm nor deny the allegation and stated valuable items are documented in communication documentation to inform the nighttime care staff, and the facility purchased drawers that have locks. 5 of 8 staff denied the allegation and stated caregivers have to label residents' belongings with the resident's full name, valuables are locked and documented in a log book, and staff notify supervisors when a resident reports missing property. Staff also stated caregivers, medtech, LVN, supervisors, housekeeping, maintenance, directors, and family have access to residents' rooms. On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm - 1:37pm, LPA conducted 10 resident interviews in regards to the allegation. 3 of 10 residents confirmed the allegation and stated they have jewelry or special items in their room, that have gone missing from their room. 7 of 10 residents denied the allegation and stated they do not have jewelry or special items in their room, nor has anything gone missing from their room, and they themselves or their family help them keep track of their things. The investigation findings continue on LIC 9099-C On 02/20/2026 between the hours of 3:38pm - 3:50pm, LPA conducted a record review and observed the following: The department did not receive a LIC 624 Unusual Incident/Injury Report from the facility in regards to Resident 1 (R1)'s personal belongings such as valuable jewelry and personal items reported missing. According to Brittany House's Personal Property Theft & Loss Property policy, it states: "We do not have a safe or other means of safely securing valuables. They are encouraged to use their own private banking institution to provide this service. We shall provide a lock for the resident's bedside drawer or cabinet upon request of and at the expense of the resident, the resident's family, or authorized representative." "Upon admission, all residents will be requested to appropriately label all clothing and personal items. Residents will be requested to keep fine jewelry and other items of value in a safe deposit box at their banking institution. No items of value will be entrusted to the facility for safekeeping and no cash or other moneys will be entrusted to the facility." Residents are advised that when they notice a personal item is missing, they are to notify the Administrator or other staff members on duty immediately. The staff will conduct a thorough search for the missing item or items. If the personal belongings cannot be found, an estimate of their value will be assessed. Also, upon further review, the LIC 621 Client/Resident Personal Property & Valuables for Resident 1 (R1) only has the resident's name handwritten but no Personal Property/Valuables Entrusted to Facility are written nor listed on the LIC 621. Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff did not ensure adequate laundry services were provided to resident. It was alleged that facility staff failed to ensure adequate laundry services, as the resident's clothing, bedding, and pajamas were frequently observed to be dirty and soiled. On 01/14/2026 at 3:05pm, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated residents' bed linens are changed as needed and on a regular basis. A1 stated residents' clothes are laundered daily. A1 stated the laundry schedule for the facility is AM daily laundry from 6:30am-3:00pm. A1 stated the facility replaces bedding or clothing if a resident's bedding or clothing becomes soiled. On 01/14/2026 between the hours of 11:05am -1:33pm, LPA conducted 9 interviews with staff in regards to the allegation. 1 of 9 staff confirmed the allegation and stated sometimes if clothes are not clean that means they are not washed, and sometimes if the bed is wet on both sides after it is flipped over. 1 of 9 staff did not confirm nor deny the allegation and stated sometimes if residents have feces or blood in their clothes, it is not in a separated bag. 7 of 9 staff denied the allegation and stated bed linens are changed every day, every other day, or when residents shower, or whenever they are dirty, and soiled bedding and clothing are changed immediately and placed in a separate area to be washed. On 01/14/2026 between the hours of 11:05am -1:33pm and on 02/23/2026 between the hours of 1:29pm -1:37pm, LPA conducted 10 resident interviews in regards to the allegation. 1 of 10 resident did not confirm nor deny the allegation and stated clothes and sheets are clean but sometimes there is a lot of dust which might mean they are not washed well. 9 of 10 residents denied the allegation and stated their clothes and sheets are cleanand provided daily, every other day, weekly, or whenever they ask. On 01/21/2026 at 10:34am, LPA conducted a random room inspection in Room 114 and observed staff removing the bed linen and providing the resident with clean bedding. The investigation findings continue on LIC 9099-C On 02/20/2026 between the hours of 4:20pm-4:30pm, LPA conducted a records review and observed the following: Based on Brittany House Housekeeping Policy under the routine section, it states routine housekeeping functions are performed to maintain the required standard of cleanliness throughout the facility premises. This encompasses cleaning of residents' rooms, baths, halls, corridors, dining rooms, lounges, offices, storerooms, utility rooms, workshops, restrooms, and any other areas frequented by personnel, as well as the laundering of personal items, bed linens, housekeeping items, and dining linens. Per the "Laundry Schedule" for Brittany House that divides staff into two groups (Group 1 and Group 2) to manage the pickup, separation, washing, drying, and folding of linen and clothing, the schedule begins at 6:30am and concludes with a mandatory work area clean-up between 2:40pm and 3:00pm. Per the "To Remember" section of the document, the LPA noted that the last round for picking up soiled linen and clothing is at 2:30pm, and staff are required to maintain and sign off on both a daily washer/dryer room cleaning log. Furthermore, the facility policy dictates that all linen closets must remain stocked at all times throughout the shift. Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff did not ensure adequate food services were provided to residents. It was alleged that facility staff failed to ensure adequate food services, as residents reportedly received insufficient meals, limited food options, and beverages were not consistently provided. On 01/14/2026 at 3:05pm, LPA interviewed A1 regarding the allegation. A1 was aware of the allegation and stated a resident across the hall from A1's office has complained about food quantity. A1 stated nutritious meals are provided to residents daily. A1 confirmed beverages are served with every meal. A1 stated cooks prepare the meals using standardized menus. A1 stated the facility accommodates residents' dietary preferences and needs on an individual basis. On 01/14/2026 between the hours of 11:05am -1:33pm, LPA conducted 7 interviews with staff in regards to the allegation. 3 of 7 staff confirmed the allegation and stated residents and family members have complained about food quality or quantity, and the same meals are provided over and over again. 4 of 7 staff denied the allegation and stated 3 meals and 2-3 snacks are provided daily, beverages are served with every meal, kitchen staff prepare the meals using menus created by corporate or standardized menus, and dietary preferences and needs are accommodated using index cards or name tags for each plate. On 01/14/2026 between the hours of 11:05am-1:33pm and on 02/23/2026 between the hours of 1:29pm - 1:37pm, LPA conducted 10 resident interviews in regards to the allegation. 3 of 10 residents confirmed the allegation and stated the food is bad with no taste, bland and the same daily with no change, they do not get enough food, and beverages are only provided sometimes with meals. 1 of 10 resident did not confirm nor deny the allegation and stated the food is okay and not terrible. 6 of 10 residents denied the allegation and stated they like the food, it is okay or good, they get different types of meals daily including protein, carbs, vegetables, baked and fried foods, beverages are served with every meal, and they get enough food and or can ask for more food if still hungry. On 02/20/2026 between the hours of 4:20pm -4:30pm, LPA conducted a records review and observed the following: The facility provided "Good For Your Health Menus" spanning from December 1, 2025, through March 1, 2026. A review of these records indicates a rotating meal cycle consisting of three daily meals—breakfast, lunch, and dinner—each containing multiple food groups including proteins, vegetables, starches, and desserts. Specifically, breakfast menus documented a variety of beverage options, including cranberry, apple, orange, pineapple, and grape juices. Every menu page reviewed contains a standing directive stating, "Milk and Beverage Offered with Every Meal,". The records further show a wide variety of food options, including specialized holiday meals such as Roast Beef with Savory Thyme Sauce and Rich Cheesecake for Christmas Day, Ham with Pineapple Sauce for New Year's Day, and Pork Chops with Creamy Garlic Sauce for Valentine's Day. Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Amy Kaplli (Wellness Director) and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 11-AS-20260107161546

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(d)(3) · Plan of correction due date: Mar 2, 2026

Incidental Medical & Dental Care if the resident is unable to determine their own medication cannot communicate symptoms clearly. . . (3) The date, time, dosage taken, and resident's response shall be documented and maintained in the resident's facility record. This requirement is not met by: Based on observation, interviews and records review: From 10/2025 - 01/14/2026, critical medications for R1's primary diagnoses of Heart Failure, Chest Pain, and anxiety—including Furosemide, Bisoprolol, Losartan, and Sertraline—were routinely omitted for weeks at a time.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: The facility will ensure all medtechs complete the daily medtech log before end of shift to document all medication administrations, refusals, and exceptions. The Administrator or designee will audit logs on a weekly bases. The administrator and or designee will submit proof of the daily medtech logs completion for the month of February by the plan of correction due date and email proof to LPA Brown at Zina.Brown@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 2, 2026

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on observation and interview, staff failed to answer the call light in a timely manner. On 02/23/2026, LPA conducted a call light test in Rm 104, RM 105, 310, 405 observed staff not responding. This violation poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: The facility will implement a new call light system in all units and will notify the department upon beginning and completion of installation. The administrator and or designee will submit an notification letter of the estimated time for the completion of installation by the plan of correction due date and email proof to LPA Brown at Zina.Brown@dss.ca.gov

Allegation investigated: Staff do not provide activities for residents

On 2/12/2026, LPA Alfonso Iniguez conducted an unannounced initial complaint visit. LPA Iniguez met Joel Niblett/Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrators Interview (A#1), Staff Interview (S#1-S#6) and Resident Interviews (R#1-R#6) .LPA gathered the following documents: copy of facility resident roster dated : 2/12/26, copy of facility staff roster or LIC 500 dated: 2/12/2026 and copies of facility activities calendar for October, November, December 2025 and January and February 2026. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff do not provide activities for residents The details of the complaint alleged that facility does not follow activities posted on the activity calendar. On February 12, 2026, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a comprehensive records review. LPA Iniguez observed a copy of the staff roster dated February 12, 2026, confirming that the facility employs a full-time Activities Director. LPA Iniguez also reviewed the facility’s activity calendars for October, November, and December 2025, as well as January and February 2026. These documents show that the facility offers a variety of scheduled activities throughout the day at 9:15 a.m., 10:00 a.m., 10:30 a.m., 11:30 a.m., 1:00 p.m., 2:30 p.m., 3:30 p.m., and 4:30 p.m. These activities comply with Title 22 requirements. They include group discussions and conversations, reminiscence activities such as looking at photos, letters, or greeting cards, cultural and/or religious activities such as holiday celebrations and cultural traditions, and other social activities, including arts and crafts, games, gardening, pet care, and recreational activities that promote social interaction. On February 12, 2026, Licensing Program Analyst (LPA) Alfonso Iniguez confirmed during a facility tour that residents were receiving the activities listed on the facility’s calendar. Evaluation Report continues LIC 9099-C On February 12, 2026, at approximately 10:00 a.m., Licensing Program Analyst (LPA) Alfonso Iniguez met with the Executive Director (A#1) to discuss the facility’s activities program. (A#1) confirmed that the activities calendar is being followed as scheduled and explained that all activities are listed to provide a variety of daily and seasonal options. This approach ensures residents have access to meaningful, person-centered activities throughout the day, including late afternoons. To ensure staff compliance with Title 22 and facility policy, (A#1) stated that the program is posted throughout the facility. Staff adherence is monitored through regular walkthroughs and by collecting feedback from family members. On February 12, 2026, at approximately 10:30 a.m., Licensing Program Analyst (LPA) Alfonso Iniguez conducted interviews with six residents in care (R#1–R#6), (6) out of (6) residents stated that they usually have activities to do during the day, mentioning, “Yeah, we play bingo and we are having a party today.” When asked what kinds of activities they enjoy or would like to do more often, residents responded with “Bingo, of course, news, checkers.” Additionally, when asked if staff assist them in joining activities when they want to participate, (6) out of (6) residents confirmed, “Yeah, they do assist me.” On February 12, 2026, at approximately 12:00 p.m., Licensing Program Analyst (LPA) Alfonso Iniguez conducted interviews with six facility staff members (S#1–S#6), (6) out of (6) staff stated that the daily activity schedule is implemented by reviewing emails upon arrival, checking the activity schedule, and starting the first scheduled activity for the units in the facility. When asked if the activity calendar is being followed as scheduled, (6) out of (6) staff confirmed that it is. In addition, the staff further explained that if scheduled activities cannot be provided, alternative engagement or supervision is offered to residents, such as bingo or card games. Evaluation Report continues LIC 9099-C During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Joel Niblett/Administrator.the state’s words, verbatim · CDSS document, Feb 12, 2026 · control 11-AS-20260205092731

Allegation investigated: Licensee does not prevent residents and staff from smoking inside the facility Staff does not ensure food is of good quality and quantity Staff does not ensure emergency signal system is in good repair

On 01/22/2026, at 8:30AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to investigate and deliver findings for the alleged allegations. LPA identified herself and met Carlos Hernandez and Marcus Falanai who were informed of the purpose of the visit. The investigation consisted of the following: On 1/22/2026 at 9:00AM LPA Allen conducted interviews with Residents 1-9 (R1-R9) and Staff Members 1-9 (S1-S9). LPA also conducted a tour of the facility that included the kitchen, Unit 1, 2,3, 4 and 5 the outside patio in Unit 3 and Unit 4 sections and tested Emergency call buttons. The investigation revealed the following: #1-Allegation: Licensee does not prevent residents and staff from smoking inside the facility The interviews conducted with Residents 1-9 (R1-R9) were asked does the licensee prevents residents Continued Unsubstantiated and staff from smoking inside the facility and 1 out of 9 residents stated they have smoked cigarettes in their room in the past, but management have spoken to them about following the house rules and they haven’t smoked in their room since. R2-R9 stated they have smelled cigarettes and marijuana lingering after residents have been smoking outside, but they have not personally seen any staff member or residents smoking inside the facility at any time. Residents also mentioned that there is a designated patio area for smoking in unit 3 and unit 4 which is used by the residents. Interviews were also conducted with staff members 1-9 (S1-S9) and 2 out of 9 staff members stated there was a resident smoking in their room (R9) in the past and house rules were discussed with them and since their discussion R9 has not been seen smoking in their room, nor have there been reports of R9 smoking inside the facility/room. The interviews with staff members 3-9 (S3-S9) stated they have heard rumors of smoking in residents room, but they have not personally seen them smoking inside the facility in the past or currently. Additionally, staff mentioned that residents have a designated smoking area outside of the facility in unit 3 and unit 4. #2 Allegation: Staff does not ensure food is of good quality and quantity The interviews conducted with Residents 1-9 (R1-R9) were asked about the food being of good quality and quantity and 9 out of 9 residents stated the food was okay and could use more seasoning on it but it’s eatable and if additional servings are requested it is provided or alternative options are available. The interviews conducted with staff members 1-9 (S1-S9) were asked does the staff ensure food is of good quality and 9 out of 9 staff members stated that the food in their opinion is of good quality and at times some residents complain about small portions, but a request for seconds can be made and provided if available. When asked, are there other options available, all 9 staff members said yes. #3 Allegation: Staff does not ensure emergency signal system is in good repair The interviews conducted with Residents 1-9 (R1-R9) were asked about the emergency signal system being in good repair and 9 out of 9 residents stated that the system works but it takes staff a long time to respond. When asked how long it takes for staff to respond, all 9 said it could be 15-30 minutes When asked does their call system works, all 9 said yes. During the tour of the facility LPA did not observe any staff or residents smoking inside of the facility and LPA did not smell any signs of Marijuana or cigarettes being smoked inside of the facility. LPA did observe residents going and coming outside from the designated smoking area in unit 3 and unit 4. LPA also toured the kitchen and LPA observed that there were menus available for review. There was a 7-day supply of non-perishables and a 5-day supply of perishable food. LPA also observed breakfast being served scrambled eggs with vegetables, toast, and raisin brain that was listed on the menu. LPA also tested the call system in rooms 204,209,212, and 216 and all buttons were in working order. Based on interviews, documents reviewed and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and provided to Joel Niblett- Administrator at conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 11-AS-20260114110524

Allegation investigated: Staff did not maintain facility sanitary Facility smells malodorous

On 01/22/2026 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Brittany House and was greeted by Administrator Joel Niblett (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S7, residents R1-R12. LPA Calderon obtained the following records: Admission Agreement (dated 06/30/2025). Housekeeping Schedule (dated 01/2026) for R1. Toured the facility with S1 to include common areas and rooms. The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff did not maintain facility sanitary’. This complaint alleged that the facility staff did not change R1 bed that had feces in the sheets. LPA Calderon noted staff cleaning the facility. LPA Calderon noted staff changing bed sheets. Records review indicate the following: Reviewed housekeeping schedule for (dated 01/2026) staff cleaning from 6:30 am to 3pm every day. Interviews indicate the following: S1 indicates that R1 was only in the facility for 3 days and transferred to a new facility. S1 indicates that staff clean rooms every day and change sheets 3 times per week or when needed. 7 out of 7 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 11 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not maintain facility sanitary” is found to be UNSUBSTANTIATED. Regarding the Allegation: Facility smells malodorous. This complaint alleged that the facility common areas and rooms smelled. LPA Calderon noted staff cleaning the facility. LPA Calderon noted staff changing bed sheets. LPA Calderon did not smell any odors in the rooms or common areas. Records review indicate the following: Reviewed housekeeping schedule for (dated 01/2026) staff cleaning from 6:30 am to 3pm every day. Interviews indicate the following: S1 indicates that R1 was only in the facility for 3 days and transferred to a new facility. S1 indicates that staff clean rooms every day and change sheets 3 times per week or when needed. 7 out of 7 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 11 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “facility smells malodorous” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff or residents smoking marijuana’. This complaint alleged that the facility staff and residents smoke marijuana inside the facility. LPA Calderon noted staff cleaning the facility. LPA Calderon noted staff changing bed sheets. LPA Calderon did not smell smoke or the smell of marijuana inside the facility. Interviews indicate the following: S1 indicates that it is against company policy for staff to smoke marijuana at work and no staff would be smoking inside the facility. 7 out of 7 staff deny the allegation. R1 could not be interviewed as R1 no longer lives in the facility. 11 out of 12 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff or resident smoking marijuana inside the facility” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Joel Niblett (S1).the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 11-AS-20260115151515

Allegation investigated: Staff did not address resident's change of condition. Staff did not seek medical attention for resident in a timely manner.

*This report supersedes the report dated 11/24/25. This report has been amended to add additional verbiage and to add additional citations*. On 11/24/25, at 9:20am, the department conducted an initial complaint visit to the facility and was greeted by Joel Niblett, Executive Director. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegation(s) mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S6), witness (W1), and residents (R1-R10). The department received the following facility documents: Resident Roster (Date: No Date), Staff Roster (Dated: 11/17/2025), Admission Agreement (Dated: 08/14/2025 ), Face Sheet/ID Emergency information (Dated:11/24/2025, 08/13/2025), Physician’s Report (Dated: 08/12/2025), Appraisal & Needs Service... Report Continued on LIC9099-C Substantiated Plan (Printed On: 11/24/2025), Lakewood Regional Medical Center Visit Summary (Dated: 08/16/2025, 11/01/2025), Preplacement Appraisal Information (Dated: 08/11/2025), Rose Villa Care Center Discharge Report (Dated: 12/16/2025), Rose Villa order Summary report (Dated: 12/15/2025) and Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) from the facility. The investigation revealed the following: Allegation #1-Staff did not address residents’ change of condition. The details of the complaint alleged that the facility did not address the residents’ change of condition. It was reported that the resident had bandages wrapped around their toe, when it was inquired why, staff stated that perhaps the residents’ shoes were too tight and probably caused the blistering on their foot. Subsequently, without medical attention, the residents’ foot became swollen, and their toe became infected. The resident as sent to the hospital on 11/01/2025 and it was determined R1’s toe needed to be amputated. On 11/24/2025, from 9:20am-2:00pm, the department interviewed staff (S1-S6), witness (W1), and residents (R1-R10) regarding the allegation. 4 of 6 staff stated that they notified the nurse (LVN) about the residents’ swollen foot and contacted the family member. They stated that the nurse is responsible for getting medical assistance for the residents. One staff member stated that the resident (R1) told them that their foot was swollen and needed assistance; staff stated that they advised the LVN of the problem. S6 stated that they were notified of the resident’s swollen foot on the day they were sent to the hospital for evaluation. S6 also stated that the toe looked red and had some discharge. Staff also stated that residents are checked on every one to two hours a day to assess their condition. The department interviewed residents (R1-R10) about the allegation and 6 of 10 residents that were interviewed stated that they believed the staff would not know if they had a change in their condition. When asked why, they stated that they believe they need more training. The department also interviewed witness (W1) about the incident, and they stated that the nursing team never called or had communication with them regarding R1, even when (W1) discovered that R1s foot was swollen and bandaged. Report Continued on LIC9099-C The department reviewed the Appraisal & Needs Service Plan (Printed On: 11/24/2025), Physician’s Report (Dated: 08/12/2025), Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025), Rose Villa Care Center Discharge Report (Dated: 12/16/2025), Rose Villa Order Summary report (Dated: 12/15/2025) and observed that the Med Tech Communication Log noted that first aid was applied because R1s foot was swollen on 10/25/2025, 10/29/2025, 10/30/2025, and 11/1/2025. The log noted that the LVN and family member were notified. However, medical services were not notified to address R1s change in condition; resulting in R1s toe becoming infected and amputated. The department also reviewed the discharge report from Rose Villa Care Center that advised R1 had a complete traumatic amputation of one right toe. Additionally, the department reviewed Lakewood Regional Medical Center Visit Summary (Dated: 08/16/2025) showing the resident had a prior history of a fall causing a right elbow fracture. Community Care Licensing Division did not receive an incident report detailing the hospital visit, amputation, nor the swollen foot. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not address residents’ change of condition, is found to be Substantiated. Title 22, Division 6, Chapter (8) is cited on the attached LIC 9099D. Citation: 87466 Observation of Resident Deficiencies were issued and plans of corrections were discussed. Note: *Citations that are not cleared by the POC due date of 1/22/26 will have a $100 fine assessed for each day that the citation is not cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. Citation cleared on todays visit. ECP: At this time, an Enhanced Civil Penalty determination is pending in reference to Health & Safety Code 1569.49(f)“Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” Civil Penalty: An immediate $500 Civil Penalty was assessed for resident’s toe amputation. Report Continued on LIC9099-C Allegation #2- Staff did not seek medical attention for resident in a timely manner. The details of the complaint alleged that the facility did not seek timely medical attention for the resident. It was reported that the residents’ foot became swollen and their toe became infected and needed to be amputated, as a result of inaction by the facility. On 11/24/2025, from 9:20am-2:00pm, the department interviewed staff (S1-S6), witness (W1), and residents (R1-R10) regarding the allegation. 4 of 6 staff stated that they told the nurse about the resident and they were responsible for getting medical services involved, if appropriate. They also stated that they believed the resident was going to get medical services for their swollen foot. While S6 stated that they were notified of the resident’s swollen foot on the day they were sent to the hospital for evaluation. S6 also stated that the toe looked red and had some discharge on the day they were sent to the hospital for evaluation. The department interviewed residents (R1-R10) about the allegation and 4 of 10 residents that were interviewed stated that staff have sought medical attention for them in a timely manner in the past. The department interviewed witness (W1) about the allegation, and they stated that they believed the facility did not seek medical attention for the resident in a timely manner. Additionally, they stated that they were not made aware of the condition before it got to the point where R1s toe needed to be amputated. The department could not review the LIC624 Unusual Incident Report about the swollen foot or subsequent hospitalization because the facility failed to submit it to Community Care Licensing Division within seven days of the occurrence. The department did review the Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) that noted R1 was receiving first aid for the swollen foot, but it did not specify that medical services were notified, or any action taken on behalf of the resident. The department also reviewed the discharge report from the Skilled Nursing Facility, Rose Villa Care Center, that advised R1 had a complete traumatic amputation of one right toe. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not seek medical attention for resident in a timely manner, is found to be Substantiated. Title 22, Division 6, Chapter (8) is being cited on the attached LIC 9099D. Citation 87411 Personnel Requirements – General Deficiencies were issued and plans of corrections were discussed. Report Continued on LIC9099-C Note: *Citations that are not cleared by the POC due date of 2/6/26 will have a $100 fine assessed for each day that the citation is not cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. An exit interview was conducted with Joel Niblett, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 11-AS-20251118115055

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jan 22, 2026

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental… functioning and that appropriate assistance is provided when such observation reveals unmet needs. When…deterioration …are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews and record reviewed, the licensee failed to ensure that appropriate assistance was provided to R1 when changes in their physical condition were found (swelling in foot and toe) resulting in the toe being amputated. Which posed a potential risk to the health, safety and personal rights of the resident in care.the state’s words, verbatim · CDSS document, Jan 22, 2026

Plan of correction: The administrator will create a plan of correction to ensure that observations of residents are conducted when significant change in the resident’s condition is observed and review and conduct in-service training for staff of 87466 Observation of Resident. In-service training with signatures of staff and plan of corrections will be submitted prior to POC due date of 2/6/26, via email, to perry.scott@dss.ca.gov to avoid monetary penalties. An IMMEDIATE CIVIL PENALTY of $500.00 will be assessed for the resident’s toe being amputated. Citation cleared on today’s visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 6, 2026

87411(a) Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee failed to ensure a sufficient number of competent staff to meet R1’s needs. R1’s foot was swollen for several weeks, no one followed up with hospital visits, and ultimately R1’s toe became infected and had to be amputated. This poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jan 22, 2026

Plan of correction: The Licensee shall create a plan to follow Title 22 87411(a) regulations and retrain staff on how to provide competent services necessary to meet residents’ needs while ensuring that staff provide personal assistance and care. In-service training with signatures of staff and plan of corrections will be submitted prior to POC due date of 2/6/26, via email, to perry.scott@dss.ca.gov to avoid monetary penalties.

Type of visit: Case Management - Other

On 1/22/2026, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced Case Management visit to the facility in connection with complaint #11-AS-20251118115055 that was conducted on 11/24/2025. The LPA met with Joel Niblett, Executive Director, and explained the purpose of the visit. The department determined that the facility was not in compliance with Title 22 Regulations in connection with the complaint and issued additional citations for 87405(b)(2) Administrator Qualifications and 87211(a)(B)(D) Reporting Requirements. Citation: 87211(a)(B)(D) Reporting Requirement was cleared during today’s visit. Citation: 87405(b)(2) Administrator Qualifications has a plan of correction due date of 2/6/2026. An exit interview was conducted with Joel Niblett, Executive Director, and a hard copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 22, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(b)(2) · Plan of correction due date: Feb 6, 2026

87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: Based on interviews and records reviewed, the Licensee/Administrator failed to adhere to Title 22 regulations, by properly ensuring facility staff were providing appropriate care for R1 in accordance with Title 22 regulations, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 22, 2026

Plan of correction: The Licensee will create a plan to ensure that the administrator performs and adheres to their duties and has knowledge of and conform to all applicable laws, rules and regulations. A written statement from the administrator stating they have reviewed and understood Title 22 87405(b)(2) Administrator-Qualifications and Duties. Plan of corrections will be sent to LPA Perry Scott by 02/6/26 at perry.scott@dss.ca.gov to avoid monetary penalties.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(B)(D) · Plan of correction due date: Jan 22, 2026

87211(a)(B)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...(B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety, or health of any resident... This requirement was not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report associated with the incident for R1 that resulted in hospitalization and amputation of R1s toe. The facility did not have proof of certified confirmations that an LIC 624 was faxed to CCL. This violation poses a potential health, safety, or personal-rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 22, 2026

Plan of correction: The Licensee shall submit a serious incident report LIC624 for R1 about the swelling of their foot and toe, and the hospitalization that resulted in the resident having to have their toe amputated because of infection. The report shall be submitted prior to POC due date of 1/22/26, via email, to perry.scott@dss.ca.gov to avoid monetary penalties. This citation was cleared during today’s visit.

Allegation investigated: Unqualified facility staff administered medication to resident Facility staff did not seek timely medical attention for resident Facility staff did not properly report incident Facility staff did not answer resident's call button in a timely manner

On 01/21/2026 at 8:30am, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit at this facility to deliver the complaint findings for the allegations above. During today’s visit, at 11:15 am, LPA met with Joel Niblett (Administrator) and explained the purpose of the visit. The investigation consisted of the following: The investigation consisted of the following: On 11/17/2025, LPA interviewed with Staff (S1-S5) & Residents (R1 - R5) between the hours of 10:02am - 3:00pm & on 12/02/2023 LPA interviewed Staff (S6-S10) then Residents (R6-R8) between the hours of 10:12am - 3:08pm and on 01/26/2026 between the hours of 9:30am -10:22am for Resident 9 (R9), Resident Roster (received 11/17/2025), Staff Roster (dated 11/17/2025), Resident #1 (R1's) documents such as LIC 601 Personnel Record (dated 09/12/2024), LIC 602: Physician Report (dated 09/18/2024), Service Plan (dated 03/03/2025), Admission Agreement (dated 09/20/2024), Assessment Plan (dated 07/25/2025), Medication Administrator Record (dated 10/2025 - 11/2025) and Committed Hospice Care Inc Hospice Care Plan (dated 08/28/2025). Substantiated The investigation revealed the following: Allegation: Unqualified facility staff administered medication to resident It was alleged that an unqualified facility staff administered liquid narcotic medication to the resident at least two times in the middle of the night (late night 10/30/2025 or early morning 10/31/2025), following the first dose given to Resident 9 (R9) by their hospice nurse on the evening of 10/30/2025. On 11/17/2025 at 9:54am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated medtechs and LVNs are authorized and trained to administer medication at the facility. A1 also stated the procedure for giving medication to hospice residents, especially after hours, is per the doctor's orders. A1 mentioned there have not been any situations where a staff member who is not medication certified gave medication to a resident, and all new staff are medtech certified. On 11/17/2025 between the hours of 10:02am -12:52pm and on 12/02/2025 between the hours of 12:26pm - 3:02pm, LPA conducted 10 interviews with staff regarding the allegation. 2 of 10 staff were aware of the allegation, of which 1 staff member stated Resident 9 (R9)'s relative mentioned Staff 11 (S11) who administered narcotic medication mixed together with another medication. 1 of 10 staff was unaware of the allegation and stated not having knowledge of a staff who is not medication certified administering medication to a resident. 7 of 10 staff denied the allegation, of which 2 staff have never witnessed a staff who is not medication certified administering medication to a resident, while 1 staff is a medtech who ensures to read medication labels and dosages while administering medication but does not have any knowledge of what occurs after hours due to not being scheduled during that time period. On 11/17/2025 between the hours of 2:05pm - 3:00pm, then on 12/02/2025 between the hours of 1:21pm - 3:40pm and on 01/26/2026 between the hours of 9:30am -10:22am, LPA conducted 9 interviews with residents regarding the allegation. 1 of 9 residents did not confirm nor deny the allegation and stated staff does not identify nor verify what medications are being given. The medtech just watches to ensure medication is taken. 1 of 9 residents confirmed the allegation, stating that in the past couple of days medication was administered at 10pm by the medtech. 7 of 9 residents denied the allegation and stated not witnessing staff giving medication late at night or at times when the nurse, medtech, or hospice workers are not present. However, 1 of the 7 residents expressed wanting more communication and explanation regarding what the medication is for and why the medication needs to be taken. On 01/20/2026 between the hours of 2:58pm -3:20pm, LPA conducted a records review and observed the following for Resident 9 (R9) Medication Administration Record (MAR) for the month of October 2025. On 10/30/2025 and 10/31/2025 it was not marked off on the MAR that narcotic medication (morphine) SULF 100 mg/5 ML CONC was administered to the resident. Also, LPA observed that the department did not receive a LIC 624: Unusual Incident/Injury Report via fax in regards to R9 receiving a double dosage of narcotic medication which caused R9 to overdose and the facility administering the Narcan to sedate the resident. Investigation findings continue on LIC 9099-C On 01/21/2026 between the hours of 12:10pm -12:15pm, LPA conducted a records review and observed the following: According to the Physician Order from Committed Hospice Care Inc for List of New/Refill Order, Start date 10/28/2025 for Morphine Sulfate 15 mg tablet with a dosage of 0.5 tablet oral every 4 hours as needed for pain and discontinue on 10/31/2025. Start date 05/25/2025 for Morphine Sulfate 20mg/1mL Solution with quantity 30 ml and a dosage of 0.25ml (5mg) oral every 4 hours as needed for severe pain and discontinue on 10/31/2025. Start date 10/30/2025 for Lorazepam 1 mg with the start date 10/30/2025 with 1 tablet dosage oral to be given 2x daily at 9am and 5pm for anxiety and restlessness and discontinue on 10/31/2025. On 01/21/2026 between the hours of 9:10am -10:31am, LPA at the time requested a copy of Staff 11 (S11) medication administration training and, the facility was unable to provide proof of medication certification for Staff 11 (S11). Based on LPA's interviews and record review, Staff 11 administered medication to Resident 9 which resulted in R9 overdosing on medication and facility staff administering Narcan. Staff 11 does not have any documented training for medication administration. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Allegation: Facility staff did not seek timely medical attention for resident It was alleged that facility staff did not seek timely medical attention for a resident following an overdose of medication and the administration of Narcan. On 11/17/2025 at 9:54am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated the process upon finding a resident unresponsive or in distress is to promptly contact emergency first responders for residents who experience a medical problem or need urgent help. Regarding the actions taken on the morning of 10/31/2025, A1 stated calling hospice and declared the decision made about calling emergency responders. Investigation Findings continues on LIC 9099-C On 11/17/2025 between the hours of 10:02am -12:52pm and on 12/02/2025 between the hours of 12:26pm -3:02pm, LPA conducted 10 interviews with staff regarding the allegation. 4 of 10 staff were aware of the allegation and stated being informed about what had occurred with Resident 9 (R9). 2 of 10 staff did not confirm nor deny the allegation, with 1 of the staff stating being scheduled to work on the evening of 10/31/2025 and explaining the process of what decision should be made about calling 911 or administering Narcan. The other staff said upon observing Resident 9 (R9), who appeared to be heavily sedated and drooling, a medtech made the decision to administer Narcan. 4 of 10 staff were unaware of the allegation, with 1 staff stating this is a question for the medtech, while the other 3 staff stated not being scheduled to work on the day of the incident. On 11/17/2025 between the hours of 2:05pm - 3:00pm, then on 12/02/2025 between the hours of 1:21pm -3:40pm and on 01/26/2026 between the hours of 9:30am - 10:22am, LPA conducted 9 interviews with residents regarding the allegation. 3 of 9 residents confirmed the allegation, with 1 of the 3 residents stating they have witnessed a delay with resident health concerns regarding their neighbor. 6 of 9 residents denied the allegation. Out of the 6 residents who denied the allegation, 4 of those residents expressed the facility staff calls for outside assistance from emergency first responders right away. On 01/21/2026, LPA conducted a record review between the hours of 12:00pm -12:05pm, and observed the following: Resident 9 (R9)'s communication log (dated 10/30/2025) by Staff 11 states resident declined medical attention, confirmed and spoke with R9 family member by phone and in person. On 01/20/2026, between the hours of 4:25pm - 4:30pm, LPA conducted a records review and observed the following: the department did not receive a LIC 624: Unusual Incident/Injury Report via fax in regards to R9 being transported by emergency first responder nor R9's refusal of wanting to go to the hospital in regard to overdose and the administration of Narcan. Based on the LPA conducting interviews and records review, the facility failed to seek timely medical attention when the resident appeared to be in distress and waited until an hour later to administer Narcan. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Investigation Findings continues on LIC 9099-C Allegation: Facility staff did not properly report incident On 11/17/2025 at 9:54am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated the steps staff are required to take when a resident has a serious incident that occurs such as an overdose is to call 911. Also, A1 stated medtech and LVN are responsible for notifying the representative, hospice, and licensing after an incident occurs. In the event something unusual or unsafe happens, staff communicate by phone notification and folders for shift to shift communication. A1 mentioned not witnessing staff failing to document and or follow up on an incident. On 11/17/2025 between the hours of 10:02am -12:52pm and on 12/02/2025 between the hours of 12:26pm -3:02pm, LPA conducted 10 interviews with staff regarding the allegation. 7 of 10 staff denied the allegation. 2 of 10 staff confirmed the allegation with 1 staff stating witnessing the LVN all the time failing to document and or follow up on incidents that occur. 1 of 10 staff was unaware of the allegation, not knowing if the medtech and LVN conduct follow up in regards to incidents that occur. On 11/17/2025 between the hours of 2:05pm - 3:00pm, then on 12/02/2025 between the hours of 1:21pm -3:40pm and on 01/26/2026 between the hours of 9:30am -10:22am, LPA conducted 9 interviews with residents regarding the allegation. 1 of 9 residents confirmed the allegation and stated they have witnessed staff failing to document or follow up on an incident. 4 of 9 residents denied the allegation, stating that the facility handles emergency and incident reporting well. 2 of 9 residents were unaware of the allegation due to not having any idea nor any knowledge of how the facility handles emergency/incident reporting. 2 of 9 residents did not confirm nor deny the allegation with 1 of the residents stating not knowing nor never really having an emergency while the other resident stated the facility sometimes handles emergency or incident reporting. Investigation Findings continue on LIC 9099-C On 01/21/2026 between 10:03am -10:05am, a records review was conducted. Upon review of Resident 9 (R9)'s communication logs dated 10/30/2025 and 10/31/2025, the following was observed: Staff 11 (S11) created an entry at 6:39am, which was last updated by Staff 5 (S5). The entry indicated that hospice was called and a nurse assisted R9 due to severe seizures and aftershocks, and morphine liquid and Ativan were administered. At 6:56pm on 10/30/2025, R9 experienced 4 seizures within 1 hour. At 7:03pm on 10/30/2025, per the hospice RN, updated orders were issued: Lorazepam (Ativan) 1 mg Q4H "Give 2 tabs of 0.5 mg PO Q4H" and Norco 5-325 mg Q6H "Give 1 tab PO Q4H" for 24 hours starting at 9:00pm on 10/30/2025. The hospice RN left a written order in the medication room. S11 documented at 8:20am on 10/30/2025 that R9 declined medical attention after staff confirmed and spoke with their family member by phone and in person, noting that R9 did not want to go to the hospital for any medical attention. S5 created an entry on 10/31/2025 at 9:55am, updated at 1:28pm, stating that R9 was found on the floor around 8:30am by Resident 4 (R4), who is R9's next-door neighbor. R4 discovered injuries on R9's right arm and knee, and R9 exhibited weakness in their legs. Hospice was notified, and the nurse instructed staff to hold the Lorazepam at 9:00pm due to R9's weakness. A medtech aide created an observation/progress note at 7:25am on 10/31/2025, indicating that R9 was okay during the NOC shift from 10:30pm - 6:30am with no seizures, and that R9 took his Ativan at 1:00am and 5:00am. S5 documented at 9:55am on 10/31/2025 that R9 was vomiting with increased confusion and slurred speech. Narcan was administered, hospice was notified about the change in condition, and staff spoke to case management requesting updated medication orders due to R9 being on routine narcotics and the medication change on 10/30/2025. The nurse stated they would assess the resident and requested a faxed order. On 01/20/2026, between the hours of 4:25pm - 4:30pm, LPA conducted a records review and observed the following: the department did not receive a LIC 624: Unusual Incident/Injury Report via fax in regards to what happened on 10/30/2025 nor 10/31/2025 with R9 being administered incorrect dosage of medicine and also there is no evidence to support the responsible party of R9 was notified in regards to this incident. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights. Investigation Findings continues on LIC 9099-C Allegation: Facility staff did not answer resident's call button in a timely manner It was alleged that facility staff did not answer the resident's call button in a timely manner between the dates of 10/30/2025-10/31/2025. It is also alleged that the resident had pulled their cord on the call light in the early morning of 10/31/2025 but no one came, so the resident attempted to get out of bed and fell at breakfast time, when staff found the resident on the floor. On 11/17/2025 at 9:54am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and stated call buttons and or monitored resident checks, especially for those on hospice, are a standard every 2 hours and as needed. The usual response time is promptly but there are not any logs on file. A1 also stated not being aware of any challenges with responding to call lights promptly. On 11/17/2025 between the hours of 10:02am -12:52pm and on 12/02/2025 between the hours of 12:26pm -3:02pm, LPA conducted 10 interviews with staff regarding the allegation. 2 of 10 staff confirmed the allegation, of which 1 of the staff stated sometimes there have been challenges with responding to the call light due to staff being short-staffed. 8 of 10 staff denied the allegation and expressed caregivers go immediately to attend to the resident's needs within 5-10 minutes and or once the beeper/pager goes off, an announcement is made over the walkie talkie for a caregiver to go assist the resident who called for help. On 11/17/2025 between the hours of 2:05pm - 3:00pm, then on 12/02/2025 between the hours of 1:21pm - 3:40pm and on 01/26/2026 between the hours of 9:30am -10:22am, LPA conducted 9 interviews with residents regarding the allegation. 3 of 9 residents did not confirm nor deny the allegation due to not using the call button. 4 of 9 residents confirmed the allegation and stated not using the call button since the staff would never come to help them so they would go to the staff for help. 2 of 9 residents denied the allegation and stated by 1 of the residents who expressed not calling for help while the other resident stated not waiting a long time for someone to respond. On 01/20/2026, between the hours of 4:25pm-4:30pm, LPA conducted a records review and observed the following: the department did not receive a LIC 624: Unusual Incident/Injury Report via fax in regards to R9 falling out of the bed which resulted in R9 being found on the floor. However, in R9's communication log (provided on 01/21/2026) it states the on 10/31/2025, R9 was found on the floor around 8:30am by R4 who is R9's next door neighbor. Injuries appeared on R9's right arm & knee as well having weakness on legs. Investigation Findings continue on LIC 9099-C On 01/21/2026, between 9:44am - 10:44am, the LPA conducted a call light button test in the following rooms: Room 105 from 9:44am - 10:22am, Room 104 from 10:22am - 10:32am, and Room 114 at 10:34am - 10:44am. It was observed that call light lit up and made a beep sound and staff did not come into any of these 3 rooms to answer the call light button. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. At this time, an Enhanced Civil Penalty determination is pending in reference to Health & Safety Code 1569.49(f) "Serious Bodily Injury" as defined in Section 243 of the Penal Code that states, "a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement." Civil Penalty: Exit interview conducted with Joel Niblett (Administrator) and a copy of this report was provided with appeal rights. The investigation revealed the following: Allegation: Facility staff did not follow resident's care plan It was alleged that facility staff did not follow the resident's care plan in which staff are supposed to check on the resident every 30 minutes but they do not. On 11/17/2025 at 9:54am, LPA interviewed A1 regarding the allegation. A1 did not confirm nor deny the allegation in regard to staff are to stay update on each resident's care plan, especially those on hospice, by reviewing the hospice folder. A1 expressed staff are supposed to check on residents who require regular monitoring every 2 hours as needed. A1 also mentioned a resident care plan's instructions are to be followed consistently across all shifts with a communication log in place.. A1 stated not applicable, no monitoring log, in regards to staff ensuring that entries in resident records reflect what actually occurred. Also A1 mentioned staff document according to their observation and it's not applicable in regards to there have not been any issues maintaining accurate logs or completing them on time. On 11/17/2025 between the hours of 10:02am -12:52pm and on 12/02/2025 between the hours of 12:26pm -3:02pm, LPA conducted 10 interviews with staff regarding the allegation. 1 of 10 staff confirmed the allegation and stated the facility doesn't really have a proper system and expressed not enough information is documented in the communication log in regards to staying updated with the resident care plan. 9 of 10 staff denied the allegation and expressed staff stay up to date with resident's care plan by using August Health, communication logs/notes, and verbal crossover exchange. On 11/17/2025 between the hours of 2:05pm-3:00pm, then on 12/02/2025 between the hours of 1:21pm -3:40pm and on 01/26/2026 between the hours of 9:30am -10:22am, LPA conducted 9 interviews with residents regarding the allegation. 1 of 9 residents confirmed the allegation and stated staff do not seem to follow each resident's care plan. 5 of 9 residents denied the allegation and expressed the staff is understanding of the resident's care needs. 3 of 9 residents did not confirm nor deny the allegation and stated some staff understand the care needs of the resident while other staff do not. Investigation findings continues on LIC 9099-C On 01/21/2026 between the hours of 1:15pm -1:25pm, LPA conducted a records review and observed the following: According to Committed Hospice Care Inc - Plan of Care (dated 05/27/2025) for Resident 9 (R9) on page 9 of 11, for pain goal: in 1-2 weeks, patient's pain level remains <3 and maintains comfort/satisfaction from pain after nursing intervention/medication. PT/PCG will verbalize/express understanding of medication/treatment orders and side effects. Intervention states administer medication as ordered: Norco 5-325mg oral 1 tab every 6 hours as needed for moderate-severe pain (5-10/10). Morphine Sulfate 20mg/1mL Solution oral 0.25ml (5mg) every 4 hours as needed for severe pain (7-10/10). Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Facility staff did not keep accurate resident records It was alleged that facility staff did not keep accurate resident records when staff used to keep a log in the resident's bedroom to initial every 30 minutes, but staff would write down several "checks" in a row that never actually occurred, so they removed it. On 11/17/2025 at 9:54am, LPA interviewed A1 regarding the allegation. A1 did not confirm nor deny the allegation and stated staff document according to their observation when asked how staff ensure that entries in resident records reflect what actually occurred. A1 said not applicable when asked if there have been any issues to maintaining accurate logs or completing them on time. Also, A1 mentioned not applicable, no monitoring log when asked how check-ins, observations, or monitoring logs are documented for residents who require frequent checks. On 11/17/2025 between the hours of 10:02am-12:52pm and on 12/02/2025 between the hours of 12:26pm -3:02pm, LPA conducted 10 interviews with staff regarding the allegation. 3 of 10 staff confirmed the allegation and expressed there have been issues with the resident's records not being accurate. 6 of 10 staff denied the allegation and stated there have not been any issues maintaining accurate logs for the resident records. 1 of 10 staff was unaware of the allegation and stated not being aware of any issues of completing and maintaining accurate logs on time. Investigation Findings continue on LIC 9099-C On 11/17/2025 between the hours of 2:05pm-3:00pm, then on 12/02/2025 between the hours of 1:21pm - 3:40pm and on 01/26/2026 between the hours of 9:30am - 10:22am, LPA conducted 9 interviews with residents regarding the allegation. 3 of 9 residents denied the allegation. 3 of 9 residents confirmed the allegation and stated not witnessing staff writing and or logging information in regard to care and regular routine checks. 3 of 9 residents did not confirm nor deny the allegation and stated sometimes witnessing staff writing and or logging information in regard to care and regular routine checks. Based on observation and records review conducted on 01/21/2026 between the hours of 1:35pm -1:40pm, in R9's hospice care plan, it does not state the resident should be checked on every 30 minutes. Also, upon observation and record review, the facility does not have a check log on file. Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Joel Niblett (Administrator) and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 11-AS-20251107081717

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(c) · Plan of correction due date: Jan 22, 2026

Personnel Requirements - General: All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Based on interview, observation & record review Staff 11 (S11) did not have any documented medication administration training on file but was administering medication to the residents which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 21, 2026

Plan of correction: The facility will review all staff training for all medication technicians to ensure they have proper medication administration training and schedule a refresher training for all medication technicians. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Jan 22, 2026

Observation of the Resident: The licensee shall ensure residents are regularly observed for changes in physical, mental, emotional, and social functioning, and appropriate assistance is provided when observations reveal unmet needs. This requirement was not met as evidenced by: Based on interviews and records review, facility staff observed Resident 9 (R9) in distress & the facility did not provide timely medical attention. Narcan was administered without a prescription from R9's primary care doctor, posing an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 21, 2026

Plan of correction: The facility will schedule a training with all caregivers and medication technicians on Observation of the Resident per Title 22 Regulations. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 26, 2026

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on observation and interview, staff failed to answer the call light in a timely manner. On 01/21/2026, LPA conducted a call light test observed staff not responding. This violation poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 21, 2026

Plan of correction: The facility will conduct an in service staff training in regards to answering call lights. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jan 28, 2026

Reporting Requirements: (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)...This requirement was not met as evidence by: Based on records review, the department did not receive a LIC 624 regarding R9 being administered a controlled medication dosage nor proof of medical attention being provided on 10/30/2025 or 10/31/2025. This violation poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 21, 2026

Plan of correction: The facility will conduct an in service staff training in regards to how to proper report to licensing in a timely manner. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

Type of visit: Case Management - Deficiencies

On 01/26/2026 at 8:25 am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced case management visit and met with Joel Niblett (Administrator) to explain the purpose of the visit. On 01/15/2026, the Department conducted its annual inspection and issued a deficiency for Title 22 Regulation for Criminal Background Clearance 87355(e)(3). As a result of the deficiency cited on 01/15/2026, and as of today, 01/21/2026, the deficiency is being re-issued with civil penalties being assessed under the California Code of Regulations, Title 22, Division 6, Chapter 8. Please refer to the attached document LIC 809-D for more information. An exit interview was conducted with Joel Niblett (Administrator), and a copy of this report was provided, including information about appeal rights.the state’s words, verbatim · CDSS document, Jan 21, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Jan 22, 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) or This requirement is not met as evidenced by: Based on observation and interview, 3 of 12 staff are not associated to the facility at the time of unannounced inspection which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 21, 2026

Plan of correction: The facility shall associate staff: Leticia Velasco, Cristina Valencia & Alma Soto in Guardian and submit proof of being associated with the facility via email zina.brown@dss.ca.gov by POC due date.

Allegation investigated: Staff are not preventing the spread of a communicable disease. Staff did not notify the resident's responsible parties of the outbreak.

On January 15, 2026, Licensing Program Analyst (LPA) Pamela Bunker conducted a subsequent visit to gather information regarding the above allegations. LPA Bunker met with Executive Director Joel Niblett and explained the purpose of today's visit. LPA was granted entry into the facility. The investigation consisted of the following: On 10/15/2025 and 01/15/2026, the following documents were reviewed and obtained as part of the investigation: Personnel Report (dated10/14/2025 and 01/09/2026), Resident Roster (dated10/15/2025 and 01/15/2026), Special Incident Report (dated 10/06/2025 and 10/09/2025) and Notification Log (dated 10/09/2025) and Los Angeles Department of Public Health Records (dated 10/06/2025). On 10/15/2025, LPA Bunker toured the facility's buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. No signs of neglect or abuse were observed during today's visit. See continued LIC9099-C page 2. Unsubstantiated Continued LIC9099-C page 2. On 01/15/2026, between 10:25 a.m. and 3:00 p.m., LPA Pamela Bunker conducted interviews with staff members #1–#5 (S1–S5) and residents #1–#6 (R1–R6) regarding the complaint allegation. Investigation revealed the following. Allegation: Staff are not preventing the spread of a communicable disease. On 01/15/2026, between 10:25 a.m. and 3:00 p.m., LPA Bunker conducted interviews with staff members #1-#5 (S1-S5). Who all agreed that on 10/03/2025, the facility had a scabies outbreak, and eight residents and one staff member tested positive for scabies, and the staff and residents were treated. S1-S5 stated on 10/06/2026 that all the appropriate agencies and responsible parties were contacted. The facility followed Title 22 Regulations, ensuring that infection control practices are maintained, and the Health Department guidelines are followed. 5 out of 5 staff members stated that they took the necessary precautions to treat the residents and to prevent other residents from contracting scabies. 5 out of 5 staff stated that during the outbreak, staff members wore personal protective equipment (PPE) gear to prevent the spread of scabies as required. 5 out of 5 staff members stated the residents were bathed daily, and Permethrin 5% cream was applied to the residents' bodies according to the physician's order, and residents showered 8 to 14 hours later. Residents were reassessed in 7 days to apply the second dosage, or depending on the doctor's order. 5 out of 5 staff stated each resident was monitored and records were documented in the residents' medical charts. S1-S5 stated residents were treated until their physician cleared them. 5 out of 5 staff members confirmed that the facility reported the incident prior to the complaint. On 01/15/2026, between 10:25 a.m. and 3:00 p.m., LPA Bunker conducted interviews with residents #1-#6 (R1-R6). 6 out of 6 residents stated that they did not have scabies, were aware of the scabies outbreak, and their responsible parties were notified, and it was posted. Allegation: Staff did not notify the resident's responsible parties of the outbreak. On 01/15/2026, between 10:25 a.m. and 3:00 p.m., LPA Bunker conducted interviews with staff members #1-#5 (S1-S5). 5 out of 5 staff members stated that the staff notified the resident's responsible parties of the scabies outbreak. 5 out of 5 staff members stated on 10/06/2025 and 10/09/2025, the residents' responsible parties, Community Care Licensing, and Long Beach Health Department were notified, via telephone and emails, of the scabies outbreak. 5 out of 5 staff members stated the scabies outbreak was posted inside the facility. LPA Bunker observed the email contacts dated 10/06/2025 and 10/09/2025 and the notification log dated 10/09/2025. See continued LIC9099-C page 3. Continued LIC9099-C page 3. On 01/15/2026, between 10:25 a.m. and 3:00 p.m., LPA Bunker conducted interviews with residents #1-#6 (R1-R6). 6 out of 6 residents stated that their responsible parties were notified of the scabies outbreak. Based on interviews, available evidence, observation, information received, and records reviewed, there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. There were no deficiencies cited. A copy of the Complaint Investigation Report LIC9099 and LIC9099-Cs was provided to Executive Director Joel Niblett. An exit interview was conducted.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 11-AS-20251009083621

Type of visit: Required - 1 Year

On 01/15/2026 at 8:15am, Licensing Program Analysts (LPAs) Zina Brown, Lizeth Villegas & Ernand Dabuet conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection (due February 2026). LPA met with Joel Niblett and the purpose of the visit was discussed. Facility is licensed to serve age range 60 and over which is approved for 170 non-ambulatory of which 24 may be bedridden (bedroom 301 - 303, 307 - 308, 311-314 may have 2 bedridden) and bedroom #304-306 and 309 may have 1 bedridden only with a waiver granted for hospice care for ten (10). There are (71) ambulatory residents, (48) non-ambulatory residents, (60) residents are diagnosed with dementia, (25) residents receiving home health, (18) residents receiving hospice care services and (2) resident receiving palliative care. The last fire inspection was completed on 05/08/2024. The facility does not handle any of the residents’ money. The facility has a current administrator certificate (7002290740) for is Joel Niblett valid 08/16/2025 - 08/15/2027. The facility has liability insurance with Mercer Insurance Company (NAIC# 14478) with each occurrence at $1,000,000 and general aggregate 3,000,000 as effective as of 07/31/2025 - 07/31/2026. The facility annual fee is $2,311. which is due on February 9, 2026. LPA provided pin #312963 if facility choose to make facility annual payment online. The facility a single story building consisting of: (142) resident bedrooms, (43) Full bathrooms, kitchen, (4) dining area, laundry room, medication room and (10) outdoor shaded patio areas. LPA Villegas toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 72.8F - 101.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Report continues on LIC 809-C A review of (10) residents files, (12) staff personnel files and (10) Medication Administration Records (MAR) and did observe discrepancies at the time of visit. Fire and Disaster Drills were conducted on 12/01/25 at 1:00 PM. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8); LPAs observed the following deficiencies: On 01/15/2026, between the hours 9:55am - 1:30pm, LPAs conducted a physical plant tour & records review and observed the following: For 87355(e)(3) Criminal Record Clearance: 3 of 12 staff are not associated with the facility. For 87465(d)(3) Incidental Medical & Dental Care Services; 6 of 10 resident had incompletion registration on the Medication Administrator Record (MAR) For 87411(c) Personnel Requirements: 1 of 12 staff ; no personnel record on file, 2 of 12 staff ; no TB Test on file 3 of 12 staff : no health screening on file and 6 of 12 staff ; no CPR on file For 87303(e)(2) Maintenance & Operation: The water test in Unit 2 shower Room 101.1F, bathroom in room 223 tested at 72.8F, and room 231 water tested at 80.4F, For 87307(2)(B) Personal Accommodations & Service: rooms 402 , 412, 214,236, 223, 231, 305 are missing a lamp and in rooms 236, 223, 231, 305 missing chairs. For 1569.625(a)(b) Training Requirement for Direct Care Staff: all staff did not have the required training needed to be in compliance with Title 22 regulations Health & Safety Code. An exit interview was conducted Joel Niblett, and a copy of Report and Appeal Rights provided.the state’s words, verbatim · CDSS document, Jan 15, 2026

Allegation investigated: Staff did not notify resident's responsible party of a scabies outbreak.

On 1/14/2026, LPA Alfonso Iniguez conducted an unannounced initial complaint visit. LPA Iniguez met Joel Niblett/Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrators Interview (A#1), Wellness Director (S#1) and Facility Nurse (S#2) .LPA gathered the following documents: copy of facility resident roster dated : 1/14/26, copy of facility staff roster or LIC 500 dated: 1/9/2026, copies of (R#2) staff notes dated: 12/7/25, 12/8/25, 12/11/25, 12/13/25, and 12/19/25, copies of (R#1)’s staff notes dated: 12/8/25/, 12/9/25, 12/14/25, and 12/26/25. Evaluation Report continues LIC 9099-C Substantiated Investigation Revealed the Following: Allegation: Staff did not notify resident's responsible party of a scabies outbreak. The details of the complaint alleged that facility did not notify (R#1)’s responsible party regarding scabies outbreak. On January 14, 2026, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a comprehensive records review, including (R#2)’s staff notes. The review found that on December 7, 2025, an email was sent to (R#2)’s home health provider regarding a possible health condition. The facility isolated (R#2) on December 8, 2025. On December 15, 2025, a health condition was diagnosed, and the following medications were prescribed: ivermectin 3mg oral tablets and permethrin 5% cream. LPA Iniguez also reviewed (R#1)’s staff notes dated 12/8/25, 12/9/25, 12/14/25, and 12/26/25, and observed no documentation indicating that facility staff informed (R#1)’s representative of (R#2)’s “health condition.” On 1/14/26 at approximately 10:30 AM, Licensing Program Analyst Alfonso Iniguez spoke with (A#1). LPA inquired if the facility had reported (R#2)’s health condition to (R#1)’s responsible party, since (R#1) and (R#2) shared a room. (A#1) responded that this responsibility belonged to the facility nurse (S#2) and wellness director (S#1), and stated, “otherwise I don’t know if it was reported.” On 1/14/2026 at approximately 10:30 AM, Licensing Program Analyst Alfonso Iniguez asked (S#1) if documentation existed showing staff reported (R#2)’s health condition to (R#1)’s responsible party. (S#1) confirmed there was no written record in the residents’ notes and indicated the facility nurse (S#2) could provide further information. Evaluation Report continues LIC 9099-C On 1/14/2026 at approximately 11:00 AM, Licensing Program Analyst Alfonso Iniguez requested documentation from (S#2) confirming that staff reported (R#2)’s communicable disease outbreak to (R#1)’s responsible party. (S#2) reviewed the resident’s electronic notes and found no record of staff notifying (R#1)’s responsible party about (R#2)’s health condition. LPA Iniguez then asked (S#2) to print the notes. During this investigation, LPA found sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). An exit interview was conducted, and a copy of the Complaint Report was given to Joel Niblett/Administrator.the state’s words, verbatim · CDSS document, Jan 14, 2026 · control 11-AS-20260112122234

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jan 27, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (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)... This requirement was not met as evidence by: Based on observation and record review, facility staff failed to ensure to report to (R#1)'s responsible party regarding (R#2)'s health condition.This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 14, 2026

Plan of correction: Licensee will adhere to Title 22 at all times. As part of the plan of correction, the facility will conduct an in-service with facility nurses, medtechs, and facility administrators regarding reporting requirements. Proof of in-service will be sent to LPA Iniguez via email before the POC due date.

Allegation investigated: Staff are not providing adequate supervision resulting in resident sustaining bruises.

On 1/7/2026, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met Joel Niblett/Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrators Interview (A#1), Witness Interview (W#1), Residents Interviews (R#1-R#6) and Staff Interviews (S#1-S#4).LPA gathered the following documents copy of (R#1)s medication list dated: 10/23/2025, copy of (R#1)’s service plan no date, copy (R#1)’s facility notes various dates, copy of (R#1)’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A dated 5/20/25, copy of (R#1) Identification and Information Emergency Information or LIC 601 dated:6/17/25, copy of (R#1)’s hospitalization records dated:10/16/25, copies of (R#1)’s Unusual Incident Reports various dates. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff are not providing adequate supervision resulting in residents sustaining bruises. The details of the complaint alleged that (R#1) sustained bruising because of the lack of supervision by facility staff. On 10/24/2025, during a comprehensive records review, Licensing Program Analyst (LPA) Alfonso Iniguez examined (R#1)’s hospitalization records dated 10/16/2025. The review focused on identifying any documentation that might indicate neglect or inadequate care by the assisted living facility. Upon careful examination, LPA observed that the medical records contained no written statements, physician notes, or diagnostic comments suggesting that (R#1) suffered negligence or harm attributable to their place of residence. The records primarily addressed (R#1)’s medical condition and treatment during hospitalization, with no reference to facility-related concerns. In addition, LPA Iniguez reviewed (R#1)’s Physician’s Report for Residential Care Facilities for the Elderly (LIC 602A) dated 05/20/2025. LPA noted that (R#1)’s documented mental condition may have contributed to their behavior and line of thinking, which could explain certain actions or resistance observed during care. On 10/23/2025, at approximately 3:30 PM, LPA Iniguez spoke with (W#1). (W#1) confirmed that the facility has contacted them whenever an incident involving (R#1) occurred. (W#1) stated they have not observed facility staff handling (R#1) in a rough manner. Additionally, during visits to (R#1), (W#1) observed that facility staff were present and assisting (R#1) appropriately. Furthermore, (W#1) explained that (R#1) bruises easily because she resists being changed by facility staff. (W#1) indicated this resistance is related to a cultural aspect, as (R#1) does not want to be seen nude by strangers. When such situations occur, (R#1) reportedly pulls herself forcefully, which may contribute to the bruising. Evaluation Report continues LIC 9099-C On 10/23/2025 at approximately 1:30 PM, LPA Iniguez interviewed (A#1) regarding (R#1)’s care and incidents at the facility. (A#1) stated the facility cannot provide incident reports or progress notes documenting when and how the bruises occurred on (R#1) because the bruises are unknown to them. (A#1) reported that body checks and skin assessments are conducted every time (R#1) is showered, and caregivers are responsible for observing any physical changes. Fall prevention measures currently in place for (R#1) include monitoring every two hours by care staff, a fall mat, and grab bars in the bathroom. (A#1) confirmed that (R#1) had a recent fall risk assessment due to previous falls. The facility’s protocol for notifying (R#1)’s family of injuries, behavioral incidents, or falls requires the MedTech or a licensed nurse to contact the family. (A#1) stated the facility has in-house notes documenting communication with (R#1)’s family regarding recent incidents. Additionally, (A#1) acknowledged language and cognitive barriers that affect communication with (R#1) and their representatives. (R#1) is checked by facility staff every two hours. On 10/23/2025 at approximately 2:30 PM, Licensing Program Analyst (LPA) Alfonso Iniguez attempted to interview (R#1). However, LPA was unable to speak with (R#1) due to cognitive impairment and language barriers. On 10/23/25 at approximately 3:00 PM, during interviews with facility residents (R#2-R#6), (5) out of (5) stated that they have ever noticed bruises or injuries on any resident including (R#1) and they feel there are enough facility staff to assist them when they need it. in addition, (5) out of (5) residents in care stated that they have never observed staff handling residents roughly or in a way that seemed inappropriate. Evaluation Report continues LIC 9099-C On 10/26/25 at approximately 2:00 PM, during interviews with facility staff (S#1-S#4), (4) out of (4) stated that body checks are routinely performed during personal care activities, such as showers and dressing. If bruising or any change in skin condition is observed on a resident (including R#1), staff document the observation in the resident’s progress notes, noting the date, time, location of the bruising, and any relevant context. Staff also stated they notify the nurse or MedTech and, when indicated, complete an incident report. Also, when asked about procedures for residents who resist care, staff explained that they use de-escalation techniques, including speaking softly, explaining each step of the process, and offering alternatives, such as assigning a different caregiver or rescheduling care for a later time. Staff emphasized maintaining resident privacy and modesty to reduce resistance. For R#1, staff follow care plan strategies designed to minimize agitation and reduce the risk of bruising. Resistant episodes and interventions used are documented in the resident’s record. In addition, (4) out of (4) facility staff stated that when asked if they had ever observed other staff handling residents, including (R#1), roughly or in an inappropriate manner, all four staff members stated they had not observed any such behavior. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Joel Niblett/Administrator.the state’s words, verbatim · CDSS document, Jan 7, 2026 · control 11-AS-20251016152401

Allegation investigated: Staff do not answer residents calls for assistance resulting in resident falling

On 12/29/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted a subsequent complaint investigation visit regarding the allegation listed above. LPA met with the Administrator Joel Niblett, and the purpose of the visit was explained. The LPA was allowed entry to the facility. The investigation consisted of the following: On 11/05/2025, Witness 1 (W1) was interviewed. On 11/07/2025, a tour of residents’ rooms in unit 1 was conducted and Staff 1 (S1) to Staff 3 (S3) were interviewed. On 11/13/2025, Resident 1 (R1) to Resident 7 (R7), S1, Staff 4 (S4) to Staff 7 (S7) and Witness 1 (W1) were interviewed. On 11/14/2025, Witness 2 (W2) to Witness 3 (W3) were interviewed. On 11/18/2025, Witness 4 (W4) was interviewed. On 12/29/2025, facility records were reviewed which consisted of Personnel Report dated 11/13/2025, Resident Roster dated 11/13/2025, and Face Sheet and Emergency Information for Residents in Unit 1. On 12/29/2025, R1’s records were reviewed which consisted of Physicians Report dated 06/22/2025, Service Plan dated 09/15/2025, Medication Administration Record (MAR) from 09/2025 to 10/2025, Unusual Incident Report dated 10/24/2025, and Progress Notes from 09/09/2025 to 10/27/2025. Unsubstantiated The investigation revealed the following: Allegation: “Staff do not answer residents calls for assistance resulting in resident falling”, it is being alleged that on 10/24/2025, R1 had an un-witnessed fall due to staff not answering their calls for assistance. Interviews conducted with R1 to R7 revealed the following: R1’s interview was inconclusive; 3 out of 7 residents indicated that they have never fallen at the facility; 3 out of 7 residents indicated that staff assist them when they need assistance. Interviews conducted with S1 to S7 indicated the following: 7 out of 7 staff denied the allegation, furthermore, staff indicated that they assist residents when they call out for help and when they press the call button. R1’s records reviewed revealed the following: R1 is diagnosed with a mild cognitive impairment and experiences episodes of confusion according to the Physicians Report dated 06/22/2025. Unusual Incident Report dated 10/24/2025, stated that on 10/24/2025 R1 “slipped while trying to get out of bed.” Progress Notes indicate that on 10/24/2025 at around 11:10 PM, R1 had an un-witnessed fall and was sent out thru non-emergency ambulance on 10/25/2025. Based on the department’s interviews, observations, and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Administrator, Joel Niblett.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 11-AS-20251103083205

Allegation investigated: Facility does not have sufficient staffing to provide care to residents.

This report supersedes the report created 10/23/25 and the findings will remain unchanged. On 12/22/2025, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met Joel Niblett/Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrators Interview (A#1), Residents Interviews (R#1-R#6) and Staff Interview (S#1-S#5). LPA obtained and reviewed the following documents: Resident Roster dated: 9/26/25, Staff Roster dated: 9/25/25, copies of (R#1 and R#4) Physicians Report for Residential Care Facilities for the Elderly or LIC 602 various dates, copies of (R#1-R#4) Admissions Agreement various dates, copies of (R#1-R#4) Identification and Emergency Information or LIC 601 various dates, copies of (R#1-R#4) Appraisal/Needs and Services Plan or LIC 625 various dates, and a copy of facility Call-off Tracking Log for the month of September 2025 and copies of residents care plans. Evaluation Report continues LIC 9099-C Unsubstantiated This report supersedes the report created 9/23/25 and the findings will remain unchanged. Investigation Revealed the Following: Allegation: Facility does not have sufficient staffing to provide care to residents. The details of the complaint alleged that it was observed that there are not enough staff during regular hours. On October 21, 2025, at 1:00 p.m., Licensing Program Analyst (LPA) Iniguez reviewed the facility’s Call-off Tracking Log for September 29–30 and October 1–3, 2025. The log showed that the facility typically schedules 30 care staff per day, with a maximum of 5 callouts per day, resulting in 25 staff available for care and supervision. On December 22, 2025, at 10:00 a.m., LPA Iniguez also reviewed Functional Capabilities Assessments (LIC 9172) for 56 residents, aged 67 to 97, whose care needs range from independent to requiring extensive assistance. The daily staffing schedule includes 9 caregivers, 3 medication technicians, and 1 LVN during the AM shift (13 staff); 8 caregivers, 3 medication technicians, and 1 LVN during the PM shift (12 staff); and 7 caregivers with 1 medication technician during the NOC shift (8 staff). This totals 24 caregivers, 7 medication technicians, and 2 LVNs, for a total of 33 staff per day. Based on this review, the facility maintains adequate staffing to meet the care and supervision needs of all 56 residents, even on days with the highest callouts. With approximately 25 care staff for 56 residents, the staff-to-resident ratio of about 1:2.2 exceeds minimum standards and is appropriate for a population with mixed acuity, provided staff are properly trained, and tasks are well organized. Evaluation Report continues LIC 9099-C This report supersedes the report created 9/23/25 and the findings will remain unchanged. On September 26, 2025, at approximately 10:00 a.m., during an Interview with the facility Administrator (A#1), he stated that we have sufficient staff to provide care and supervision for the memory care residents. However, there are days when we experience a high number of callouts from facility staff. This situation often requires some employees to work overtime and double shifts. Additionally, (A#1) mentioned that when there are call-outs, the remaining facility staff members covering for those absent are expected to meet the needs of the residents in their care. (A#1) also expressed that when staff members call out, he does not believe there is an immediate danger to the residents. On September 26, 2025, at approximately 11:00 AM, during an interview with residents (R#1-R#6), (6) out of (6) stated that the facility does not have enough staff to take care of them and the rest of the residents in care. On September 26, 2025, at approximately 12:00 PM, during an interview with facility staff (S#1-S#6), (5) out of (6) stated that the facility does not have enough staff to provide care to residents. In addition, (6) out of (6) facility staff said that they feel the residents are not in immediate danger due to staffing issues; however, this can potentially become a problem since sometimes there are (1) caregiver per (20) residents with different care needs. Evaluation Report continues LIC 9099-C This report supersedes the report created 9/23/25 and the findings will remain unchanged. During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Joel Niblett/Administrator.the state’s words, verbatim · CDSS document, Dec 22, 2025 · control 11-AS-20250919104757

Type of visit: Case Management - Deficiencies

On 12/17/2025, at 00:00, Licensing Program Analyst, LPA Zina Brown conducted a Case Management for complaint Control Number 11-AS-20251201153121. LPA met with Joel Niblett (Administrator) as the purpose of the visit was explained. On 12/02/2025 between the hours of 8:55am – 4:15pm LPA conducted an initial unannounced complaint investigation in regards to a resident sustained an unstageable pressure injury due to staff neglect/lack of supervision. Based on records review the facility retained Resident 1 (R1), who had a unstageable pressure injury which is prohibited by title 22 regulations. The facility failed to submit an exception request from the department to retain R1. Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. Exit interview conducted with Joel Niblett (administrator), and copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Dec 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Dec 18, 2025

Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:(1) Stage 3 & 4 pressure injuries. Based on records review the facility retained R1, who had a unstageable pressure injury which is prohibited by title 22 regulations. The facility failed to submit an exception request from the department to retain R1.the state’s words, verbatim · CDSS document, Dec 17, 2025

Plan of correction: The facility will develop & schedule a mandatory in-service training for all staff on the topic: Prohibited Health Conditions to be in compliance with Title 22 requirements. Also, if necessary the facility will submit any exception requests for Prohibited Health Condition to the department as required. . . upon the residents change in condition to be in compliance with Title 22 regulations. The facility will submit proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016, Attn: Zina Brown, or via email at zina.brown@dss.ca.gov by the POC due date.

Allegation investigated: Staff does not ensure facility is kept clean, safe, and sanitary at all times.

On 12/16/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding the allegation listed above. LPA met with the Administrator Joel Niblett, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 12/16/2025, a facility tour was conducted, interviews were conducted, and records were reviewed. Interviews were conducted with Resident 1 (R1) to Resident 11 (R11) and Staff 1 (S1) to Staff 7 (S7). Facility records were reviewed which consisted of Personnel Report dated 11/17/2025, Resident Roster, Facility Map, and Staff Census for 12/08/2025. Unsubstantiated The investigation revealed the following: Allegation: “Staff does not ensure facility is kept clean, safe, and sanitary at all times”, it is being alleged that the on 12/08/2025 the facility roof was cleaned, and due to that debris and dust blew into the hallways and rooms which caused residents to have breathing problems. Interviews conducted with R1 to R11 revealed the following: 11 out of 11 residents denied the allegation. Interviews conducted with S1 to S7 revealed the following: 7 out of 7 staff denied the allegation, furthermore, staff indicated that on 12/08/2025 the facility did not clean the roof. Observations on 12/16/2025 revealed the following: A tour of the facility was conducted, and debris and dust were not observed in community rooms, dining rooms, hallways, and rooms. Rooms 201, 203, 204, 205, 208, 209, 212, 214, 215, 216, 217, 218, 220, 235, and 236 were observed to be clean without debris and dust. Records reviewed of Unusual Incident/Injury Reports (UIR) from 12/2025 revealed the following: There were no UIRs that indicated that the facility cleaned the roof and/or residents having difficulty breathing. Based on the department’s interviews, observations, and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Administrator, Joel Niblett.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 11-AS-20251209091931

Allegation investigated: Staff did not provide resident's authorized representative with an itemized list of charges Resident's medical tube was pulled out due to staff neglect resulting in resident needing to go to the hospital

On 12/10/2025 at 8:54am, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit at this facility to deliver the complaint findings for the allegations above. During today’s visit, at 11:15 am, LPA met with Joel Niblett (Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 10/13/2025, LPA interviewed with Administrator (A1) and Staff (S1-S9) & received the following documents: Resident Roster (received 10/13/2025), Staff Roster (dated 10/13/2025), Resident #1 (R1's) documents such as LIC 601 Personnel Record (dated 07/28/2025), LIC 602: Physician Report (dated 07/25/2025), LIC 603: Pre-Placement Appraisal (dated 7/25/2025), LIC 604: Admission Agreement (dated 07/25/2025), Invoice of Rent (dated 09/01/2025 & 10/01/2025), Receipt of Payment, After Summary Visit from Kaiser (Dated 09/13/2025), Assessment Plan 07/25/2025, Discharge Report (dated 09/12/2025), Medication Administrator Record (dated 09/2025) and Communication Logs (dated 09/03/2025, 09/13/2025,09/17/2025, & 09/29/2025). Report continues on LIC 9099-C Substantiated The investigation revealed the following: Allegation: Staff did not provide resident's authorized representative with an itemized list of charges It is alleged that the facility did not provide Resident 1's representative with an itemized list of additional care services at the time of admission. On 10/13/2025, between the hours of 11:15am - 12:09pm, LPA interviewed Administrator (A1) regarding the allegation. A1 neither confirmed nor denied the allegation. A1 stated based on the physician report determines how charges and extra care fees are explained and to the residents and their representative. A1 responded not applicable and did not provide the process. On 10/13/2025, between the hours of 9:04am - 1:00pm LPAs conducted interviews with Staff (S1-S9). 8 of 9 staff were unaware of the allegation as the caregivers have no knowledge of families being given itemized list of charges or a breakdown of extra care services. 1 of 9 staff did not confirm nor deny the allegation and S9 stated not generating the statement for invoices as that was the role of someone else who no longer works for the facility. However, Grandview does the billing for the residents. However, S9 stated its two care levels which is 17 (is when resident can still feed themselves, some in a wheelchair and ambulate) and level 22 (handfeeding, full care assist). S9 also stated R1 was level 22 because R1 couldn’t sit up without assistance and needed repositioning and transfers. On 10/13/2025 between the hours of 12:30pm - 12:45pm & on 12/03/2025 between the hours of 4:00pm -5:00pm, LPA conducted a records review and observed the following: receipts for care $7,200 - dated 07/28/2025 , for deposit (#4255) $500 - dated 07/25/2025, for deposit (#4258) $500 - dated 08/01/2025, for other half of pay (#4261) - $500 dated 08/09/2025, for September 2025 rent (#4267) $8,825. - dated 09/02/2025. Also based on Resident 1's Admission Agreement (signed on 07/29/2025) R1's room rate for a semi-private studio cost $5,000 with an additional miscellaneous care fee of $2,200 which comes to a total of $7,200. The review of the Admission Agreement does not itemize nor specify what the miscellaneous care service consist of nor rates of care services. LPA also review the invoices (statement dates 09/01/2025 and 10/01/2025). The review of both invoices show multiple dates and charges for room and board for $7200 and does not itemize the current months charges. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Report continues on LIC 9099-C The investigation revealed the following: Allegation: Resident's medical tube was pulled out due to staff neglect resulting in resident needing to go to the hospital. It is alleged that the facility failed to provide adequate supervision and medical care, resulting in the resident’s gallbladder (cholecystostomy) tube being pulled out on two separate occasions, which led to hospitalizations and infection. On 10/13/2025, between the hours of 11:15am - 12:09pm, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated Resident 1 (R1) did not have a g-tube and stated the resident was not on hospice nor receiving home health but was on Kaiser. On 10/13/2025, between the hours of 9:04am - 1:00pm, LPAs conducted interviews with Staff (S1-S8). 3 of 9 staff confirmed the allegation and stated by S2 observing R1 with a g-tube upon the partner of R1 informing staff that the g-tube was pulled out. S4 stated upon R1 first being at the facility he didn't have a g-tube but after the third time of R1 going to the hospital he returned to the facility with a g-tube. S8 stated R1 had a g-tube for 2-3 weeks which the caregiver did not know that R1 pulled out the g-tube himself. 1 of 9 staff denied the allegation and stated by S5 that R1 did not have a g-tube while residing at the facility. 3 of 9 staff were unaware of the allegation and stated having no knowledge of R1 having a g-tube. 2 of 9 staff didn't not confirm nor deny the allegation and stated upon admission resident never had a tube. However it was discovered R1 had some type gallbladder infestation which required him to have some kind of tube which he pulled out himself which isn't a g-tube. On 12/10/2025, the LPA conducted a records review and observed the following: In R1’s file, there was no documented care plan or approved exception request on file from the Department. The LPA observed a Kaiser Permanente discharge note dated 09/13/2025 indicating that R1 had a cholecystostomy tube. However, there was no documentation of a restricted health care plan or reappraisal related to the cholecystostomy tube. Additionally, the post-discharge plan of care did not document the presence of the cholecystostomy tube or the required care. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted with Administrator Joel Niblett and a copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Dec 10, 2025 · control 11-AS-20251008154333

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87609(b)(2) · Plan of correction due date: Jan 26, 2026

Allowable Health Conditions and the Use of Home Health Agencies(b)Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (2) The licensee provides the supporting care & supervision needed to meet the needs of the resident receiving home health care. Based on interviews and record review, the facility did not have a restricted health care plan for the cholecystostomy tube, and staff were not informed of the type of tube inserted or the required care & supervision need.the state’s words, verbatim · CDSS document, Dec 10, 2025

Plan of correction: The facility will submit a plan to the department outlining how the facility will be in compliance with Title 22 regulations. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(3)(B)(1) · Plan of correction due date: Jan 26, 2026

Admission Agreements...(B)Rate for additional items and services, including: (1) A comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed. Based on record review and interviews, the licensee did not ensure R1 admission agreement contained a comprehensive description of additional fees or the fee schedule for services not included in the basis services.the state’s words, verbatim · CDSS document, Dec 10, 2025

Plan of correction: The facility will submit a updated resident Admission Agreement which will be in compliance with Title 22 regulations for the Department to review. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

Allegation investigated: Staff did not address resident's change of condition. Staff did not seek medical attention for resident in a timely manner.

On 11/24/25, at 9:20am, the department conducted an initial complaint visit to the facility and was greeted by Joel Niblett, Executive Director. The department explained the purpose of this visit is to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegation(s) mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S5), witness (W1), and residents (R1-R10). The department received the following facility documents: Resident Roster (Date: No Date), Staff Roster (Dated: 11/17/2025), Admission Agreement (Dated: 08/14/2025 ), Face Sheet/ID Emergency information (Dated:11/24/2025, 08/13/2025), Physician’s Report (Dated: 08/12/2025), Appraisal & Needs Service Plan (Printed On: 11/24/2025), Incident Report (Dated: None), Preplacement Appraisal Information (Dated: 08/11/2025), and Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) from the facility. Report Continued On LIC9099-C Substantiated The investigation revealed the following: Allegation #1-Staff did not address residents’ change of condition. The details of the complaint alleged that the facility did not address the residents’ change of condition. It was reported that the resident had bandages wrapped around their toe, when it was inquired why, staff stated that perhaps the residents’ shoes were too tight and probably caused the blistering on their foot. Subsequently, without medical attention, the residents’ foot became swollen, and their toe became infected and needed to be amputated. On 11/24/2025, from 9:20am-2:00pm, the department interviewed staff (S1-S5), witness (W1), and residents (R1-R10) regarding the allegation. 4 of 5 staff stated that they notified the nurse (LVN) about the residents’ swollen foot and contacted the family member. They stated that the nurse is responsible for getting medical assistance for the residents. One staff member stated that the resident (R1) told them that their foot was swollen and needed assistance; staff stated that they advised the LVN of the problem. Staff also stated that residents are checked on every one to two hours a day to assess their condition. The department interviewed residents (R1-R10) about the allegation and 6 of 10 residents that were interviewed stated that they believed the staff would not know if they had a change in their condition. When asked why, they stated that they believe they need more training. The department also interviewed witness (W1) about the incident, and they stated that the nursing team never called or had communication with them regarding R1, even when (W1) discovered that R1s foot was swollen and bandaged. The department reviewed the Appraisal & Needs Service Plan (Printed On: 11/24/2025), Physician’s Report (Dated: 08/12/2025), and the Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) and observed that the Med Tech Communication Log noted that first aid was applied because R1s foot was swollen on 10/25/2025, 10/29/2025, 10/30/2025, and 11/1/2025. The log noted that the LVN and family member were notified. However, medical services were not notified to address R1s change in condition; resulting in R1s toe becoming infected and amputated. Additionally, the department did not receive an incident report detailing the hospital visit, amputation, nor the swollen foot. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not address residents’ change of condition, is found to be Substantiated. Title 22, Division 6, Chapter (8) is being cited on the attached LIC 9099D. Report Continued On LIC9099-C Allegation #2- Staff did not seek medical attention for resident in a timely manner. The details of the complaint alleged that the facility did not seek timely medical attention for the resident. It was reported that the residents’ foot became swollen and their toe became infected and needed to be amputated, as a result of inaction by the facility. On 11/24/2025, from 9:20am-2:00pm, the department interviewed staff (S1-S5), witness (W1), and residents (R1-R10) regarding the allegation. 4 of 5 staff stated that they told the nurse about the resident and they were responsible for getting medical services involved, if appropriate. Staff stated that they believed the resident was going to get medical services for their swollen foot. The department interviewed residents (R1-R10) about the allegation and 4 of 10 residents that were interviewed stated that staff have sought medical attention for them in a timely manner in the past. The department interviewed witness (W1) about the allegation, and they stated that they believed the facility did not seek medical attention for the resident in a timely manner. Additionally, they stated that they were not made aware of the condition before it got to the point where R1s toe needed to be amputated. The department could not review the LIC624 Unusual Incident Report about the swollen foot or subsequent hospitalization because the facility failed to submit it to Community Care Licensing Division within seven days of the occurrence. The department did review the Med Tech to Med Tech Communication Log (Dated: 10/25/2025, 10/29/2025, 10/30/2025, 11/01/2025) but it did not specify that medical services were notified, or any action taken on behalf of the resident. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff did not seek medical attention for resident in a timely manner, is found to be Substantiated. Title 22, Division 6, Chapter (8) is being cited on the attached LIC 9099D. Deficiencies were issued and plans of corrections were discussed. Note: *Citations that are not cleared by the POC due date of 12/05/25 will have a $100 fine assessed for each day that the citation is not cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. An exit interview was conducted with Joel Niblett, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Nov 24, 2025 · control 11-AS-20251118115055

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Dec 5, 2025

Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental… functioning and that appropriate assistance is provided when such observation reveals unmet needs. When…deterioration …are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews and record reviewed, the licensee failed to ensure that appropriate assistance was provided to R1 when changes in their physical condition were found (swelling in foot and toe) resulting in the toe being amputated. Which poses a potential risk to the health, safety and personal rights of the resident in care.the state’s words, verbatim · CDSS document, Nov 24, 2025

Plan of correction: The administrator will create a plan of correction to ensure that observations of residents are conducted when significant change in the resident’s condition is observed and review and conduct in-service training for staff of 87466 Observation of Resident. In-service training with signatures of staff and plan of corrections will be submitted prior to POC due date of 12/05/25, via email, to perry.scott@dss.ca.gov to avoid monetary penalties.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(B)(D) · Plan of correction due date: Dec 5, 2025

87211(a)(B)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...(B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety, or health of any resident... This requirement was not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report associated with the incident for R1 that resulted in hospitalization and amputation of R1s toe. The facility did not have proof of certified confirmations LIC 624 was faxed to CCL. This violation poses a potential health, safety, or personal-rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 24, 2025

Plan of correction: The Licensee shall submit a serious incident report LIC624 for R1 about the swelling of their foot and toe, and the hospitalization that resulted in the resident having to have their toe amputated because of infection. The report shall be submitted prior to POC due date of 12/05/25, via email, to perry.scott@dss.ca.gov to avoid monetary penalties.

Allegation investigated: Licensee did not ensure resident records were maintained and readily available for emergency medical staff.

This report supersedes the report dated 10/20/2025 to include additional information. On 11/21/2025 The Department conducted a subsequent complaint visit at this facility to deliver findings. During today’s visit, LPAs met with Joel Niblett (Executive Director) & explained the purpose of the visit. The investigation consisted of the following: On 09/10/2025, an unannounced initial complaint visit was conducted at the facility by Licensing Program Analysts (LPA) Zina Brown. On 09/10/25 LPA Brown interviewed the Residents (R1-R12), between the hours of 10:17am - 11:52, Administrator (A1) between the hours of 3:20pm - 3:38pm and Staff (S1) between the hours of 2:07pm - 2:15pm. LPA requested the resident and staff roster, resident roster, LIC 601; Emergency Info (for R1-R2,R13), LIC 602: Physician's Report for Resident Care Facilities for the Elderly (for R1-R2,R13), Admission Agreement (for R1-R2,R13), LIC 603: Pre-Placement Appraisal (for R1-R2, R13) and Medication Administrator Record (for R1-R2,R13), and Staff Schedule (dated 09/05/2025). Substantiated The investigation revealed the following: Allegation: Licensee did not ensure resident records were maintained and readily available for emergency medical staff It is being alleged that facility staff were not able to provide resident information to emergency personnel such insurance information, physician report, basic next of kin and medication list. On 08/11/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated when emergency responders requested information for the resident, it is unknown what records were readily available for the first responders. A1 stated the Licensed Nurses and MedTech staff are trained and aware of where the medical chart is located, which includes the physician’s report, emergency contacts, insurance, and medication lists. A1 added that staff are instructed to provide this information upon request from emergency medical personnel. On 09/10/2025 and on 10/13/2025, LPA Brown conducted interviews with Staff (S1- S4) regarding the allegation. 3 out 4 staff interviewed confirmed of the allegation and stated caregivers are not trained on how to obtain resident records, and it's only Medtechs and/or LVNs who manage records in the event of an medical emergency. 1 out 4 staff denied the allegation and stated staff are trained to locate and provide LIC 602, medication list and facesheet of the resident. On 09/10/2025, between the hours of 10:17am - 11:42am LPA Brown conducted interviews with Residents 1-12 (R1-R12) regarding the allegation above. 9 of 12 residents interviewed reported being unaware of the allegation and stated not knowing if the facility has in their file their doctors name, list of medication and family contact information. 3 of 12 residents interviewed denied the allegation and stated they know the facility has their personal record on file. On 10/17/2025 between the hours of 4:20pm, LPA conducted a records review and observed that there is no training on file for staff to ensure resident record are maintained and readily available for emergency first responders. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). Exit interview conducted, appeal rights explained, and a copy of this report was provided. Allegation: Staff did not seek timely medical attention It is being alleged that facility staff failed to contact emergency services for a resident in care. On 09/19/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated that documentation reflected staff recognized the change in the resident’s condition and called 911 for medical attention. A1's expectation of the staff is to respond appropriately and take immediate action when a resident exhibits serious symptoms. A1 indicated that staff are expected to notify a Certified MedTech and/or a Licensed Nurse immediately, and 911 should be called as needed. On 09/10/2025 and 10/13/2025, LPA conducted interviews with Staff (S1- S4) regarding the allegation above. 1 out of 4 staff interviewed confirmed the allegation above and reported witnessing the incident in question with Resident 13 (R13), per 1 of 4 staff protocol was followed and 911 was called. 1 out of 4 staff interviewed reported being aware of the incident but did not witness it. 2 out of 4 staff interviewed denied the allegation and stated not having knowledge nor witness any emergency regarding the Resident 13 (R13). On 09/10/2025, between the hours of 10:17am - 11:42am LPA Brown conducted interviews with Residents 1-12 (R1-R12), regarding the allegation above. 1 of 12 residents confirmed the allegation and stated that on the day of 09/10/2025 and a week from 09/10/2025 their neighboring resident had to wait a long time before getting help from the facility staff. 11 of the 12 residents reported having no knowledge of the allegation above. On 10/17/2025 between the hours of 4:11pm - 4:20pm LPA conducted a records review and observed the following: the department did not receive a LIC 625: Serious/Unusual Incident Report in regard to Resident 13 (R13) shaking from fever and having chills. On 10/17/25 LPA reviewed the staff schedule (dated on 09/05/2025), and observed the following: during the AM shift two (2) caregivers in Units 1 and Unit 4, three (3) caregivers in Unit 2, one (1) caregiver in Units 3 and Unit 5. During the PM shift in Unit 1, Unit 3 , and Unit 5 - two (2) caregiver each were scheduled to work. In Unit 4 - one (1) caregiver is scheduled to work. Based on interviews and record review conducted there is no not enough evidence to support that the facility staff did not provide enough supervision to the resident therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 21, 2025 · control 11-AS-20250909103914

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(5) · Plan of correction due date: Dec 5, 2025

Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training &/or related experience shall provide knowledge of & skill in the following: (5) Knowledge necessary in early signs of illness & the need for professional help.the state’s words, verbatim · CDSS document, Nov 21, 2025

Plan of correction: This requirement was not met as evidenced by: based on observation and interview staff did not provide emergency first responders with the proper documentation such as medical insurance card, primary care physician information, etc. needed for the resident to be admitted to the hospital

Allegation investigated: Licensee did not ensure resident records were maintained and readily available for emergency medical staff.

This report supersedes the report dated 10/20/2025 to include additional information. On 11/21/2025 The Department conducted a subsequent complaint visit at this facility to deliver findings. During today’s visit, LPAs met with Joel Niblett (Executive Director) & explained the purpose of the visit. The investigation consisted of the following: On 09/10/2025, an unannounced initial complaint visit was conducted at the facility by Licensing Program Analysts (LPA) Zina Brown. On 09/10/25 LPA Brown interviewed the Residents (R1-R12), between the hours of 10:17am - 11:52, Administrator (A1) between the hours of 3:20pm - 3:38pm and Staff (S1) between the hours of 2:07pm - 2:15pm. LPA requested the resident and staff roster, resident roster, LIC 601; Emergency Info (for R1-R2,R13), LIC 602: Physician's Report for Resident Care Facilities for the Elderly (for R1-R2,R13), Admission Agreement (for R1-R2,R13), LIC 603: Pre-Placement Appraisal (for R1-R2, R13) and Medication Administrator Record (for R1-R2,R13), and Staff Schedule (dated 09/05/2025). Substantiated The investigation revealed the following: Allegation: Licensee did not ensure resident records were maintained and readily available for emergency medical staff It is being alleged that facility staff were not able to provide resident information to emergency personnel such insurance information, physician report, basic next of kin and medication list. On 08/11/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated when emergency responders requested information for the resident, it is unknown what records were readily available for the first responders. A1 stated the Licensed Nurses and MedTech staff are trained and aware of where the medical chart is located, which includes the physician’s report, emergency contacts, insurance, and medication lists. A1 added that staff are instructed to provide this information upon request from emergency medical personnel. On 09/10/2025 and on 10/13/2025, LPA Brown conducted interviews with Staff (S1- S4) regarding the allegation. 3 out 4 staff interviewed confirmed of the allegation and stated caregivers are not trained on how to obtain resident records, and it's only Medtechs and/or LVNs who manage records in the event of an medical emergency. 1 out 4 staff denied the allegation and stated staff are trained to locate and provide LIC 602, medication list and facesheet of the resident. On 09/10/2025, between the hours of 10:17am - 11:42am LPA Brown conducted interviews with Residents 1-12 (R1-R12) regarding the allegation above. 9 of 12 residents interviewed reported being unaware of the allegation and stated not knowing if the facility has in their file their doctors name, list of medication and family contact information. 3 of 12 residents interviewed denied the allegation and stated they know the facility has their personal record on file. On 10/17/2025 between the hours of 4:20pm, LPA conducted a records review and observed that there is no training on file for staff to ensure resident record are maintained and readily available for emergency first responders. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). Exit interview conducted, appeal rights explained, and a copy of this report was provided. Allegation: Staff did not seek timely medical attention It is being alleged that facility staff failed to contact emergency services for a resident in care. On 09/19/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated that documentation reflected staff recognized the change in the resident’s condition and called 911 for medical attention. A1's expectation of the staff is to respond appropriately and take immediate action when a resident exhibits serious symptoms. A1 indicated that staff are expected to notify a Certified MedTech and/or a Licensed Nurse immediately, and 911 should be called as needed. On 09/10/2025 and 10/13/2025, LPA conducted interviews with Staff (S1- S4) regarding the allegation above. 1 out of 4 staff interviewed confirmed the allegation above and reported witnessing the incident in question with Resident 13 (R13), per 1 of 4 staff protocol was followed and 911 was called. 1 out of 4 staff interviewed reported being aware of the incident but did not witness it. 2 out of 4 staff interviewed denied the allegation and stated not having knowledge nor witness any emergency regarding the Resident 13 (R13). On 09/10/2025, between the hours of 10:17am - 11:42am LPA Brown conducted interviews with Residents 1-12 (R1-R12), regarding the allegation above. 1 of 12 residents confirmed the allegation and stated that on the day of 09/10/2025 and a week from 09/10/2025 their neighboring resident had to wait a long time before getting help from the facility staff. 11 of the 12 residents reported having no knowledge of the allegation above. On 10/17/2025 between the hours of 4:11pm - 4:20pm LPA conducted a records review and observed the following: the department did not receive a LIC 625: Serious/Unusual Incident Report in regard to Resident 13 (R13) shaking from fever and having chills. On 10/17/25 LPA reviewed the staff schedule (dated on 09/05/2025), and observed the following: during the AM shift two (2) caregivers in Units 1 and Unit 4, three (3) caregivers in Unit 2, one (1) caregiver in Units 3 and Unit 5. During the PM shift in Unit 1, Unit 3 , and Unit 5 - two (2) caregiver each were scheduled to work. In Unit 4 - one (1) caregiver is scheduled to work. Based on interviews and record review conducted there is no not enough evidence to support that the facility staff did not provide enough supervision to the resident therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 21, 2025 · control 11-AS-20250909103914

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(5) · Plan of correction due date: Dec 5, 2025

Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training &/or related experience shall provide knowledge of & skill in the following: (5) Knowledge necessary in early signs of illness & the need for professional help.the state’s words, verbatim · CDSS document, Nov 21, 2025

Plan of correction: This requirement was not met as evidenced by: based on observation and interview staff did not provide emergency first responders with the proper documentation such as medical insurance card, primary care physician information, etc. needed for the resident to be admitted to the hospital

Allegation investigated: Facility staff do not properly address changes in condition of residents(s).

This report supersedes report dated 10/20/25 due to additional info being added to report. This report does not change complaint findings. On 10/20/25 at 8:51 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Joel Niblett as the purpose of today’s visit was explained. The investigation consisted of the following: On 10/20/25 LPA Villegas obtained copies of the staff and resident rosters, and copies of the following documents for Resident #11-13 (R11-R13) emergency ID form, pre-appraisals, physicians reports, service plans, and home health or hospice documentation if applicable. On 10/20/25 from 9:00 am- 11am LPA conducted Interviews with R1-R10, and from 1pm-2:30pm LPA conduct interviews with staff #1-7 (S1-S7). On 10/20/25 conducted a file review for R11-13. The investigation revealed the following: Allegation: Facility staff do not properly address changes in conditions of residents. Substantiated It is being alleged that changes in conditions are going unnoticed which lead to hospitalizations. On 10/20/25 from 9:00 am- 11am LPA conducted Interviews with R1-R10 regarding the allegation above. 8 of 10 residents denied the allegation above and reported seeing a Dr. when needed. 2 of 10 residents confirmed the allegation and reported they have not been seen by a Dr. when they do not feel good. On 10/20/25 from 1pm-2:30pm LPA conduct interviews with S1-S7. 7 of 7 staff interviewed denied the allegation above and reported that med techs or LVN will assess a resident for change in condition, and resident will be sent out as needed. Additionally, during interview S1 reported that when a change in condition is observed the standard would be to call 911. On 10/20/25 LPA conducted a file review of R11-13 files. During file review LPA did not observe a re-assessment available for review when R11 returned from the hospital. LP A also observed that there was no care plan for the catheter R11 returned to the facility with, nor was there any documentation indicating that staff have been trained in catheter care. Based on LPAs observations and interviews conducted, record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 21, 2025 · control 11-AS-20251015105817

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Dec 5, 2025

87463 Reappraisals: The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition.... based on records review and interviews LPA did not observe a re-aappraisal on file for when R11 returned to the facility nor a care plan for catheter which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 21, 2025

Plan of correction: Licensee/Executive Director to review regulation cited and submit a plan to CCLD detailing how facility will get into compliance. In service to be conducted on reappraisal procedures, LPA to obtain copy of in-service sign in sheet and materials reviewed. Citation was already cleared, prior to superceded report.

Type of visit: Case Management - Other

On 11/21/2025 The Department conducted an unannounced visit to deliver findings for the alleged allegations for complaint Control Number 11-AS-20250909103914. LPA met with Joel Niblett (Administrator) as the purpose of the visit was explained. On 10/17/2025 between the hours of 4:11pm - 4:20pm LPA conducted a records review and observed the following: the department did not receive a LIC 625: Serious/Unusual Incident Report in regard to Resident 13 (R13) shaking from fever and having chills. The facility failed to report the incident as required to the department. Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 21, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 28, 2025

Reporting Requirements(a)(1)Each licensee shall submit serious incident reports to. . . the Department may require, including the following: (1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurance of any of the events This requirement was not met as evidenced by: based observation, LPA observed that the facility did submit a LIC 624 to the department within 7 day of incident occurring.the state’s words, verbatim · CDSS document, Nov 21, 2025

Plan of correction: The facility shall will submit a serious incident reports for the incident that occur on 09/09/2025 with the resident who had symptoms of chill and fevers. The report must be fax to 424-544-1016 to department by POC due date.

Type of visit: Case Management - Incident

On 11/17/2025 at 8:25am, Licensing Program Analyst, LPA Zina Brown conducted a Case Management visit to follow up on the incident reported for Resident #1 (R1). LPA was greeted by Marcus Falanai. LPA explained the purpose of the visit was to gather information surrounding incident of R1 leaving the facility on 11/07 approximately at 12 noon. The regional office received a fax of an unusual incident/injury report from the facility on 11/10/2025. The incident report stated that R1 went missing from 11/08 - 11/09. On 11/10/2025, Long Beach Memorial hospital notified the facility that R1 has been admitted to the hospital. LPA requested the following documents: Admission Record from Holiday Manor Care Center (dated 10/13/2025) LIC 602A:Physician's Report for Residential Care Facilities for the Elderly (dated 10/13/2025) LIC 603: Preplacement Appraisal Information LIC 603 (dated 11/14/2025) Los Angeles County Department of Mental Health Office of Public Guardian (dated 11/04/2025) SOC Worksheet Patient Information (dated 11/06/2025) Superior Court of the State California for the County of Los Angeles Mental Health Letters of Conservatorship (dated 06/16/2025) Due to insufficient information available at this time a further investigation is needed. An exit interview was conducted with Joel Niblett (Administrator) and a hard copy was provided.the state’s words, verbatim · CDSS document, Nov 17, 2025

Allegation investigated: Staff do not ensure resident has access to call button/pendent

On 11/13/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted a subsequent complaint investigation visit regarding the allegation listed above. LPA met with the Administrator Joel Niblett, and the purpose of the visit was explained. The LPA was allowed entry to the facility. The investigation consisted of the following: On 11/05/2025, Witness 1 (W1) was interviewed. On 11/07/2025, a tour of residents’ rooms in unit 1 was conducted and Staff 1 (S1) to Staff 3 (S3) were interviewed. On 11/13/2025, Resident 1 (R1) to Resident 7 (R7), S1, Staff 4 (S4) to Staff 7 (S7) and Witness 1 (W1) were interviewed. Substantiated Allegation: “Staff do not ensure resident has access to call button/pendent.” Observations revealed the following: On 11/07/2025, residents’ bedrooms and bathrooms in unit 1 had call buttons with a long string on the wall. On 11/13/2025 around 10:30 AM, room 404 did not have a call button with a long string on the wall, furthermore, S1 and Staff 8 (S8) searched R1’s room for the said call button and S8 found said call button in drawer. On 11/13/2025, S8 screwed the call button on the wall next to R1’s bed. Interviews conducted on 11/13/2025 revealed the following: R1 indicated that they did not know where call button was located; Staff 6 (S6) indicated that R1’s call button fell and they had their call button on their bed next to them; S1, Caregiver Supervisor morning shift and S7, Caregiver Supervisor evening shift both indicated that they were not informed that R1’s call button fell from the wall. Substantiated: Based on observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 11-AS-20251103083205

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 13, 2025

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation and interviews the licensee did not comply with the section cited above by R1 not being accorded a safe environment by not having access to their equipment such as their call button which posed a potential health, safety or personal rights risk to person in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: On 11/13/2025, the licensee corrected this deficiency by placing a call button on the wall next to R1's bed.

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: Facility failed to seek timely medical attention to the resident. Staff did not communicate with resident's representative in a timely manner.

** This report supersedes 11/05/2025 to obtain additional information.** On 11/05/2025 at 8:25am, Licensing Program Analysts (LPA) Zina Brown conducted a subsequent complaint visit at this facility to deliver findings. During today’s visit, LPA met with Joel Niblett (Executive Director) & explained the purpose of the visit. The investigation consisted of the following: On 10/13/2025 at 8:35am, Licensing Program Analyst (LPA) Zina Brown conducted an initial unannounced complaint investigation for the allegations listed above. On 10/13/2025, LPA interviewed with Administrator (A1), Staff (S1-S7) between the hours of 9:04am – 1:23pm. On 10/20/2025, LPAs conducted interviews with Residents (R2 - R11) between the hours of 8:30am - 10:15am. Also, LPA obtained the following documentation: Resident Roster (received 10/13/2025), Staff Roster (dated 10/13/2025), Resident #1 (R1's) documents such as LIC 601 Personnel Record (dated 09/16/2025), LIC 602: Physician Report (dated 09/10/2025), LIC 603: Pre-Placement Appraisal (dated 09/08/2025), and LIC 604: Admission Agreement (dated 09/16/2025). Unsubstantiated The investigation revealed the following: Allegation: Facility failed to seek timely medical attention to the resident It was alleged that the facility failed to seek timely medical attention for Resident 1 (R1), who was believed to be sleeping throughout the morning of September 27, 2025, but was later found unresponsive around 12:40 p.m. and was transported to the hospital. On 10/13/2025, between the hours of 1:12pm - 1:23pm, LPA interviewed Administrator (A1) regarding the allegation. A1 was unaware of the allegation and stated he doesn't recall anything at all in regard to the resident's condition nor what steps were taken when staff realized the resident was unresponsive on the morning of 09/27/2025 at approximately 8am. A1 did not have a response when asked at what point did staff notice that the resident was unresponsive or show signs of distress. A1 stated the facility process for checking on residents consist of standard practice every 2 hours for residents. If resident is asleep, the staff won't wake up the resident for dignity and will do otherwise if necessary for physical/medical needs for food and or medication. A1 stated the staff makes the determination to contact emergency services or for medical help. On 10/13/2025, between the hours of 9:04am - 11:30am, LPA interviewed 7 staff in regard to the allegation. 1 of 7 staff confirmed the allegation and stated a Medtech informed Staff 7 (S7) and a previous LVN who no longer work at the facility were informed that Resident 1 (R1) wasn't looking well. S7 and former LVN observed R1 unresponsive and contacted 911 who then came to the facility to take R1 to the hospital. 3 of 7 staff were aware of the allegation due to being informed by other staff since these staff were off from work on the day of the incident occurring. 3 of 7 staff were unaware of the allegation by not have any knowledge of the incident due to not being scheduled to work that day. On 10/20/2025, between the hours of 8:30am - 10:00am, LPA interviewed 10 residents regarding the allegation. 2 of 10 residents confirmed the allegation and stated that staff do not take action, respond slowly, and provide poor assistance to those in need of medical attention. 6 of 10 residents denied the allegation and stated not having to wait a long time before receiving help when sick. 2 of 10 residents were unaware of the allegation stated not knowing and or never witnessing it due to keeping to themselves. LPA unable to interview Resident 1 (R1) as resident passed away while at the hospital on 09/30/2025. On 11/05/2025, between the hours of 9:35am - 9:45am, LPA conducted a records review and observed the following: LIC 602 Physician Report for Residential Care Facilities for the Elderly (RCFE) - dated on 09/10/2025 states that R1 had dementia and his primary diagnosis was coronary artery and secondary diagnosis(es) was congestive heart failure. LIC 603 Preplacement Appraisal Information stated R1's health history of 3 back surgeries and a heart stent. Furthermore, staff informed the Medtech and former LVN that R1 appeared to look unwell which has resulted in R1 being unresponsive. The facility immediately contacted emergency first responders who arrived at the facility to transport R1 to the hospital. Upon R1 being transported to the hospital, the resident was alive. Report continues on LIC 9099-C Based on information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff did not communicate with resident's representative in a timely manner. It was alleged that staff failed to communicate with the resident’s representative in a timely manner regarding the resident’s condition and subsequent hospitalization, and that the facility administrator did not respond to the representative’s multiple attempts to discuss the incident. On 10/13/2025, between the hours of 1:12pm - 1:23pm, LPA interviewed Administrator (A1) regarding the allegation. A1 did not confirm nor deny the allegation and stated A1 stated that the Medtech or licensed nurse is typically responsible for informing the resident’s family when there is a medical emergency or major change in condition. A1 further stated that management or staff did not follow up with the family after the incident, as it is the family’s responsibility to communicate with the hospital once the resident is transferred, and the hospital is responsible for providing updates to the family. On 10/13/2025, between the hours of 9:04am - 11:30am, LPA interviewed 7 staff regarding the allegation. 5 of 7 staff denied the allegation and stated that when it's a change in the residents’ condition the family is notified immediately.1 of 7 staff were unaware of the allegation and stated not knowing if family is notified of the resident's change in condition. 1 of 7 staff did not confirm nor deny the allegation but stated staff told the nurse and Medtech first who will then contact the family. On 10/20/2025, between the hours of 8:30am - 10:00am, LPA interviewed 10 residents regarding the allegation. 1 of 10 residents confirmed the allegation and stated the facility doesn't tell their family right away when something happens with their health. 7 of 10 residents denied the allegation and stated their family have not and did not find out late about something that has happened to them such as not feeling well or going to the doctor and or hospital while being here at the facility. 1 of 10 residents didn't confirm nor deny the allegation and stated that their family doesn't care. 1 of 10 residents was unsure of the allegation and stated not knowing if the facility contacts their family later or after the fact if and when something has happened such as not feeling well or going to the doctor and or hospital. LPA unable to interview Resident 1 (R1) as resident passed away while at the hospital on 09/30/2025. On 11/05/2025 between the hours of 8:25am - 8:45am, LPA conducted a records review and observed the following: Upon the incident occurring, an initial report was made to the resident's responsible representative by the facility in regard to the incident that occurred with R1. However, the facility did not communicate after the incident occurred with R1's responsible party. Report continues on LIC 9099-C Based on information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. No deficiencies were cited for the allegations above. An exit interview was conducted, and a copy of this report was provided to Joel Niblett (Administrator).the state’s words, verbatim · CDSS document, Nov 6, 2025 · control 11-AS-20251006160920

Allegation investigated: Facility failed to seek timely medical attention to the resident Staff did not communicate with resident's representative in a timely manner.

On 11/05/2025 at 8:25am, Licensing Program Analysts (LPA) Zina Brown conducted a subsequent complaint visit at this facility to deliver findings. During today’s visit, LPAs met with Joel Niblett (Executive Director) & explained the purpose of the visit. The investigation consisted of the following: On 10/13/2025 at 8:35am, Licensing Program Analyst (LPA) Zina Brown conducted an initial unannounced complaint investigation for the allegations listed above. On 10/13/2025 , LPA interviewed with Administrator (A1), Staff (S1-S7) between the hours of 9:04am – 1:23pm. On 10/20/2025, LPA conducted interviewed with Residents (R1-R10) between the hours of 8:30am - 10:15am. Also LPA obtained the following documentation: Resident Roster (received 10/13/2025), Staff Roster (dated 10/13/2025), Resident #1 (R1's) documents such as LIC 601 Personnel Record (dated 09/16/2025), LIC 602: Physician Report (dated 09/10/2025), LIC 603: Pre-Placement Appraisal (dated 09/08/2025), and LIC 604: Admission Agreement (dated 09/16/2025). Report continues on LIC 9099-C Unsubstantiated The investigation revealed the following: Allegation: Facility failed to seek timely medical attention to the resident It was alleged that the facility failed to seek timely medical attention for Resident 1 (R1), who was believed to be sleeping throughout the morning of September 27, 2025, but was later found unresponsive around 12:40 p.m. and was transported to the hospital. On 10/13/2025, between the hours of 1:12pm - 1:23pm, LPA interviewed Administrator (A1) regarding the allegation. A1 was unaware of the allegation and stated he doesn't recall anything at all in regards to the resident's condition nor what steps were taken when staff realized the resident was unresponsive on the morning of 09/27/2025 at approximately 8am. A1 did not have a response when asked at what point did staff notice that the resident was unresponsive or show signs of distress. A1 stated the facility process for checking on residents consist of standard practice every 2 hours for resident. If resident is asleep, the staff won't wake up the resident for dignity and will do otherwise if necessary for physical/medical needs for food and or medication. A1 stated the staff makes the determination to contact emergency services or for medical help. On 10/13/2025, between the hours of 9:04am - 11:30am, LPA interviewed 7 staff in regards to the allegation. 1 of 7 staff confirmed the allegation and stated a Medtech informed Staff 7 (S7) and a previous LVN who not longer work at the facility were informed that Resident 1 (R1) wasn't looking well. S7 and former LVN observed R1 unresponsive and contacted 911 who then came to the facility to take R1 to the hospital. 3 of 7 staff were aware of the allegation due to being informed by other staff since these staff were off of work on the day of the incident occurring. 3 of 7 staff were unaware of the allegation by not have any knowledge due to not being scheduled to work on that day and time of the incident occurring. On 10/20/2025, between the hours of 8:30am - 10:00am, LPA interviewed 10 residents in regards to the allegation. 2 of 10 residents confirmed the allegation and stated that staff do not take action, respond slowly, and provide poor assistance to those in need of medical attention. 6 of 10 residents denied the allegation and stated not having to wait a long time before receiving help when sick. 2 of 10 residents were unaware of the allegation stated not knowing and or never witnessing it due to keeping to themselves. On 11/05/2025, between the hours of 9:35am - 9:45am, LPA conducted a records review and observed the following: LIC 602 Physician Report for Residential Care Facilities for the Elderly (RCFE) - dated on 09/10/2025 states that R1 had dementia and his primary diagnosis was coronary artery and secondary diagnosis(es) was congestive heart failure. LIC 603 Preplacement Appraisal Information stated R1's health history of 3 back surgeries and a heart stents. Furthermore, staff informed the Medtech and former LVN that R1 appeared to look unwell which as resulted in R1 being unresponsive. The facility immediately contacted emergency first responders who arrived to the facility to transport R1 to the hospital. Upon R1 being transported to the hospital, the resident was alive. Based on information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff did not communicate with resident's representative in a timely manner. It was alleged that staff failed to communicate with the resident’s representative in a timely manner regarding the resident’s condition and subsequent hospitalization, and that the facility administrator did not respond to the representative’s multiple attempts to discuss the incident. On 10/13/2025, between the hours of 1:12pm - 1:23pm, LPA interviewed Administrator (A1) regarding the allegation. A1 did not confirm nor deny the allegation and stated A1 stated that the Medtech or licensed nurse is typically responsible for informing the resident’s family when there is a medical emergency or major change in condition. A1 further stated that management or staff did not follow up with the family after the incident, as it is the family’s responsibility to communicate with the hospital once the resident is transferred, and the hospital is responsible for providing updates to the family. On 10/13/2025, between the hours of 9:04am - 11:30am, LPA interviewed 7 staff in regards to the allegation. 5 of 7 staff denied the allegation and stated when it's a change in the resident's condition the family is notified immediately. 1 of 7 staff were unaware of the allegation and stated not knowing if family is notified in the resident's change in condition. 1 of 7 staff did not confirm nor deny the allegation but stated staff tell the nurse and the Medtech first who will then contact the family. On 10/20/2025, between the hours of 8:30am - 10:00am , LPA interviewed 10 residents in regards to the allegation. 1 of 10 residents confirmed the allegation and stated the facility doesn't tell their family right away when something happens with their health. 7 of 10 residents denied the allegation and stated their family have not and did not found out late about something that has happened to them such as not feeling well or going to the doctor and or hospital while being here at the facility. 1 of 10 residents didn't confirm nor deny the allegation and stated that their family doesn't care. 1 of 10 resident was unsure of the allegation and stated not knowing if the facility contacts their family later or after the fact if and when something has happened such as not feeling well or going to the doctor and or hospital. On 11/05/2025 between the hours of 8:25am - 8:45am, LPA conducted a records review and observed the following: Upon the incident occurring, an initial report was made to the resident's responsible representative by the facility in regards to the incident that occurred with R1. However the facility did not communicate after the incident occurred with R1's responsible party. Report continues on LIC 9099-C Based on information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. No deficiencies were cited for the allegations above. An exit interview was conducted, and a copy of this report was provided to Joel Niblett (Administrator).the state’s words, verbatim · CDSS document, Nov 5, 2025 · control 11-AS-20251006160920

Type of visit: Case Management - Deficiencies

On 11/05/2025 at 8:25am, Licensing Program Analysts (LPA) Zina Brown conducted an unannounced visit to deliver findings for the alleged allegations for complaint Control Number 11-AS-20251006160920. LPA met with Joel Niblett (Administrator) who was informed of the purpose of the visit. On 11/05/2025 between the hours of 8:25am -8:45am, LPA conducted a records review and observed the following: The facility did not submit a LIC 624 Unusual Incident/Injury Report in regards to Resident 1 being transported to Long Beach Memorial Hospital on 09/27/2025 nor a LIC 624A Death Report in regards to Resident 1 passing away at the hospital on 09/30/2025. The facility failed to report the incident as required to the department. Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. Exit interview conducted with Joel Niblett (Administrator) and copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Nov 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 12, 2025

Each licensee shall submit serious incident reports to the licensing agency such as the Department may require, including the following: (1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence of any of the events. This requirement was not met as evidenced by: LPA observed no LIC 624 Unusual Incident/Injury Report nor a LIC624A Death Report for Resident 1 was not submitted to the department within 7 day of incident occurringthe state’s words, verbatim · CDSS document, Nov 5, 2025

Plan of correction: The facility will submit a LIC 624 Unusual Incident/Injury Report & a LIC624A Death Report for Resident 1 (R1). Also the facility will conduct an in-service training for Medtechs, Licensed Nurses & Department Directors on Reporting Requirement per Title 22 regulations. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

Allegation investigated: Facility does not have sufficient staffing to provide care to residents.

On 10/23/2025 at approximately 4:00 PM, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met Joel Niblett/Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrators Interview (A#1), Residents Interviews (R#1-R#6) and Staff Interview (S#1-S#5). LPA obtained and reviewed the following documents: Resident Roster dated: 9/26/25, Staff Roster dated: 9/25/25, copies of (R#1 and R#4) Physicians Report for Residential Care Facilities for the Elderly or LIC 602 various dates, copies of (R#1-R#4) Admissions Agreement various dates, copies of (R#1-R#4) Identification and Emergency Information or LIC 601 various dates, copies of (R#1-R#4) Appraisal/Needs and Services Plan or LIC 625 various dates, and a copy of facility Call-off Tracking Log for the month of September 2025. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Facility does not have sufficient staffing to provide care to residents. The details of the complaint alleged that it was observed that there are not enough staff during regular hours. On October 21, 2025, at approximately 1:00 p.m., during a records review, Licensing Program Analyst (LPA) Iniguez examined the facility’s Call-off Tracking Log for the dates of September 29-30 and October 1-3, 2025. The log indicated that the facility typically employs around 20 care staff members each day. According to the documentation, the highest number of staff callouts on a single day was five. This left approximately 15 care staff members on duty that day to provide care and supervision for the residents. On September 26, 2025, at approximately 10:00 a.m., during an Interview with the facility Administrator (A#1), he stated that we have sufficient staff to provide care and supervision for the memory care residents. However, there are days when we experience a high number of callouts from facility staff. This situation often requires some employees to work overtime and double shifts. Additionally, (A#1) mentioned that when there are call-outs, the remaining facility staff members covering for those absent are expected to meet the needs of the residents in their care. (A#1) also expressed that when staff members call out, he does not believe there is an immediate danger to the residents. On September 26, 2025, at approximately 11:00 AM, during an interview with residents (R#1-R#6), (6) out of (6) stated that the facility does not have enough staff to take care of them and the rest of the residents in care. Evaluation Report continues LIC 9099-C On September 26, 2025, at approximately 12:00 PM, during an interview with facility staff (S#1-S#6), (5) out of (6) stated that the facility does not have enough staff to provide care to residents. In addition, (6) out of (6) facility staff said that they feel the residents are not in immediate danger due to staffing issues; however, this can potentially become a problem since sometimes there are (1) caregiver per (20) residents with different care needs. During this investigation, LPA did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Joel Niblett/Administrator.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 11-AS-20250919104757

Allegation investigated: Staff did not seek timely medical attention. Licensee did not ensure resident records were maintained and readily available for emergency medical staff.

On 10/20/2025 at 8:25am, Licensing Program Analysts (LPAs) Zina Brown conducted a subsequent complaint visit at this facility to deliver findings. During today’s visit, LPAs met with Joel Niblett (Executive Director) & explained the purpose of the visit. The investigation consisted of the following: On 09/10/2025, an unannounced initial complaint visit was conducted at the facility by Licensing Program Analysts (LPA) Zina Brown. On 09/10/25 LPA Brown interviewed the Residents (R1-R12), between the hours of 10:17am - 11:52, Administrator (A1) between the hours of 3:20pm - 3:38pm and Staff (S1) between the hours of 2:07pm - 2:15pm. LPA requested the resident and staff roster, resident roster, LIC 601; Emergency Info (for R1-R2,R13), LIC 602: Physician's Report for Resident Care Facilities for the Elderly (for R1-R2,R13), Admission Agreement (for R1-R2,R13), LIC 603: Pre-Placement Appraisal (for R1-R2, R13) and Medication Administrator Record (for R1-R2,R13), and Staff Schedule (dated 09/05/2025). Report continues on LIC 9099-C Substantiated The investigation revealed the following: Allegation: Staff did not seek timely medical attention It is being alleged that facility staff failed to contact emergency services for a resident in care. On 09/19/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated that documentation reflected staff recognized the change in the resident’s condition and called 911 for medical attention. A1's expectation of the staff is to respond appropriately and take immediate action when a resident exhibits serious symptoms. A1 indicated that staff are expected to notify a Certified MedTech and/or a Licensed Nurse immediately, and 911 should be called as needed. On 09/10/2025 and 10/13/2025, LPA conducted interviews with Staff (S1- S4) regarding the allegation above. 1 out of 4 staff interviewed confirmed the allegation above and reported witnessing the incident in question with Resident 13 (R13), per 1 of 4 staff protocol was followed and 911 was called. 1 out of 4 staff interviewed reported being aware of the incident but did not witness it. 2 out of 4 staff interviewed denied the allegation and stated not having knowledge nor witness any emergency regarding the Resident 13 (R13). On 09/10/2025, between the hours of 10:17am - 11:42am LPA Brown conducted interviews with Residents 1-12 (R1-R12), regarding the allegation above. 1 of 12 residents confirmed the allegation and stated that on the day of 09/10/2025 and a week from 09/10/2025 their neighboring resident had to wait a long time before getting help from the facility staff. 11 of the 12 residents reported having no knowledge of the allegation above. On 10/17/2025 between the hours of 4:11pm - 4:20pm LPA conducted a records review and observed the following: the department did not receive a LIC 625: Serious/Unusual Incident Report in regard to Resident 13 (R13) shaking from fever and having chills. On 10/17/25 LPA reviewed the staff schedule (dated on 09/05/2025), and observed the following: during the AM shift two (2) caregivers in Units 1 and Unit 4, three (3) caregivers in Unit 2, one (1) caregiver in Units 3 and Unit 5. During the PM shift in Unit 1, Unit 3 , and Unit 5 - two (2) caregiver each were scheduled to work. In Unit 4 - one (1) caregiver is scheduled to work. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). Allegation: Licensee did not ensure resident records were maintained and readily available for emergency medical staff It is being alleged that facility staff are not properly trained to communicate with emergency medical staff. On 08/11/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated when emergency responders requested information for the resident, it is unknown what records were readily available for the first responders. A1 stated the Licensed Nurses and MedTech staff are trained and aware of where the medical chart is located, which includes the physician’s report, emergency contacts, insurance, and medication lists. A1 added that staff are instructed to provide this information upon request from emergency medical personnel. On 09/10/2025 and on 10/13/2025, LPA Brown conducted interviews with Staff (S1- S4) regarding the allegation. 3 out 4 staff interviewed confirmed of the allegation and stated caregivers are not trained on how to obtain resident records, and it's only Medtechs and/or LVNs who manage records in the event of an medical emergency. 1 out 4 staff denied the allegation and stated staff are trained to locate and provide LIC 602, medication list and facesheet of the resident. On 09/10/2025, between the hours of 10:17am - 11:42am LPA Brown conducted interviews with Residents 1-12 (R1-R12) regarding the allegation above. 9 of 12 residents interviewed reported being unaware of the allegation and stated not knowing if the facility has in their file their doctors name, list of medication and family contact information. 3 of 12 residents interviewed denied the allegation and stated they know the facility has their personal record on file. On 10/17/2025 between the hours of 4:20pm, LPA conducted a records review and observed that there is no training on file for staff to ensure resident record are maintained and readily available for emergency first responders. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).the state’s words, verbatim · CDSS document, Oct 20, 2025 · control 11-AS-20250909103914

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 24, 2025

Reporting Requirements(a)(1)Each licensee shall submit serious incident reports to. . . the Department may require, including the following: (1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence of any of the events. This requirement was not met as evidenced by: based observation, LPA observed that the facility did submit a LIC 624 to the department within 7 day of incident occurringthe state’s words, verbatim · CDSS document, Oct 20, 2025

Plan of correction: The facility shall will submit a serious incident reports for the incident that occur on 09/09/2025 with the resident who had symptoms of chill and fevers. The report must be fax to 424-544-1016 to department by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(5) · Plan of correction due date: Oct 27, 2025

Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training &/or related experience shall provide knowledge of & skill in the following: (5) Knowledge necessary in early signs of illness & the need for professional help. This requirement was not met as evidenced by: based on observation and interview staff did not provide emergency first responders with the proper documentation such as medical insurance card, primary care physician information, etc. needed for the resident to be admitted to the hospitalthe state’s words, verbatim · CDSS document, Oct 20, 2025

Plan of correction: The facility will conduct an in service training for all staff to be trained on how to provide all necessary documentation needed upon request by emergency first responders. Also the facility shall create form to be signed by the emergency first responders for proof of receiving resident records before . . . transporting the resident to the hospital. The facility will submit proof of staff in-service training with signatures and the proof of resident record form provided to emergency first responders to department by POC due date via email Zina.Brown@dss.ca.gov

Allegation investigated: Facility staff do not properly address changes in condition of resident(s).

On 10/20/25 at 8:51 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with as the purpose of today’s visit was explained. The investigation consisted of the following: On 10/20/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #11-13 (R11-R13) emergency ID form, preappraisals, physicians reports, service plans, and home health or hospice documentation if applicable. On 10/20/25 from 9:00 am- 11am LPA conducted Interviews with R1-R10, and from 1pm-2:30pm LPA conduct interviews with staff #1-7 (S1-S7). On 10/20/25 conducted a file review for R11-13. The investigation revealed the following: Allegation: Facility staff do not properly address changes in condition of resident(s). Substantiated It is being alleged that change in conditions are going unnoticed which lead to hospitalization's. On 10/20/25 from 9:00 am- 11am LPA conducted Interviews with R1-R10 regarding the allegation above. 8 of 10 residents denied the allegation above and reported seeing a Dr. when needed. 2 of 10 residents confirmed the allegation and reported they have not been seen by a Dr. when they do not fell good. On 10/20/25 from 1pm-2:30pm LPA conduct interviews with S1-S7. 7 of 7 staff interviewed denied the allegation above and reported med techs or LVN will assess a resident for change in condition, and resident will be sent out as needed. On 10/20/25 conducted a file review for R11-13, LPA observed that there was no re-assessment available for review for R11. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided. It is being alleged that facility is frequently admitting residents without proper triage or assessment. On 10/20/25 from 9:00 am- 11am LPA conducted Interviews with R1-R10 regarding the allegation above, 3 of 10 residents interviewed denied the allegation above, and reported having a pre-placement appraisal conducted prior to admitting to Brittany House. 7 of 10 residents interviewed reported they could not remember if a pre placement appraisal was conducted prior to admitting to Brittany House. On 10/20/25 from 1pm-2:30pm LPA conduct interviews with S1-S7, 7 of 7 staff interviewed denied the allegation above. On 10/20/25 conducted a file review for R11-13, LPA observed completed pre-placement appraisal conducted prior to admitting to Brittany House. Allegation: Facility staff are retaining resident(s) beyond their level of care. It is being alleged that residents at Brittany House require a higher level of care by qualified personnel. On 10/20/25 from 9:00 am- 11am LPA conducted Interviews with R1-R10 regarding the allegation above. 9 of 10 residents interviewed denied the allegation above and reported Brittany House is meeting their care needs 1 of 10 residents interviewed confirmed the allegation above, and reported their needs are not being met. On 10/20/25 from 1pm-2:30 pm LPA conduct interviews with S1-S7 regarding the allegation above. 4 of 7 staff interviewed denied the allegation above. 3 of 7 staff interviewed confirmed the allegation as reported there are residents who require a higher level of care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 20, 2025 · control 11-AS-20251015105817

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Nov 3, 2025

87463 Reappraisals :The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition.... based on records review and interviews LPA did not observe a re-assessmnet on file for when R11 returned to the facility which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 20, 2025

Plan of correction: Licensee/Executive Director to review regulation cited and submit a plan to CCLD detailing how facility will get into compliance. In service to be conducted on reappraisal proceudres, LPA to obtain copy of inservice sign in sheet and maerials reviewed.

Allegation investigated: Staff did not seek timely medical attention. Licensee did not ensure resident records were maintained and readily available for emergency medical staff.

On 10/20/2025 at 8:25am, Licensing Program Analysts (LPAs) Zina Brown conducted a subsequent complaint visit at this facility to deliver findings. During today’s visit, LPAs met with Joel Niblett (Executive Director) & explained the purpose of the visit. The investigation consisted of the following: On 09/10/2025, an unannounced initial complaint visit was conducted at the facility by Licensing Program Analysts (LPA) Zina Brown. On 09/10/25 LPA Brown interviewed the Residents (R1-R12), between the hours of 10:17am - 11:52, Administrator (A1) between the hours of 3:20pm - 3:38pm and Staff (S1) between the hours of 2:07pm - 2:15pm. LPA requested the resident and staff roster, resident roster, LIC 601; Emergency Info (for R1-R2,R13), LIC 602: Physician's Report for Resident Care Facilities for the Elderly (for R1-R2,R13), Admission Agreement (for R1-R2,R13), LIC 603: Pre-Placement Appraisal (for R1-R2, R13) and Medication Administrator Record (for R1-R2,R13), and Staff Schedule (dated 09/05/2025). Report continues on LIC 9099-C Substantiated The investigation revealed the following: Allegation: Staff did not seek timely medical attention It is being alleged that facility staff failed to contact emergency services for a resident in care. On 09/19/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated that documentation reflected staff recognized the change in the resident’s condition and called 911 for medical attention. A1's expectation of the staff is to respond appropriately and take immediate action when a resident exhibits serious symptoms. A1 indicated that staff are expected to notify a Certified MedTech and/or a Licensed Nurse immediately, and 911 should be called as needed. On 09/10/2025 and 10/13/2025, LPA conducted interviews with Staff (S1- S4) regarding the allegation above. 1 out of 4 staff interviewed confirmed the allegation above and reported witnessing the incident in question with Resident 13 (R13), per 1 of 4 staff protocol was followed and 911 was called. 1 out of 4 staff interviewed reported being aware of the incident but did not witness it. 2 out of 4 staff interviewed denied the allegation and stated not having knowledge nor witness any emergency regarding the Resident 13 (R13). On 09/10/2025, between the hours of 10:17am - 11:42am LPA Brown conducted interviews with Residents 1-12 (R1-R12), regarding the allegation above. 1 of 12 residents confirmed the allegation and stated that on the day of 09/10/2025 and a week from 09/10/2025 their neighboring resident had to wait a long time before getting help from the facility staff. 11 of the 12 residents reported having no knowledge of the allegation above. On 10/17/2025 between the hours of 4:11pm - 4:20pm LPA conducted a records review and observed the following: the department did not receive a LIC 625: Serious/Unusual Incident Report in regard to Resident 13 (R13) shaking from fever and having chills. On 10/17/25 LPA reviewed the staff schedule (dated on 09/05/2025), and observed the following: during the AM shift two (2) caregivers in Units 1 and Unit 4, three (3) caregivers in Unit 2, one (1) caregiver in Units 3 and Unit 5. During the PM shift in Unit 1, Unit 3 , and Unit 5 - two (2) caregiver each were scheduled to work. In Unit 4 - one (1) caregiver is scheduled to work. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). Allegation: Licensee did not ensure resident records were maintained and readily available for emergency medical staff It is being alleged that facility staff are not properly trained to communicate with emergency medical staff. On 08/11/2025, LPA interviewed Administrator (A1) regarding the allegation. A1 denied the allegation. A1 stated when emergency responders requested information for the resident, it is unknown what records were readily available for the first responders. A1 stated the Licensed Nurses and MedTech staff are trained and aware of where the medical chart is located, which includes the physician’s report, emergency contacts, insurance, and medication lists. A1 added that staff are instructed to provide this information upon request from emergency medical personnel. On 09/10/2025 and on 10/13/2025, LPA Brown conducted interviews with Staff (S1- S4) regarding the allegation. 3 out 4 staff interviewed confirmed of the allegation and stated caregivers are not trained on how to obtain resident records, and it's only Medtechs and/or LVNs who manage records in the event of an medical emergency. 1 out 4 staff denied the allegation and stated staff are trained to locate and provide LIC 602, medication list and facesheet of the resident. On 09/10/2025, between the hours of 10:17am - 11:42am LPA Brown conducted interviews with Residents 1-12 (R1-R12) regarding the allegation above. 9 of 12 residents interviewed reported being unaware of the allegation and stated not knowing if the facility has in their file their doctors name, list of medication and family contact information. 3 of 12 residents interviewed denied the allegation and stated they know the facility has their personal record on file. On 10/17/2025 between the hours of 4:20pm, LPA conducted a records review and observed that there is no training on file for staff to ensure resident record are maintained and readily available for emergency first responders. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D).the state’s words, verbatim · CDSS document, Oct 20, 2025 · control 11-AS-20250909103914

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 24, 2025

Reporting Requirements(a)(1)Each licensee shall submit serious incident reports to. . . the Department may require, including the following: (1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence of any of the events. This requirement was not met as evidenced by: based observation, LPA observed that the facility did submit a LIC 624 to the department within 7 day of incident occurringthe state’s words, verbatim · CDSS document, Oct 20, 2025

Plan of correction: The facility shall will submit a serious incident reports for the incident that occur on 09/09/2025 with the resident who had symptoms of chill and fevers. The report must be fax to 424-544-1016 to department by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(5) · Plan of correction due date: Oct 27, 2025

Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training &/or related experience shall provide knowledge of & skill in the following: (5) Knowledge necessary in early signs of illness & the need for professional help. This requirement was not met as evidenced by: based on observation and interview staff did not provide emergency first responders with the proper documentation such as medical insurance card, primary care physician information, etc. needed for the resident to be admitted to the hospitalthe state’s words, verbatim · CDSS document, Oct 20, 2025

Plan of correction: The facility will conduct an in service training for all staff to be trained on how to provide all necessary documentation needed upon request by emergency first responders. Also the facility shall create form to be signed by the emergency first responders for proof of receiving resident records before . . . transporting the resident to the hospital. The facility will submit proof of staff in-service training with signatures and the proof of resident record form provided to emergency first responders to department by POC due date via email Zina.Brown@dss.ca.gov

Type of visit: Case Management - Deficiencies

On 10/20/25, Licensing Program Analyst (LPA) Villegas conducted an unannounced case management deficiencies. The purpose of the visit is to issue a citation observed during the complaint investigation - Control 11-AS-20251015105817. During the complaint investigation, LPA learned that there was no documented care plan for the use of a catheter. Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. Exit interview conducted with Executive Director Joe Niblett and copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Oct 20, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87623(b)(2)(B)(C) · Plan of correction due date: Dec 4, 2025

87623 Indwelling Urinary Catheter In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for thefollowing:Ensuring that the bag and tubing are changed by an appropriately skilled professional should the resident require assistance. There should be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed...This requirement was not met as there was no plan in place for catheter care which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 20, 2025

Plan of correction: Licensee/Executive director to review section cited and submit a plan on how to get into compliance. Facility will ensure there are care plans available for review, plan should detail what staff will oversee the care.

Allegation investigated: Staff are not following proper eviction procedures

On 10/14/2025 at approximately 1:00 PM, LPA Alfonso Iniguez conducted an unannounced initial complaint visit. LPA Iniguez met Joel Niblett/Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrators Interview (A#1) and Facility Staff Interview (S#1). LPA obtained and reviewed the following documents: Resident Roster dated: 10/14/25, Staff Roster dated: 10/9/25. Evaluation Report continues LIC 9099-C Substantiated Investigation Revealed the Following: Allegation: Staff are not following proper eviction procedures The details of the complaint alleged that facility does not want to take (R#1) back from hospital. On October 14, 2025, at approximately 2:00 PM, during an interview with (S#1), it was mentioned that (R#1) is currently hospitalized and has a Foley catheter in place. (S#1) expressed concern about who would assist (R#1) with catheter care outside the hours when the Licensed Vocational Nurse (LVN), identified as (S#2), is on duty from 8:00 AM to 4:00 PM. Additionally, (S#1) noted that (R#1)’s insurance does not cover home health services for assistance with the Foley catheter. (S#1) also stated that they spoke with the hospital social worker to inform them that (R#1) requires more support than the facility can provide. Furthermore, (S#1) acknowledged that they did not assess (R#1) before discharge while the resident was still at the hospital, which prevented (R#1) from returning to the facility. During this investigation, the Department found sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). An exit interview was conducted, and a copy of the Complaint Report was given to Joel Niblett/Administrator.the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 11-AS-20251013130805

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Oct 17, 2025

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)... This requirement was not met as evidence by: Based on interviews with (S#1), the facility failed to ensure that resident (R#1) was properly assessed prior to hospital discharge. (S#1) informed the hospital social worker that (R#1) required more assistance than the facility could provide, which resulted in (R#1) not being able to return to the facility upon discharge. This poses a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2025

Plan of correction: License will adhere to Title 22 at all times. As Plan of Correction, the licensee will conduct a proper discharge assessment of (R#1) and accommodate their medical needs at the facility. A proof of correction will be provided to the department before POC due date.

Allegation investigated: Staff did not provide resident with proper notification prior to rate increase. Staff did not follow proper eviction procedures.

On 10/09/2025 Licensing Program Analyst (LPA) Troy Watson conducted an initial complaint visit to the facility listed above. LPA met with Administrator Joel Niblett and the purpose of the visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: On 10/09/2025 LPA Watson requested, reviewed and obtained the following: Personnel Report, Resident Roster, Admission Agreement, Medical Assessment, emailed correspondence, and an Account Balance Sheet 10/10/25. On 10/09/2025 LPA Watson conducted interviews with Resident # 1- Residents #12 (R1-C12) and Staff#1 – Staff #7 (S1-S7). LPA Watson toured the facility with the Care Giver Dafne Diaz and found the facility clean and in good repair. CONTINUED ON LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not provide residents with proper notification prior to rate increase. On 10/09/2025 LPA Watson interviewed Staff #1-Staff #7 (S1-S7). Of those interviewed, 7 out of 7 staff denied the above allegation. On 10/09/2025 LPA Watson interviewed Residents #1 – Residents #12 (R1-R12). Of those interviewed 11 out of 12 denied the above allegation. LPA Watson reviewed the Notice or Rate increase document and it showed that they were properly notified of the rate increase of their room. Based on record reviews, staff and client interviews and observations there is insufficient evidence to support the allegation: “Staff does not treat residents with dignity and respect” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not follow proper eviction procedures. On 10/09/2025 LPA Watson interviewed Staff #1-Staff #7 (S1-S7). Of those interviewed, 7 out of 7 staff denied the above allegation. On 10/09/2025 LPA Watson interviewed Residents #1 – Residents #12 (R1-R12). Of those interviewed 11 out of 12 denied the above allegation. LPA Watson requested an eviction notice in regard to the complainant from the Administrator Joel Niblett, and he stated that he never formerly gave an eviction notice to anyone. LPA Watson requested and did not receive any records that showed an eviction notice was given. Based on record reviews, staff and client interviews and observations there is insufficient evidence to support the allegation: “Staff does not treat residents with dignity and respect” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with the Administrator Joel Niblett and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 11-AS-20251001083704

Allegation investigated: Staff did not provide adequate supervision resulting in resident falling and sustaining a fracture. Staff did not seek medical attention to resident

On 10/02/2025 the Community Care Licensing Division (CCLD) conducted a subsequent visit to deliver an updated version of the investigation report regarding the allegations listed above. The purpose of this report is to provide additional information and to provide the correct definition of serious bodily injury. CCLD staff met with Manager Dafne Villavelazques and the purpose of the visit was explained. The investigation consisted of the following: 09/10/2025 CCLD staff conducted a subsequent complaint investigation to deliver the investigation findings for the allegations listed above. On 01/27/2025 CCLD staff toured the facility and requested copies of Staff and Resident roster, LIC500, Needs and Service Plan, Physician Report, Hospital Records, incident reports for 1 of 6 residents and interviewed 5 staff and 6 residents. On 02/12/2025 CCLD staff interviewed the witness (W1). CCLD staff obtained and reviewed the following: Facility Service Plan 01/02/2025, 01/14/2025, 01/15/2025), St. Mary Hospital records (dated 02/01/2024 to 01/28/2025) and Specialty Hospice Care records (dated 06/14/2024 to 02/03/2025). Substantiated On 08/07/2025 CCLD staff requested copies of Staff and Resident roster, LIC500, Physician Report, Incontinence care records, caregiver notes, Medication Administration Record for R1 and interviewed 4 staff and 6 residents. The investigation revealed the following: Regarding the allegation: “Staff did not provide adequate supervision, resulting in the resident falling and sustaining a fracture.” Records reviewed indicate the following: The Physician Report (dated 10/31/2024) indicates that R1 was non-ambulatory and had secondary diagnoses of Dementia. The Facility Service Plan (dated 09/06/2024) notes that R1 wanders throughout the building and into other residents’ rooms. R1 requires assistance with orientation, redirection, and wayfinding due to forgetfulness and difficulty concentrating. On 11/05/2024, the Specialty Hospice Care nurse instructed facility staff to assist R1 and not leave R1 unattended due to declining health and generalized body weakness. The Incident Report states that on 01/02/2025, R1 experienced a witnessed fall and was taken to the hospital. On 01/14/2025, R1 had an unwitnessed fall and was found on the floor near R1’s room, complaining of hip pain. On 01/15/2025, R1 again complained of right hip pain and was transported to the hospital. St. Mary’s Hospital medical records (dated 01/15/2025) confirm that R1 was diagnosed with a right femoral fracture. Interviews indicate the following: Witness W1 stated that R1 was a fall risk and required supervision while ambulating with a walker. Staff members S1 through S13 consistently indicated that R1 was a fall risk and required supervision. S1 reported that on 01/14/2025, S1 and S2 were supervising R1 and other residents in the dining room. However, both staff members left the dining room to respond to an unexpected death in another resident’s room, leaving R1 unsupervised for approximately 20 minutes. During this time, R1 wandered away and had an unwitnessed fall in another resident’s room. Based on the records review and interviews, the preponderance of evidence standard has been met. Therefore, the allegation that “staff did not provide adequate supervision, resulting in the resident falling and sustaining a fracture” is found to be SUBSTANTIATED. Regarding the Allegation: “Staff Did Not Seek Medical Attention for Resident.” This complaint alleged that staff failed to seek timely medical attention for a resident who was in pain after an unwitnessed fall. Records reviewed indicate the following: Physician Report (dated 10/31/2024) indicates that R1 was non-ambulatory and had secondary diagnoses of Dementia. R1 requires assistance with orientation, redirection, and wayfinding due to forgetfulness and difficulty concentrating. The Incident Report states that on 01/02/2025, R1 experienced a witnessed fall and was taken to the hospital. The incident reports dated 01/14/2025 and 01/15/2025 show that on 01/14/2025, R1 was found on the floor following an unwitnessed fall. On 01/15/2025, R1 complained of pain in the right hip. The medical report from St. Mary Medical Center indicates that R1 had fallen on 01/14/2025 and complained of right hip pain. On 01/15/2025, R1 was transported to the hospital and diagnosed with a right femoral fracture. Interviews revealed the following: Staff members S1 through S13 confirmed that R1 experienced an unwitnessed fall on 01/14/2025 and complained of right hip pain. Medtech Jordan Morales and caregiver Marie Reyes recognized that R1 was experiencing pain in the right hip/leg but did not notify the hospice agency or R1’s daughter/POA at the time. Based on observations and interviews conducted by CCLD staff, as well as the records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation that “Staff did not seek medical attention for the resident” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are cited on the attached LIC 9099D. An immediate civil penalty of $500.00 is being assessed, please see LIC421IM. At this time, an additional civil penalty determination is pending in reference to The Welfare and Institutions Code Section 15610.67 which defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” An exit interview was conducted, and plans of corrections were developed and a copy of this report and appeals rights were provided to Administrator JOEL NIBLETT.the state’s words, verbatim · CDSS document, Oct 2, 2025 · control 11-AS-20250124110111

Allegation investigated: Staff did not provide adequate supervision resulting in resident falling and sustaining a fracture. Staff did not seek medical attention to resident

On 09/18/2025 the Community Care Licensing Division (CCLD) staff conducted a subsequent complaint investigation at Brittany House Facility to deliver the investigation findings for the allegations listed above. CCLD staff met with Manager Joel Niblett (S1) and the purpose of the visit was explained. The investigation consisted of the following: On 01/27/2025 CCLD staff toured the facility and requested copies of Staff and Resident roster, LIC500, Needs and Service Plan, Physician Report, Hospital Records, incident reports for 1 of 6 residents and interviewed 5 staff and 6 residents. On 02/12/2025 CCLD staff interviewed the witness (W1). CCLD staff obtained and reviewed the following: Facility Service Plan 01/02/2025, 01/14/2025, 01/15/2025), St. Mary Hospital records (dated 02/01/2024 to 01/28/2025) and Specialty Hospice Care records (dated 06/14/2024 to 02/03/2025). On 08/07/2025 CCLD staff requested copies of Staff and Resident roster, LIC500, Physician Report, Incontinence care records, caregiver notes, Medication Administration Record for R1 and interviewed 4 staff and 6 residents. Substantiated The investigation revealed the following: Regarding the allegation: “Staff did not provide adequate supervision, resulting in the resident falling and sustaining a fracture.” Records reviewed indicate the following: The Physician Report (dated 10/31/2024) indicates that R1 was non-ambulatory and had secondary diagnoses of Dementia. The Facility Service Plan (dated 09/06/2024) notes that R1 wanders throughout the building and into other residents’ rooms. R1 requires assistance with orientation, redirection, and wayfinding due to forgetfulness and difficulty concentrating. On 11/05/2024, the Specialty Hospice Care nurse instructed facility staff to assist R1 and not leave R1 unattended due to declining health and generalized body weakness. The Incident Report states that on 01/02/2025, R1 experienced a witnessed fall and was taken to the hospital. On 01/14/2025, R1 had an unwitnessed fall and was found on the floor near R1’s room, complaining of hip pain. On 01/15/2025, R1 again complained of right hip pain and was transported to the hospital. St. Mary’s Hospital medical records (dated 01/15/2025) confirm that R1 was diagnosed with a right femoral fracture. Interviews indicate the following: Witness W1 stated that R1 was a fall risk and required supervision while ambulating with a walker. Staff members S1 through S13 consistently indicated that R1 was a fall risk and required supervision. S1 reported that on 01/14/2025, S1 and S2 were supervising R1 and other residents in the dining room. However, both staff members left the dining room to respond to an unexpected death in another resident’s room, leaving R1 unsupervised for approximately 20 minutes. During this time, R1 wandered away and had an unwitnessed fall in another resident’s room. Based on the records review and interviews, the preponderance of evidence standard has been met. Therefore, the allegation that “staff did not provide adequate supervision, Regarding the Allegation: “Staff Did Not Seek Medical Attention for Resident.” This complaint alleged that staff failed to seek timely medical attention for a resident who was in pain after an unwitnessed fall. Records reviewed indicate the following: Physician Report (dated 10/31/2024) indicates that R1 was non-ambulatory and had secondary diagnoses of Dementia. R1 requires assistance with orientation, redirection, and wayfinding due to forgetfulness and difficulty concentrating. The Incident Report states that on 01/02/2025, R1 experienced a witnessed fall and was taken to the hospital. The incident reports dated 01/14/2025 and 01/15/2025 show that on 01/14/2025, R1 was found on the floor following an unwitnessed fall. On 01/15/2025, R1 complained of pain in the right hip. The medical report from St. Mary Medical Center indicates that R1 had fallen on 01/14/2025 and complained of right hip pain. On 01/15/2025, R1 was transported to the hospital and diagnosed with a right femoral fracture. Interviews revealed the following: Staff members S1 through S13 confirmed that R1 experienced an unwitnessed fall on 01/14/2025 and complained of right hip pain. Medtech Jordan Morales and caregiver Marie Reyes recognized that R1 was experiencing pain in the right hip/leg but did not notify the hospice agency or R1’s daughter/POA at the time. Based on observations and interviews conducted by CCLD staff, as well as the records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation that “Staff did not seek medical attention for the resident” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are cited on the attached LIC 9099D. An immediate civil penalty of $500.00 is being assessed, please see LIC421IM. At this time, an additional civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An exit interview was conducted, and plans of corrections were developed and a copy of this report and appeals rights were provided to Administrator Manager Joel Niblett (S1). The investigation consisted of the following: Regarding the Allegation: “Staff did not prevent residents from developing a UTI while in care.” This complaint alleged that staff failed to provide residents with adequate assistance for their incontinent needs, resulting in Resident 1 (R1) developing two urinary tract infections (UTIs) while in care. Records reviewed indicate the following: At Specialty Hospice Care, R1 has a history of falls and a recent right hip fracture. The Physician Report (dated 10/31/2024) lists the primary diagnosis as non-ambulatory and the secondary diagnosis as urinary tract infection (UTI). It also notes bladder and bowel impairments and states that R1 requires assistance with bathing and toileting. St. Mary’s Hospital records (dated 01/15/2025) indicate that, multiple UTIs in the past, which were resolved with antibiotics. Interviews indicate the following: 9 out of 9 staff members denied the allegation. R1 could not be interviewed, as R1 no longer resides at the facility. 9 out of 12 residents denied the allegation. Based on the records reviewed and interviews conducted, the preponderance of evidence standard has not been met. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that "Staff did not prevent resident from developing a UTI while in care" is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided to Administrator Manager Joel Niblett (S1).the state’s words, verbatim · CDSS document, Sep 18, 2025 · control 11-AS-20250124110111

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 22, 2025

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: Based on record reviews and interviews conducted the licensee failed to ensure that supervision was provided to meet the residents’ needs. On 01/14/2025 staff S1 and S2 left R1 unsupervised which resulted to R1 falling and sustaining a fracture which posed an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: POC: The licensee agreed to create a plan to ensure that staff are sufficient in numbers and competent to provide the services necessary to meet resident needs. Proof of correction will be submitted to jose.calderon@dss.ca.gov.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Sep 22, 2025

Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidence by: Based on records and interviews conducted the licensee failed to ensure that 911 was called after R1’s unwitnessed fall on 11/14/2024, which posed an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: The licensee agreed to provide additional training to staff on PIN 25-06-ASC Calling 9-1-1 in Residential Care Facilities for the Elderly (RCFE), proof of correction will be submitted to jose.calderon@dss.ca.gov.

Allegation investigated: Staff not treating resident with dignity and respect. Staff leave residents soiled for an extended period of time. Staff are not answering call buttons in a timely manner.

On 09/10/2025 at 9:15am, Licensing Program Analyst (LPA) Zina Brown conducted a unannounced subsequent complaint visit at this facility to deliver the complaint findings. During today’s visit, LPA met with Joel Niblett and explained the purpose of the visit. On 07/09/2025, at 8:55 am Licensing Program Analyst (LPA) Zina Brown conducted an initial complaint visit LPA met with Joel Niblett (Administrator) explained the purpose of the visit. The investigation consisted of the following: On 07/09/2025, LPA Brown interviewed the staff (S1-S7), and Residents (R1-R8). LPA requested the resident and staff roster, resident roster, Face Sheet & Emergency Info (for R1), Medicine History & Physical MCH (for R1), Discharge Medication Reconciliation Order Report (for R1),Admission Agreement (for R1), LIC 603: Pre-Placement Appraisal (for R1),Service Plan (for R1) andLIC 602: Medical Assessment for Resident Care Facilities for the Elderly. Report continues on LIC 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff not treating residents with dignity and respect It is alleged that a staff member has been verbally abusive, calling Resident 7 derogatory names such as "stupid bitch" and using profanity. On 07/09/2025 at 10:02 AM, LPA interviewed A1. A1 who denied the allegation stated not hearing nor witness staff using profanity nor being disrespectful to the residents. A1 states staff must be respectful at all time which is standard practice at the facility. On 07/09/2025 between the hours of 10:00am - 1:58pm. LPA interviewed (7) staff regarding the allegation. Of the 7 staff: 6 out of 7 staff denied the allegation. 1 out of 7 staff did not confirm nor deny the allegation. On 07/09/2025, between the hours of 2:35pm - 3:35 pm and on 09/10/2025, between the hours of 10:45am - 1:42, LPA interviewed (11) residents regarding the allegation. Of the (11) residents: 1 out of 11 confirmed the allegation. 10 out of 11 denied the allegation. 10 of the residents stated the facility it's alright, everyone is treated fair, and with respect. 1 of the resident stated an employee has used inappropriate language and has threatened her. Based on interviews conducted, records review and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED Report continues on LIC 9099-C Allegation: Staff leave residents soiled for an extended period of time It is alleged that residents are not being changed in a timely manner, resulting in them remaining soiled for prolonged periods. On 07/09/2025 at 10:02 AM, LPA interviewed A1. A1 who denied the allegation stated not aware of residents being left soiled nor not being changed in a timely manner as the facility documents when residents are changed and provided incontinence care. Between the hours of 10:00am - 1:58pm, LPA interviewed (7) staff regarding the allegation. Of the 7 staff: 6 out of 7 staff denied the allegation (1) out of (7) staff confirmed the allegation. Staff states R7 will be assisted with their changing needs by staff and just minutes later R7 will request to have a depends and or diapers changed although the resident is not soiled. Also, its been stated by the staff R7 only wants certain staff to meet her needs and if R7's does not get their way and or needs met immediately, the resident throws food, water and or items at the staff. On 07/09/2025, between the hours of 2:35pm - 3:35 pm and on 09/10/2025, between the hours of 10:45am - 1:42pm, LPA interviewed (11) residents regarding the allegation. 2 out of 11 confirmed the allegation. 9 out of 11 denied the allegation. Out of the 11 residents: (4) residents are incontinent and stated staff come quickly to help residents to the bathroom and or help with getting dressed. (5) of the residents stated they do not wear depends nor diapers and are fully independent and is capable of taking care of themselves. (2) of residents who confirmed the allegation, one stated she is not incontinent but just can't walk but as a result of having to wait a long time to be changed or cleaned as of result of that they have had an accident. On 09/05/2025 at 11:35am, LPA conducted a records review and observed the following: On the LIC 602A Medical Assessment for Residential Care Facilities for the Elderly, on page 4 of 9 under the section 1. Overall Physical Health the following physical health status are checked yes: bowel incontinence, bladder incontinence, motor impairment/paralysis (with a history of Cerebrovascular Accident (CVA) and requires assistance with repositioning and transferring due to left side weakness. In the comments it states that R7 had a stroke in 2023 that resulted in left hemiparesis. Since the stroke R7 has been mostly bed-bound occasionally sits up in a wheelchair. On page 5 of 9 on the LIC 602A under the section 2. Capacity for Self-Care d. Able to Care for Own Toileting Needs is checked no which explains due to left sided weakness. On the Face Sheets and Emergency Info form on page 2 of 7 under the toileting section it states full assistance by a caregiver is needed daily with grooming in the morning and at bedtime with two-person assistance. Based on interviews conducted, records review and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED Allegation: Staff are not answering call buttons in a timely manner It is alleged that there is a delay in staff responding to residents’ call button requests. On 07/09/2025 at 10:02 AM, LPA interviewed A1. A1, who denied the allegation, stated that when the facility is alerted by the call light, the protocol requires staff to respond promptly. A1 does not recall any incidents on or around 07/07/2025–07/08/2025 where Resident 7’s (R7) request for assistance was not received in a timely manner. Between the hours of 10:00am - 1:58pm, LPA interviewed seven (7) staff regarding the allegation. Of the (7) staff, 7 out of 7 staff denied the allegation. Of the 7 staff, 2 of the caregiver stated most of the resident's do not use their call light button as most of the resident will yell out for the staff to come assist and or staff caregivers typically conduct 30 minute rounds around the facility to check on the residents. On 07/09/2025, between the hours of 2:35pm - 3:35 pm and on 09/10/2025, between the hours of 10:45am - 1:42pm, LPA interviewed (11) residents regarding the allegation. 1 out of 11 resident confirmed the allegation. 10 out of 11 residents denied the allegation. 11 of the residents, 9 stated not using, don't need a call button and or will call out for the staff to assist with their needs. 1 resident stated the staff response when pressing the call button. 1 resident stated the call string from the call button came off so resident yells but the staff still does not respond when she does so. On 09/10/2025 between the hours of 1:53pm - 3:20pm, LPA conducted a tour of the Memory Care Unit (located in Unit 1, Unit 2 and Unit 5) and Assisted Living Unit (located in Unit 3 - Unit 4). LPA observed the following respond time for staff to answer the residents call lights: Room 114 (3:05pm - 3:06pm), Room 201 (3:05pm - 3:06pm), Room 230 (3:11pm - 3:20pm), Room 304 (1:53pm - 2:00pm) and Room 407(3:03pm - 3:04pm). Estimated response time was 7-10 minutes for staff to clear the resident call lights. Based on interviews conducted, records review and observation there is no evidence to support the allegation, therefore the allegation is UNSUBSTANTIATED Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Joel Niblett (Administrator) and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 10, 2025 · control 11-AS-20250708131324

Allegation investigated: Staff left resident in soiled clothing for a period of time. Staff not keeping resident’s room free from odor.

On 08/27/25, at 09:30am, Licensing Program Analyst (LPA) Perry Scott conducted an initial complaint visit to the facility and was greeted by Joel Niblett, Executive Director. LPA explained the purpose of this visit is to gather information about the complaint, gather facility files, interview staff and residents, and deliver findings for the allegations mentioned above. The investigation consisted of the following: The department investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S5) and residents (R1-R10). The department received the following: Resident Roster (No Date) Staff Roster (Dated: 08/25/2025), Admission Record (Dated: 06/26/2025), Physician Report LIC 602A (Dated: 07/02/2025), Medical Assessment (Dated: 08/06/2025), Service Plan (Dated: 07/09/2025), CalAIM Tier Level Assessment Form (Dated: 07/11/2025), and Caregiver Daily Flow Sheet and Shower Schedule (Dated: 08/01/2025-08/31/2025), and Discharge Notes from Memorial Care (Dated: 08/20/25) were obtained from the facility. Report Continued on LIC9099-C Substantiated The investigation revealed the following: Allegation #1- Staff left resident in soiled clothing for a period of time. The details of the complaint alleged that emergency services came to the facility on 08/20/25 because the resident (R1) was having difficulties that needed to be addressed. While at the facility it was reported that (R1) was observed to not have been cared for properly and smelled as though (R1) had not showered in weeks and was in soiled clothing. On 08/27/25, from 9:30am-2:00pm, the department interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 4 of 5 staff stated that the resident has a history of refusing to shower and urinating on themselves as well as in their room. They state that they make every effort to change the resident when they discover that the resident has urinated or defecated on themselves but adds that the resident is very aggressive and combative when they try to change the resident. They further state that it takes several caregivers to achieve this, and it happens multiple times per day, but they do their best to keep the resident dry. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that they were never left in soiled clothing for an extended period of time. They state that the staff is attentive to their needs, when assistance is needed. The department reviewed the Caregiver Daily Flow Sheet and Shower Schedule (Dated: 08/01/2025-08/31/2025) and Service Plan (Dated: 07/09/2025) and observed the resident has refused to take a shower on the following dates: 08/01/25, 08/03/25, 08/05/25, 08/06/25, 08/10/25, and 08/18/25 which were the resident’s scheduled shower days. The department did not find any evidence that the issue was being properly addressed by the facility knowing that the resident has these particular ongoing issues. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation Staff left resident in soiled clothing for a period of time, is found to be Substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. Allegation #2- Staff not keeping resident’s room free from odor. The details of the complaint alleged that the staff does not ensure that the resident’s room is free from odor. It was reported that staff is not ensuring that the resident is not urinating in the resident’s room and therefore the resident’s room smells of urine. On 08/27/25, from 9:30am-2:00pm, the department interviewed staff (S1-S5) and residents (R1-R10) regarding the allegation. 4 of 5 staff corroborated the allegation that Staff not keeping resident’s room free from odor. The majority of staff stated that the resident does urinate in their room and in their bed. They state that the resident’s room must be cleaned daily because the resident urinates in their urinal container and then pours it out onto the bed as well as on the floor. They further state that they make every effort to keep the room sanitized and clean and to change the resident often. However, this is an ongoing occurrence with the resident, stated staff. Report Continued on LIC9099-C The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that their room does not have any odors, and staff cleans their room daily. The department toured the resident’s room and observed that there is a strong urine smell as you enter the room, as well as stains on the carpet, which smells of urine. Based on observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation Staff not keeping resident’s room free from odor, is found to be Substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. Note: *Citations that are not cleared by the due date of 09/12/25 will have a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. Deficiency was cleared at the time of the visit. Deficiencies were issued and plans of corrections were discussed. An exit interview was conducted with Joel Niblett, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 11-AS-20250820143555

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Sep 12, 2025

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and the appropriate assistance is provided when such observations\ reveals unmet needs…This requirement was not met as evidence by: Based on observation and interviews, staff did change resident, however due to the frequency of the urination, the resident continued to be in soiled clothing for a period of time due to the resident urinating on themselves and in their bed. This violation poses a potential health and safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Licensee/Administrator shall read Title 22 Section 87466 Observation of the Resident. Licensee to do in-service training with staff on observation of residents and send proof of the in-service with signatures of staff working in assisted living and acknowledgement of the regulation. The facility will submit the plan of correction by the due date of 09/12/25 and email it to LPA Perry Scott’s email at perry.scott@dss.ca.gov to avoid monetary penalties.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 12, 2025

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observation, the resident’s bedroom #207 has a strong odor of urine and the carpet was observed to have liquid stains, possibly urine stains based on the odor emanating from the carpeting. This violation poses a potential health and safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: The Administrator will develop a plan of correction that will address the resident urinating in the room; and ensure that the carpeting in the room is cleaned and sanitized regularly to ensure the health and safety of the resident, employees, and visitors. The facility will submit the plan of correction by the due date of 09/12/25 and email it to LPA Perry Scott’s email at perry.scott@dss.ca.gov to avoid monetary penalties.

Type of visit: Case Management - Deficiencies

On 08/20/2025, Licensing Program Analyst (LPA), Antonine Richard, conducted a case management visit to document deficiencies observed during an investigation related to Complaint Control Number:11-AS-20250812125512. LPA explained the purpose of the visit to staff member Girma Yodit. On 08/20/2025 at 10:00 am, LPA conducted a file review. LPA found that one of the facility staff members did not have background clearance and was not associated with the facility. Interviews conducted, observation, and records reviewed revealed that the facility was not in compliance with the California Code of Regulations Title 22. Deficiency cited based on interviews conducted, records reviewed, and observation in accordance with the California Code of Regulations, Title 22. A copy of the appeal rights and this report was left with the Staff Girma Yodit. On 08/21/2025, the license was cited with Title 22 Criminal Clearance Record Regulations 87355(e)(2). Based on interviews, observation, and record reviews, the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiency was issued. An exit interview was conducted with staff member, Girma Yodit. A copy of this report, appeal rights, and civil penalty was provided.the state’s words, verbatim · CDSS document, Aug 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Aug 22, 2025

87355 Criminal Record Clearance - (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on review of records, the licensee did not comply with the section. LPA identified that one staff member did not have a Criminal Clearance Background, Clearance Transfer associated with this facility. This violation poses an immediate health, safety, or personal rights risk to the person in care.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: Licensee to ensure that all staff, before working in the facility, obtain a Criminal Background Clearance and Criminal Background Transfer Request and provide proof of correction to CCLD by the POC due date. Proof of Correction due date: 08/22/25. Antonine.Richard@dss.ca.gov

Allegation investigated: Facility unlawfully evicted resident

On 8/20/2025, at 10:50 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct an investigation and deliver findings for the alleged allegation. LPA identified herself and met Joel Niblett-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 8/20/2025 at 10:50 AM, LPA Allen obtained and reviewed files for Resident 1 (R1), which included face sheet, medical assement date 7/9/2025, physicians orders for life sustaining treatment, pre-placement appraisal unsigned but dated 6/17/2025, concent for treatment dated 7/9/2025 ,Admission agreement from Mission Community Hospital dated 4/16/2025 and discharge report dated 6/14/2025,Resident sign-out sheet dated 7/19/2025, A written statement of resident transfer to new facility Simla Villas dated 8/20/2025. LPA also conducted interviews with staff members 1-2 (S1-S2),Witness1-2 (W1-W2) and Resident 1(R1). Continued Unsubstantiated Investigation revealed the following: Allegation: Facility unlawfully evicted resident On August 20, 2025, at 11:00 AM, LPA Allen conducted interviews with Staff 1-2 (S1–S2). 2 out of 2 staff members stated that Resident 1 (R1) was not evicted from the facility. LPA did not observe any documentation indicating that R1 was evicted. According to S1 and S2, R1 had been requesting relocation to another facility since June 17, 2025, due to concerns that the current staff could not meet their level of care needs. Upon R1’s arrival on June 17, 2025, staff began the process of identifying a new facility that could accommodate R1’s required services. R1 was scheduled to transfer to the new facility, Simla Villas, on July 19, 2025. However, R1 declined the transfer and informed S1 and S2 that they would be leaving the facility with a friend. S2 advised R1 that leaving the facility without transferring to the new location would be considered leaving Against Medical Advice (AMA), and that re-admittance would not be possible under those circumstances. LPA also conducted an interview with Witness 1 (W1), who stated that Resident 1 (R1) was scheduled to be relocated to a new facility on July 19, 2025, but refused the transfer. Witness 2 (W2) confirmed that R1 was expected to be admitted to their facility on the same date; however, R1 never arrived. W2 was unable to confirm or deny the reason for R1 not being admitted. Additionally, LPA interviewed R1, who confirmed that they left the facility on July 19, 2025, of their own free will with a friend who would be providing care. R1 stated they were never issued a written eviction notice. R1 denied ever wanting to leave the facility. Based on the evidence gathered during the interviews, records reviewed, and observations during the investigation, the above allegations are found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed and provided to Joel Niblett-Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 11-AS-20250814140557

Allegation investigated: Staff mishandle the residents medications.

On 08/20/2025, at 09:30 am, Licensing Program Analyst (LPA) Antonine Richard conducted an initial complaint visit and delivered findings. LPA met with Joel Niblett Administrator, and explained the purpose of the visit. The investigation consisted of the following: On 08/20/2025, LPA Richard requested the residents and staff roster, Medication Mar (Dated July 20, 2025), License vocational Nurse (LVN), and Med Teck (MT) scheduled (Dated July 20, 2025),Timecard by labor Level (Dated 07/20/2025). On 08/20/2025, LPA interviewed seven residents #1-7 (R1-R7), four staff #1-4 (S1-S4), and the Administrator #1 (A1). Continued Report LIC9099C Unsubstantiated Allegation: Staff mishandled the residents' medications. The complaint alleges that medication errors occurred and delays happened on 07/20/2025. On 08/20/2025, from 10:30 am to 1:45 pm, LPA Richard interviewed Administrator #1 (A1), who denied the allegation and stated that no medication errors or delays took place that day. The facility had a staff member call off, but the facility found a staff member to cover the shift. During the same time frame, LPA Richard also interviewed seven residents #1-7 (R1-R7), all of whom denied any medication delays or missed doses since they have been living here. Additionally, LPA interviewed four staff members #1-4 (S1-S4), all of whom denied the allegation. On 08/20/2025, LPA Richard reviewed medication records showing that all residents received their medications, and there were no discrepancies. LPA also reviewed the facility's Chat Note confirmed there were no medication errors or missing medications administered to any residents. Based on the information collected from the facility inspection, interviews, and records reviewed, LPA found no evidence to support the above allegations. Although the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegation is unsubstantiated. No deficiencies cited. An exit interview conducted. A copy of this report was provided to the Administrator Joe Niblettthe state’s words, verbatim · CDSS document, Aug 20, 2025 · control 11-AS-20250812125512

Type of visit: Case Management - Other

On 08/13/2025 around 08:00am Licensing Program Analyst (LPA) Jose Calderon initiated an announced Case Management - Other to Brittany House provide Technical Assistance to the above said facility. The LPA Calderon requested copies of the facility's records which include but are not limited to staff and resident rosters, 5 resident records. LPA Calderon conducted an interview with Administrator Joel Niblett. The Administrator Joel Niblett will provide updated status of resident’s records are secured. An exit interview was conducted with Administrator Joel Niblett and a hard copy was provided via email for signature.the state’s words, verbatim · CDSS document, Aug 13, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Aug 22, 2025

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 evidence by: Based on observation and interviews conducted S1 could not locate or find R1 file. This is a safety risk to clients in care.the state’s words, verbatim · CDSS document, Aug 13, 2025

Plan of correction: Administrator to move all closed and open resident files to a centeral location which is locked. Administrator to have a sign in sheet for residents files which are pulled by staff.

Allegation investigated: staff do not meet resident's dietary needs. staff do not meet resident's dental hygiene needs. staff do not provide outdoor activities to residents. staff do not provide comfortable accommodations to residents. staff do not provide refunds to responsible parties. staff do not keep the facility in a sanitary condition.

** The report dated 8/1/2025 serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected in the report published on 12/20/24. ** On 04/30/2025 LPA Watson conducted a subsequent complaint visit to the facility listed above. LPA met with the Resident Care Coordinator Marcus Fulanai and the purpose of today’s visit was explained. LPA was given access to the facility. CONTINUED ON LIC9099-C Unsubstantiated The investigation consisted of the following: On 12/20/2024 Licensing Program Analyst (LPA) Watson requested, reviewed, and obtained copies of the Staff Roster, Client Roster, Face Sheet & Emergency Info. Appraisal Needs and Services, Admission Agreement (05/25/21), Physicians Reports (09/28/24), ID & Emergency Information (12/06/24) Copy of Citi Bank Check, December Dietary Calendar, December Activities Calendar (12/25). On 12/20/24 LPA Watson interviewed Staff#1-Staff#4 (S1-S4) and Residents #1-Residients #5 (R1-R5). CONTINUED ON LIC-9099C The investigation revealed the following: Allegation: Staff do not meet residents’ dietary needs. It is being alleged that the staff do not make the necessary dietary adjustments for meals served to the residents. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the visit. LPA Watson asked the residents if staff neglected to meet their dietary needs. Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if they met the residents’ dietary needs. Of those interviewed, 4 out of 4 staff stated that residents’ dietary needs were met. ON 7/25/2025 LPA reviewed the Physicians Report for (R1), and it showed a special diet recommendation of mechanical soft food. On 7/25/2025 a letter was provided by facility cook, which states that facility kitchen prepared a mechanical soft diet for R1. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not meet residents’ dental hygiene needs. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff helped them with their dental hygiene needs. Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if they assisted residents with their hygiene needs. Of those interviewed, 4 out of 4 staff denied the above allegation. On 7/25/2025 LPA Watson reviewed the Physicians Report for R1 and it showed that R1 needs help with her dental hygiene. Based on the information gathered, interviews conducted, and review of records LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not provide outdoor activities for residents. It is being alleged that staff do not schedule outdoor activities for the residents. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff provided outdoor activities for them. Of those interviewed, 5 out of 5 residents interviewed stated that activities were provided to them by the facility. On 04/30/25 LPA Watson asked the residents if they were allowed to go outside and participate in outdoor activities. 5 out of 5 residents interviewed stated that they were allowed to go outside and participate in outdoor activities. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if the facility provided outdoor activities for the residents. 4 out of 4 staff interviewed stated that the facility provided outdoor activities for the residents. On 04/30/25 LPA Watson asked the staff if residents were allowed to go outside and participate in outdoor activities. 4 out of 4 staff interviewed stated that residents were allowed to go outside and participate in outdoor activities. On 12/20/24 LPA Watson reviewed the facilities Activities Calendar for December 2024 and observed that every day of the month, the facility scheduled activities for the residents. Further review of records shows that admissions agreement, addendum O, states facility activities programing includes neighborhood walks, field trips and occasional outings. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not provide comfortable accommodation to residents. It is being alleged that staff do not ensure that residents living accommodations are comfortable at the facility. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff provided comfortable accommodation. Of those interviewed, 5 out of 5 residents stated that the staff provided comfortable accommodations for the residents. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if they provided comfortable accommodation such as private rooms free of noise. Of those interviewed, 4 out of 4 staff stated that residents are provided with comfortable accommodation. LPA Watson toured the facility with the Resident Care Coordinator Marcus Falanai and observed residents being accommodated comfortably in a minimal noise free environment. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not provide refunds to responsible parties. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff provided refunds to responsible parties. Of those interviewed, 5 out of 5 stated that the staff have never had to issue a refund to them because they and or their responsible parties handled their money. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if they provided refunds to responsible parties. Of those interviewed, 4 out of 4 staff stated that they do not handle or have access to the residents’ monies. LPA Watson reviewed the Admission Agreements for (R1) and it shows on Page 8, under Section VI A. Termination:” This Agreement may be terminated by Resident within thirty (30) days’ written notice, with the rate provided in this Agreement and thereafter modified from time to time, payable to the end of that termination date or Resident’s unit is vacated.” LPA Watson reviewed the Admission Agreement for Resident # 1 (R1) and it states on Page 8, under Section VI “Refunds: Refunds are generally available only if Resident gives Community thirty (30) – days’ advanced notice of his/her intention to leave Community, Refunds , needs will not be adequately met by care provided in the Community, and Resident’s condition prevents him/her giving thirty (30)-days’ written notice to Community/ In such case, a refund will be made on a daily pro-rated basis. Daily charges will not be incurred if the Resident’s person effects are removed from the Community by 12:00 p.m.” LPA Watson followed up with Administrator Joel Niblett regarding refunds and was informed that facility did not receive Thirty day notice of termination from family of R1. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not keep the facility in a sanitary condition. It is being alleged that the facility is not maintained in a clean and sanitary condition. On 12/20/2024 LPA Watson conducted interviews with Residents #2- Residents #6 (R2-R6). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff do not keep the facility in a sanitary condition? Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 LPA Watson interviewed Staff #1- Staff #4 (S1-S4). LPA Watson asked the staff if they do not keep the facility in a sanitary condition. Of those interviewed, 4 out of 4 staff denied the above allegation. LPA Watson toured the facility with the Resident Care Coordinator Marcus Fulanai and observed the facility clean, sanitary and in good repair. Based on the information gathered, interviews conducted, and an analysis of records reviewed, LPA Watson found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with the Administrator Joel Niblett and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 1, 2025 · control 11-AS-20241216112039

Type of visit: Case Management - Other

On 07/24/2025 Licensing Program Analyst (LPA) Troy Watson made an unannounced subsequent visit to deliver findings regarding the above allegation(s). Because of more documentation needed this investigation will have to continue at a later date. Please : REFERENCE COMPLAINT # 11-AS-20241216112039.Due to insufficient time the above allegations need further investigation. An exit interview was conducted with the Administrator Joel Niblet and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 24, 2025

Allegation investigated: Staff do not prevent a residents from suffering multiple falls while in care. Untrained staff administer medication. Staff handle residents in a rough manner.

***This report supersedes the original report delivered on 5/28/2025. On 7/17/2025, the LPA arrived at the facility to deliver the corrected 9099, providing clarification on the original report issued on 5/28/2025. *** On 5/28/2025, at 9:00 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met Joel Niblett-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 5/28/2025 at 01:25 PM, LPA Allen obtained and reviewed files for Resident 1- 10 (R1-R10) , Special Incident Reports/Death-LIC624A (UIR) for R1 and R3, LPA conducted a search in Community Care Licensing (CCL) data base for death reports resulting from falls. LPA also conducted interviews with staff members1-10 (S1-S10) and Residents 1 – 10 (R1–R10) Unsubstantiated LPA reviewed current in-service training conducted on 1/10/2025 residents’ rights, 2/25/2025 In-service-reporting trainings, and 4/7/2025 Medication Administration (MARS)Training's signed by staff members. Investigation revealed the following: 1 Allegation: Staff do not prevent a resident from suffering multiple falls while in care. Interviews with staff members (S1-S10) stated residents are closely monitored throughout the day & night and are not left unattended for extended periods. For residents identified as fall risks, staff maintain close supervision, either by remaining nearby while assisting other residents or by coordinating with additional staff to ensure continuous observation and support is provided to residents. LPA also interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members help them with their needs and have not fallen. The remaining 8 residents were unable to engage in a clear conversation. A random audit of resident files (R1-R6) and Special Incident Reports (SIRs) in the Community Care Licensing (CCL) database revealed no incident reports indicating that a resident death resulted from a fall. Furthermore, LPA reviewed UIRs for residents who had passed away and confirmed that their causes of death were unrelated to falls. During a facility tour, LPA observed staff actively assisting residents, with no individuals appearing to be left unattended. Based on these observations, it appears that residents receive consistent supervision, and staff have a structured plan in place to promote safety and prevent falls. LPA reviewed current in-service training conducted on 2/25/2025 and 4/7/2025, Medication Administration Training's signed by staff members. 2. Allegation: Untrained staff administer medication On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members stated that, to their knowledge, all medication technicians (MedTechs) are certified to pass out medications. During the investigation, LPA observed that the MedTech certifications for S7 and S9 were up to date and dispense medications. Interviews with S1, S2, S3, and S8 confirmed that they hold certifications, and LPA requested and obtained staff training records for MedTechs. LPA observed re-certifications through Elite Medical Academy for S1, S2, S3, and S8. Interviews with staff also indicated that they have not seen staff members S4, S5, and S6 dispensing medications, and there are no records of current MedTech training for these staff members, only in-service training's. 3 Allegation: Staff handle residents in a rough manner. On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - 10 (S1–S10), Of all the staff interviewed 10 out of the 10 staff stated residents have not been handled in a rough manner that could have resulted in injuries to any resident in care. LPA interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members have not handled them in a rough manner. The remaining 8 residents were unable to engage in a clear conversation. Based on the evidence gathered during the investigation, the above allegations are found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the report was provided to the Joel Niblett- Administrator at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 11-AS-20241217143234

Allegation investigated: Unstageable pressure injury due to lack of care from staff Staff did not provide resident's medication as prescribed Staff did not provide daily activities for residents Staff did not ensure that resident was adequately fed

**This report supersedes the original report delivered on 5/28/2025. On 7/17/2025 , LPA Allen arrived at the facility to deliver the corrected 9099, which included corrections based on resident interviews conducted for the original report issued on 5/28/2025.** On 5/28/2025, at 8:15 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met with Joel Niblett-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 5/12/2025 at 9:00 AM, LPA Allen obtained and reviewed files for Resident 1 (R1), which included a face sheet, medication list, appraisal, needs and services plan, physician's report, admissions agreement with personal property valuables list dated 4/21/2023, staff and client roster for 6/2024 & 4/2025. Continued Unsubstantiated healthcare progress notes/summary from Brittany House & Shoreline Healthcare Center dated 4/28/2023, and Specialty Hospice Care records dated 8/5/2024 - 10/11/2024. LPA also conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - 8 (R1–R8), Witness 1(W1) and attempted to interview Resident 9 (R9) who no longer resides at the facility. Investigation revealed the following: #1- Allegation: Resident sustained an unstageable pressure injury due to lack of care from staff. On 5/12/2025, at 11:00 AM, LPA Allen conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members denied knowing if R1 suffered from a pressure wound or whether an outside agency was providing wound care. LPA interviewed Residents 1 - 8 (R1–R8). Of the 8 residents, 2 stated that they do not have any pressure injuries, The remaining 6 residents were unable to engage in a clear conversation, and LPA did not observe any visible pressure injuries on residents. W1 stated there was a pressure injury caused due to lack of care but could not provide evidence to corroborate the allegation. LPA reviewed R9’s facility file and found hospice records from Specialty Hospice confirming services were provided 2x/week from 06/14/2024 - 10/11/2024, and The Wound Pros provided care 1x/week from 8/5/2024- 10/11/2024. The needs and service plan dated 4/28/2023 - 10/16/2023 does not indicate the presence of a pressure injury. LPA could not obtain sufficient evidence to substantiate that R9 sustained a pressure injury due to a lack of care by facility staff. #2- Allegation: Staff did not provide resident's medication as prescribed On 5/12/2025, LPA conducted interviews with Staff 1- Staff 10 (S1-S10), of those interviewed, 10 out of 10 stated that all residents are given their medications as prescribed by their physicians. On 5/12/2025 LPA reviewed R9’s file and found no records to verify whether R9 received their medication as prescribed. On 5/12/2025 and 5/22/2025 the Medication Administration Records (MARS) could not be provided for R9 therefore, LPA was unable to verify if their medications were given or not. LPA interviewed Residents 1 – Resident 8 (R1–R8) of the 8 residents, 2 stated they get their medications daily the remaining 6 residents were unable to engage in a clear conversation. #3- Allegation: Staff did not provide daily activities for residents. On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members stated that residents are provided with daily activities and showed a schedule of activities posted on the wall and provided a printed copy. LPA interviewed Residents 1 - 8 (R1–R8). Of the 8 residents, 2 stated they have engaged in daily activities, while the remaining 6 residents were unable to engage in a clear conversation. On 5/12/2025, during a facility tour, LPA observed the activity director conducting rounds throughout the premises, actively facilitating various activities with the residents. These included morning exercise, coloring, nail painting, and arts & crafts. Additionally, a monthly activity schedule dated September 2024, outlining events from 9:15 AM to 6:00 PM, was available for review. #4- Allegation: Staff did not ensure that residents were adequately fed On May 12, 2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members stated that all residents in care receive three meals daily, including snacks, and that meals are determined based on their dietary needs. S10 mentioned that R9 was on a fortified mechanical soft meal and thin liquids, but specific dates could not be provided. LPA reviewed R9’s physician's report dated 4/27/2023 and Specialty Hospice Care records dated 6/14/2024, which confirmed that R9 was on a fortified mechanical soft meal and thin liquids diet. Additionally, LPA interviewed Residents 1 - 8 (R1–R8). Of the 8 residents, 2 stated they receive three meals daily, while the remaining 6 residents were unable to engage in a clear conversation. On 5/12/2025, LPA observed residents having meals, including a balanced breakfast of bacon, eggs, and oatmeal, followed by lunch consisting of baked pork chops, mashed potatoes, mixed vegetables, cornbread, water, and juice. Continued On May 22, 2025, LPA again observed residents consuming a balanced lunch, which included tuna casserole, green beans, salad, cornbread, juice, and water. LPA also observed menus that coincided with the meals being provided each day. During a tour of the facility kitchen, LPA noted a five-day supply of perishable food and a seven-day supply of non-perishable food items. The kitchen appeared clean, and no health or safety concerns were observed during the visit. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Joel Niblett- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 11-AS-20240909085113

Allegation investigated: Staff handled residents in a rough manner which resulted in injuries Staff inappropriately restrained resident Staff did not provide a safe and comfortable environment for residents Staff did not provide residents with privacy Staff mismanaged residents’ medication Residents are being left unattended for extended periods Staff did not provide adequate food service Medications are not being stored properly Residents are not being changed in a timely manner

**This report supersedes the original report delivered on 5/22/2025. On 7/17/2025, LPA Allen arrived at the facility to deliver the corrected 9099, which included corrections based on resident interviews conducted for the original report issued on 5/22/2025.** On 5/22/2025, at 8:00AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met Joel Niblett- Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 5/12/2025 at 9:00 AM, LPA Allen obtained and reviewed records for Resident 1 (R1), including the face sheet dated July 5, 2024, Controlled Drug Record dated for July 5,2024 through September 8, 2024,Medication Administration log dated for August 2024 , Supportive Hospice Care-Discharge Unsubstantiated Summary and Post Discharge Plan of care dated 7/5/2024, Identification and Emergency Information, Needs and services plan dated 7/5/2024, Physician's Report dated 7/2/2024. Admissions Agreement dated 7/3/2024, Personal property valuables list dated 7/3/2024 , Staff and Resident rosters for 6/2024 and 4/2025, LPA also conducted interviews with Staff 1- Staff 10 (S1–S10) and Residents 1 - Resident 10 (R1–R10), in addition to observations made during the tour of the facility. Investigation revealed the following: 1 Allegation: Staff handled residents in a rough manner which resulted in injuries On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - Resident 10 (R1–R10). The 10 staff members interviewed stated that residents have not been handled in a rough manner that could have resulted in injuries. LPA interviewed Residents 1 - 10 (R1–R10) Of the interviews conducted, 3 residents stated that staff members have not handled them in a rough manner causing injury. The remaining 7 residents were unable to engage in a clear conversation. 2 Allegation: Staff inappropriately restrained resident LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members interviewed stated that residents have not been inappropriately restrained in any way. LPA requested any special incident reports during the visit, but none could be provided as there were no incidents to report regarding restraining residents. LPA interviewed Residents 1 - 10 (R1–R10) Of the interviews conducted, 3 residents stated that staff members have not restrained them in any way. The remaining 7 residents were unable to engage in a clear conversation. 3 Allegation: Staff did not provide a safe and comfortable environment for residents LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members interviewed stated that staff provides a safe and comfortable environment for residents. LPA interviewed Residents 1 - 10 (R1–R10) Of the interviews conducted, 3 residents stated that staff members have provided a safe and comfortable environment . The remaining 7 residents were unable to engage in a clear conversation. During the tour of the facility, LPA observed that the residents were in a safe and comfortable environment, with no health and safety concerns noted. 4 Allegation: Staff did not provide residents with privacy On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members interviewed stated that staff provide residents with privacy while assisting with showers and any ADLs requiring privacy. LPA interviewed Residents 1 - 10 (R1–R10) Of the 10 residents, 3 stated that staff provide them with privacy, while the remaining 7 residents were unable to engage in a clear conversation. During the tour of the facility, LPA did not observe any residents’ rights being violated. 5 Allegation: Staff mismanaged residents’ medication On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members interviewed stated that staff have not mismanaged residents’ medication. LPA interviewed Residents 1 - 10 (R1–R10). Of the 10 residents, 3 stated that staff provide them with their medications daily, while the remaining 7 residents were unable to engage in a clear conversation. On 5/12/2025, LPA observed R1's Medication Administration Records (MARS) and based on LPA's observations and documentation it appeared that R1's medications had been administered as prescribed by their physicians. 6 Allegation: Residents are being left unattended for extended periods On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members interviewed stated that residents are not left unattended for extended periods of time. Staff mentioned that there are no records of residents being changed, but residents are checked on every 2-3 hours to address incontinence issues and as needed. LPA interviewed Residents 1 - 10 (R1–R10). Of the 10 residents, 3 stated that staff help them with their Activities of Daily Living (ADLs) as needed or when asked and has not been left unattended to for extended periods. The remaining 7 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were receiving incontinence and (ADLs) assistance from staff members. Continued 7 Allegation: Staff did not provide adequate food service On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members stated that residents are provided adequate food service based on their dietary needs or modified diets. LPA interviewed Residents 1 - 10 (R1–R10). Of the 10 residents, 3 stated they receive three meals and snacks daily, while the remaining 7 residents were unable to engage in a clear conversation. On 5/12/2025, LPA observed residents being fed and eating a balanced meal for breakfast (hot cereal, eggs, bacon, and toast) and lunch (baked pork chops, cornbread, mashed potatoes, and mixed veggies). On 5/22/2025, LPA toured the kitchen and observed a 5-day supply of perishables and a 7-day supply of non-perishable food items. Lunch served included tuna casserole, green salad, green beans, cornbread, water, juice, and coffee. A menu available for review reflected the meals served. 8 Allegation: Medications are not being stored properly On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10). All 10 staff members stated that the medication room is locked when not in use. LPA observed residents’ medications stored properly in the medication room, locked in drawers inaccessible to residents. LPA also observed Medication Technicians (MEDTECHS) using their keys to open the medication drawers during a random audit of records/medications. LPA interviewed Residents 1 - 10 (R1–R10). Of the 10 residents, 3 stated they were unsure about medications being stored properly, while the remaining 7 residents were unable to engage in a clear conversation. 9 Allegation: Residents are not being changed in a timely manner. On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10) and Residents 1 - 10 (R1–R10). All 10 staff members stated that staff have not left residents unattended for extended periods of time. Staff mentioned that there are no records of residents being changed, but residents are checked on every 2-3 hours or as needed to address incontinence issues. Continued... LPA interviewed Residents 1 - 10 (R1–R10). Of the 10 residents, 3 stated that staff help them with their Activities of Daily Living (ADLs) /incontinence issues and or as needed in a timely manner. The remaining 7 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were receiving incontinence assistance from staff members. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Joel Niblett- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 11-AS-20240719115501

Allegation investigated: Staff did not assist resident with care needs in a timely manner.

On 07/02/25, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced complaint visit. LPA Richard met with Joel Niblett, the Executive Director (ED), and explained the purpose of this visit. The investigation consisted of the following: the Licensing Program Analyst (LPA) interviewed, reviewed, and obtained records, along with a tour of the facility. Interviews were conducted with six staff members (S1-S6), five residents (R1-R5), and the Admission/Social Service Director (ASSD). LPA Richard reviewed multiple documents, including the Personnel Report LIC 500, the Resident Roster, the Face Sheet and Identification/Emergency Information for Resident #1 (R1), the Service Plan, the Resident Assessment, Preplacement Appraisal Information, the Admissions Agreement, the Medication Administration Record (MAR), and other relevant records related to this complaint. Report Continued LIC9099-C Unsubstantiated Allegation: Staff did not assist resident with care needs in a timely manner. The complaint alleges that a resident has been neglected, specifically claiming that they have been unable to use the bathroom and have had to sit in their urine. On July 2, 2025, between 10:00 AM and 1:00 PM, the Licensing Program Analyst (LPA) interviewed six staff members (S1-S6), all of whom denied the allegations and stated that they provide care for all residents. Staff members S5 and S6, who primarily assist resident #1 (R1), also denied the claims, asserting that R1 has not been neglected and has not been left sitting in urine or unable to use the bathroom. LPA additionally interviewed the Assistant Director of Staff Development (ASSD), who denied the allegations and explained that all three shifts routinely perform incontinent services every two hours or as needed. R1 is scheduled for diaper changes every two hours or as needed. Later, on July 2, 2025, between 1:30 PM and 2:30 PM, LPA interviewed five residents (R1-R5). Four out of five residents denied the allegations, stating that staff regularly change their diapers and assist with their activities of daily living (ADLs). They also reported that when they pull the alarm cord, staff usually respond within two to four minutes. Report continued LIC9099-C A review of the Caregiver Daily Flow Sheet and staff notes for residents' ADLs, dated July 01 to July 02, 2025, confirmed that R1 receives daily assistance unless R1 refuses. LPA reviewed the Nursing-issued 24-hour report dated June 22 to June 29, 2025, which showed that R1 refused staff assistance very often. Furthermore, on July 2, 2025, the LPA pulled the alarm cord in R1's room, and staff arrived to assist within two minutes. The LPA also observed that the residents looked well-groomed and clean, and they did not appear to be neglected. Based on the information collected from the facility inspection, observations, interviews, and records analysis, LPA found no evidence to support the above allegations. Although the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of the report was provided to Executive Director Joel Niblett.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 11-AS-20250624095034

Allegation investigated: Lack of supervision resulting in resident being assaulted by another resident while in care.

This report supersedes report dated 05/08/2025 to include additional information. The complaint investigation findings remain the same. On 06/18/2025 at 8:47am Licensing Program Analyst (LPA) Zina Brown conducted a subsequent complaint visit at this facility to deliver the complaint findings. During today’s visit, LPA met with Joel Niblett, Administrator Designee and the explained the purpose of the visit. The investigation consisted of the following: On 04/03/2025, LPA interviewed Administrator (A1), Staff #1 - Staff #6 (S1 - S6) and Resident #1- #6 (R1 – R6). LPA requested copies of the staff roster (dated 01/31/2025) and resident roster, centrally stored medication record (for R7), Service Plans (for R6 - R7), Physician's Order (List of Medication for R6-R7), LIC 602: Physician Report for RCFE, LIC 601 Identification and Emergency Information. Unsubstantiated On 06/18/2024, LPA interviewed Staff# 8 - Staff# 10, requested a copy of the LIC 624: Unusual Incident Injury for R1-R2 (dated 12/21/2024) and staff schedule (December 2024). The investigation revealed the following: Allegation: Lack of supervision resulting in resident being assaulted by another resident while in care. On 04/03/2025 between the hours of 12:18pm - 12:28pm, LPA interviewed the Administrator (A1), regarding the above allegation. A1 stated she was unaware of the allegation. On 04/03/2025 between the time of 9:31am - 12:28pm, LPA interviewed Staff # 1 (S1)– Staff 6 (S6) and on 04/23/2025 between the hours of 9:21am – 9:38am, LPA interviewed Staff (7) regarding the allegation. On 06/18/2025, between the hours of 10:53am - 12:05pm, LPA interviewed Staff #8 (S8) - Staff #10 (S10) regarding the allegation. 3 out 10 staff interviewed confirmed an incident occurred between Resident #1 (R1) and Resident #2 (R2), but Staff had different various of the incident that occurred between R1 and R2. 7 out 10 staff interviewed had no knowledge of the incident that occurred between R1 and R2. On 04/03/2025 between the hours 1:17pm - 2:26pm, LPA interviewed Resident #1(R1) – Resident #5 (R5). On 04/03/2025 LPA attempted to interview Resident# 1 (R1) but due to the communication barriers, the resident was unable to answer interview questions. On 04/03/2025 LPA attempted to interview Resident #2 (R2) who declined to be interviewed. Report continues on LIC 9099-C 5 out of the 5 residents interviewed were unaware of the incident. On 05/06/2025 between the hours of 2:30pm – 3:30pm, LPA conducted a records review for Resident #7 (R1) records and observed the following: No history of aggravation per the resident’s physicians report (dated 09/29/2023) and need and service plan (dated 10/30/2024) No history and or record of LIC 624: Unusual Incident/Injury Report (from December 2024 – April 2025) On 06/18/2025, LPA returned to the facility and conducted a records review of the staff scheduled (December 2024) during the time of the incident. On the date of the incident 12/21/2024 at approximately 4:45pm, seven (7) staff worked between the hours of 8:45am - 6:12pm. On shift, there were a total of 6 Caregivers, 1 Medtech and Administrative Staff. During the time of the incident, the facility had a census of 61. This incident is the first occurrence between R1 and R2. No similar incidents were reported for R1 and R2. The incident occurred suddenly which did not allow the staff to prevent the incident from occurring at the time Based on the information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is unsubstantiated. Exit interview conducted with Joel Niblett, Administrator Designee & copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 11-AS-20250401131451

Allegation investigated: Staff handled residents in a rough manner which resulted in injuries Staff inappropriately restrained resident Staff did not provide a safe and comfortable environment for residents Staff did not provide residents with privacy Staff mismanaged residents’ medication Residents are being left unattended for extended periods Staff did not provide adequate food service Medications are not being stored properly Residents are not being changed in a timely manner

**This report supersedes the original report delivered on 5/22/2025. On June 4,2025 at 8:30 LPA arrived at the facility to deliver the revised 9099, providing clarification on the original report issued on 5/22/2025.** On 5/22/2025, at 8:00AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met Joel Niblett- Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 5/12/2025 at 9:00 AM, LPA Allen obtained and reviewed records for Resident 1 (R1), including the face sheet dated July 5, 2024, Controlled Drug Record dated for July 5,2024 through September 8, 2024,Medication Administration log dated for August 2024 , Supportive Hospice Care-Discharge Summary and Post Discharge Plan of care dated 7/5/2024, Identification and Emergency Information, Needs and services plan dated 7/5/2024, Physician's Report dated 7/2/2024 Continued.... Unsubstantiated Admissions Agreement dated 7/3/2024, Personal property valuables list dated 7/3/2024 , Staff and Resident rosters for 6/2024 and 4/2025, LPA also conducted interviews with Staff 1- Staff 10 (S1–S10) and Residents 1 - Resident 10 (R1–R10), in addition to observations made during the tour of the facility. Investigation revealed the following: 1 Allegation: Staff handled residents in a rough manner which resulted in injuries On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). Of all the staff interviewed 10 out of 10 staff interviewed stated residents have not been handled in a rough manner that could have resulted in injuries. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the interviews conducted 2 residents stated staff members have not handled them in a rough manner causing injury. The remaining 8 residents were unable to engage in a clear conversation. 2 Allegation: Staff inappropriately restrained resident On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). Of all the staff interviewed 10 out of 10 staff members stated residents have not been inappropriately restrained in any way. LPA requested any special incident reports during the visit, and none could be provided because there were no incidents to report regarding restraining residents. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the interviews conducted 2 residents stated staff members have not restrained them in any way. The remaining 8 residents were unable to engage in a clear conversation. Continued... 3 Allegation: Staff did not provide a safe and comfortable environment for residents On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated staff does provide a safe and comfortable environment for residents. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated that staff members have provide a safe and comfortable environment. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility LPA observed the residents to be in a safe and comfortable environment and no health and safety concerns were observed. 4 Allegation: Staff did not provide residents with privacy On 5/12/2025, LPA conducted interviews with Staff 1 -Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated staff does provide residents with privacy while assisting with showers and any ADL's requiring privacy. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated that staff members have provide them with privacy. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility LPA didn’t observe any residents’ rights being violated. 5 Allegation: Staff mismanaged residents’ medication On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated staff has not mismanaged residents’ medication. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated staff members have provided them with their medications daily. The remaining 8 residents were unable to engage in a clear conversation. On 5/12/2025 LPA observed R1 Medication Administration Records (MARS) and based on LPA observations it appeared that R1s medications had been administered as prescribed by their physicians. Continued... 6 Allegation: Residents are being left unattended for extended periods On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated residents are not left unattended for extended periods of time. Staff stated there is no records of residents being changed however residents are checked on every 2-3 hours to ensure their incontinence issues are addressed or as needed. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated that staff members help them with their Assistance with Daily Living (ADLS) as needed or when asked. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were getting incontinence assistance from staff members. 7 Allegation: Staff did not provide adequate food service On 5/12/2025 LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated the residents are provided adequate food service based on their dietary needs or modified diets. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated they get three (3) meals and snacks daily the remaining 8 residents were unable to engage in a clear conversation. On 5/12/2025, LPA observed the residents in care being fed and eating a balanced meal for breakfast -hot cereal, eggs, bacon and toast, Lunch- Baked pork chops, cornbread, mashed potatoes, and mixed veggies. On 5/22/2025 LPA toured the kitchen and observed there to be a 5-day supply of perishables and a 7-day supply of non-perishable food items. Lunch served tuna casserole, green salad, green beans and cornbread, water, juice and coffee. There was a menu available for review that reflected meals served. 8 Allegation: Medications are not being stored properly On 5/12/2025 LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), 10 out of 10 staff members stated the medication room is locked when not in use. LPA observed the residents’ medications to be stored properly in the medication room locked in drawers inaccessible to the residents. LPA also observed the Medication Technicians (MEDTECHS) using their keys to open the medication drawers during the random audit of records/medications. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated they are not sure about medications being stored properly. Continued .. 9 Allegation: Residents are not being changed in a timely manner. On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated staff has not left residents unattended for extended periods of time. Staff stated there is no records of residents being changed however residents are checked on every 2-3 hours to ensure their incontinence issues are addressed. LPA was unable to interview R1. LPA attempted to interview Residents 2 – Resident 9 (R2-R9). Of the 10 residents, 2 stated that staff members help them with their Assistance with Daily Living (ADLS) as needed or when asked. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were getting incontinence assistance from staff members. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Joel Niblett- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 11-AS-20240719115501

Allegation investigated: Staff do not prevent a residents from suffering multiple falls while in care. Untrained staff administer medication. Staff handle residents in a rough manner.

On 5/28/2025, at 9:00 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegation. LPA identified herself and met Joel Niblett-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 5/28/2025 at 01:25 PM, LPA Allen obtained and reviewed files for Resident 1-Resident 6 (R1-R6) files, Special Incident Reports/Death-LIC624A (SIR) for R1-R3, LPA conducted a search in Community Care Licensing (CCL) data base for death reports resulting from falls. Continued... Unsubstantiated Investigation revealed the following: 1 Allegation: Staff do not prevent a resident from suffering multiple falls while in care. Interviews with staff members (S1-S10) stated residents are closely monitored throughout the day & night and are not left unattended for extended periods. For residents identified as fall risks, staff maintain close supervision, either by remaining nearby while assisting other residents or by coordinating with additional staff to ensure continuous observation and support. LPA also interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members help them with their needs and have not fell. The remaining 8 residents were unable to engage in a clear conversation. A random audit of resident files (R1-R6) and Special Incident Reports (SIRs) in the Community Care Licensing (CCL) database revealed no incident reports indicating that resident deaths resulted from falls. Furthermore, LPA reviewed SIRs for residents who had passed away and confirmed that their causes of death were unrelated to falls. During a facility tour, LPA observed staff actively assisting residents, with no individuals appearing to be left unattended. Based on these observations, it appears that residents receive consistent supervision, and staff have a structured plan in place to promote safety and prevent falls. 2. Allegation: Untrained staff administer medication On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Of those interviewed, 10 out of 10 staff stated to their knowledge all medication technicians (Medtech) are certified to pass out medications. During the investigation LPA observed MedTech certifications for S7 and S9 which were up to date. Interviews with S1, S2, S3, and S8 confirmed that they hold certifications but were unable to provide current copies. Staff have also stated they have registered for re-certification through Elite Medical Academy and they have not seen staff members S4, S5, and S6 dispensing medications. Continued... 3 Allegation: Staff handle residents in a rough manner. On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). Of all the staff interviewed 10 out of the 10 staff all stated residents have not been handled in a rough manner that could have resulted in injuries to any resident in care. LPA interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members have not handled them in a rough manner. The remaining 8 residents were unable to engage in a clear conversation. Based on the evidence gathered during the investigation, the above allegations are found to be Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the report was provided to the Joel Niblett- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 29, 2025 · control 11-AS-20241217143234

Type of visit: Case Management - Deficiencies

On 5/29/2025, at 8:15 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations for complaint Control Number 11-AS-20241217143234. LPA identified herself and met Joel Niblett- Administrator who was informed of the purpose of the visit. On May 12, 2025, the LPA conducted a random audit of the Medication Administration Record (MAR) for Residents 1 through 4 (R1–R4). During the audit, LPA observed that R1’s medications appeared to have been dispensed; however, staff were unable to provide the corresponding MAR for review. Additionally, LPA noted that R2’s medications were recorded as dispensed on May 2 and May 12, 2025, but were still in their original packaging. Marcus Falanai resident care coordinator, was unable to confirm whether R2’s medications had actually been dispensed. Meanwhile, LPA verified that R3 and R4’s medications had been dispensed and signed off by a medtech. This violation poses a potential health, safety, or personal rights risk to residents in care and a citation was issued. On May 29, 2025, LPA conducted interviews, observations and reviewed the LIC500, noting that some staff members are listed as caregivers and medtechs. Interviews with S1, S2, S3, and S8 confirmed that they hold certifications but were unable to provide current copies. They also stated that they have registered for re-certification through Elite Medical Academy. Additionally, staff members S4, S5, and S6 have not been observed dispensing medications. Joel was informed that the absence of current certification documentation for staff members presents a potential health, safety, and personal rights risk to residents in care. As a result, a citation will be issued for failure to maintain complete and up-to-date staff files for review at the time of the visit. Continued.... Interviews with S4, S5, and S6 confirmed that they do not have certification to dispense medications and have not administered medications to residents in care. The interview with Joel Niblette, the Administrator, verified that all staff members (S1–S9) have been provided links to register for medtech training through Elite Medical Academy as of May 29, 2025. Joel was informed that medtechs who are not certified should not be listed as medtechs. LPA requested that the LIC500 be updated with accurate titles until certifications are obtained. LPA also suggested to Joel Niblett the following regulations be read 87413,87412,87411,87465 and health and safety code 1569.625 An exit interview was conducted where this report LIC809, LIC809 -C and LIC809-D was discussed and provided to Joel Niblett at the conclusion of the visitthe state’s words, verbatim · CDSS document, May 29, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a)-(h) · Plan of correction due date: Jun 6, 2025

Personnel Records (a) - (h) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:... This requirement was not met as evidenced by: LPA reviewed staff 1-9 files and observed that there were no annual tranings, mectech certifications for S1-S7 This violation poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: Joel Niblett-Administrator has agreed to conduct an audit of all staff files monitouring progress daily to esure files are completed with all documents by the POC date. Joel has agreed to provide proof of annual training to all staff members, including medtech trainings . Details of the course prvided and signed by all staff will be emailed to LPA by the POC date of 6/6/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(c)(3) · Plan of correction due date: Jun 6, 2025

Incidental Medical and Dental Care (c) (3)If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:... This requirement was not met as evidenced by: LPA observed R1 and R2 medications were not signed as being dispensed and there was medication signed off as being disspensed but in package. This violation poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 29, 2025

Plan of correction: Joel Niblett-Administrator has agreed to conduct training to all medtecs LVNs on documentation requirements policy and procedures standards by the POC date of 6/6/2025. Proof of traing signed by all staff and certifications will be emailed to LPA by the POC date 6/6/2025.

Allegation investigated: Resident sustained an unstageable pressure injury due to lack of care from staff Staff did not provide resident's medication as prescribed Staff did not provide daily activities for residents Staff did not ensure that resident was adequately fed

On 5/28/2025, at 8:15 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met with Joel Niblett-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 5/12/2025 at 9:00 AM, LPA Allen obtained and reviewed files for Resident 1 (R1), which included face sheet, medication list, appraisal, needs and services plan, physicians report, admissions agreement with personal property valuables list dated 4/21/2023, staff and client roster for 6/2024 & 4/2025, healthcare progress notes/summery from Brittany house & Shoreline Healthcare Center dated 4/28/2023,Specialty Hospice Care dated 8/5/2024-10/11/2024. LPA also conducted interviews with Staff 1- Staff 10 (S1 – S10), Residents 2-Resident 8 (R2-R8) and observations during the tour of the facility. Continued .... Unsubstantiated #2- Allegation: Staff did not provide resident's medication as prescribed On 5/12/2025, LPA conducted interviews with Staff 1- Staff 10 (S1-S10), of those interviewed, 10 out of 10 stated that all residents are given their medications as prescribed by their physicians. On 5/12/2025 LPA reviewed R1’s file and found no records to verify whether R1 received their medication as prescribed. On 5/12/2025 and 5/22/2025 the Medication Administration Records (MARS) could not be provided for R1 therefore, LPA was unable to verify if their medications were given or not. LPA interviewed Residents 2 – Resident 8 (R2–R8) of the 8 residents, 2 stated they get their medications daily the remaining 6 residents were unable to engage in a clear conversation. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. #3- Allegation: Staff did not provide daily activities for residents. On 5/12/2025, LPA conducted interviews with Staff 1- Staff 10 (S1 – S10), of those interviewed, 10 out of 10 stated residents are provided with daily activities and showed a schedule of activities on the wall posted and provided a printed copy. LPA interviewed Residents 2 – Resident 8 (R2–R8) of the 8 residents, 2 stated they have engaged in daily activities the remaining 6 residents were unable to engage in a clear conversation. On May 12, 2025, during a facility tour, LPA observed the activity director conducting rounds throughout the premises, actively facilitating various activities with the residents. These included morning exercise, coloring, nail painting, and arts & crafts. Additionally, a monthly activity schedule dated September 2024, outlining events from 9:15 AM to 6:00 PM, was available for review. Continued Investigation revealed the following: #1- Allegation: Resident sustained an unstageable pressure injury due to lack of care from staff. On 5/12/2025, at 11:00 AM, LPA Allen conducted interviews with Staff 1–Staff 10 (S1–S10). Of those interviewed, 10 out of 10 staff denied knowing if R1 suffered from a pressure wound or whether an outside agency was providing wound care. LPA interviewed Residents 2 – Resident 8 (R2–R8) of the 8 residents, 2 stated that they do not have any pressure injuries and based on LPA observations there was no visible pressure injuries. The remaining 6 residents were unable to engage in a clear conversation and LPA did not observe any visible pressure injuries. LPA reviewed R1’s facility file and found no medical records indicating wound care services were provided. The needs and service plan dated 4/28/2023–10/16/2023 does not indicate the presence of a pressure injury. However, hospice records from Specialty Hospice confirm services were provided 2x/week from 06/14/2024–10/11/2024, and The Wound Pros provided care 1x/week from 8/5/2024–10/11/2024. LPA could not obtain sufficient evidence to substantiate that R1 sustained a pressure injury due to a lack of care by facility staff. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. #4- Allegation: Staff did not ensure that resident was adequately fed On May 12, 2025, the LPA conducted interviews with Staff 1 - Staff 10 (S1– S10), of those interviewed, 10 out of 10 state all residents in care receive three meals daily, including snacks and meals are determined based on their dietary needs. S10 stated that R1 was on a fortified mechanical soft meal and thin liquids but specific dates could not be provided. LPA reviewed R1’s physicians report date 4/27/2023 and Specialty Hospice Care dated 6/14/2024 which states R1 was on a fortified mechanical soft meal and thin liquids. Additionally, LPA interviewed Residents 2 - Resident 8 (R2–R8); 2 stated they receive three meals daily, the remaining 6 residents were unable to engage in a clear conversation. On 5/12/2025, LPA observed residents having meals, including a balanced breakfast of bacon, eggs, and oatmeal, followed by lunch consisting of baked pork chops, mashed potatoes, mixed vegetables, cornbread, water, and juice. On May 22, 2025, LPA again observed residents consuming a balanced lunch, which included tuna casserole, green beans, salad, cornbread, juice, and water. LPA also observed menus which coincides with the meals being provided for each day. A tour of the facility kitchen was also conducted, during which LPA observed a five-day supply of perishable food and a seven- day supply of nonperishable food items were noted. The kitchen appeared clean, and no health or safety concerns were observed during the visit. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Joel Niblett- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 28, 2025 · control 11-AS-20240909085113

Allegation investigated: Staff handled residents in a rough manner which resulted in injuries Staff inappropriately restrained resident Staff did not provide a safe and comfortable environment for residents Staff did not provide residents with privacy Staff mismanaged residents’ medication Residents are being left unattended for extended periods Staff did not provide adequate food service Medications are not being stored properly Residents are not being changed in a timely manner

On 5/22/2025, at 8:00 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met Joel Niblette- Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 5/12/2025 at 9:00 AM, LPA Allen obtained and reviewed files for Resident 1 (R1), including the face sheet, medication list/MAR date 8/27/2024, appraisal, needs and services plan, physician's report, admissions agreement with personal property valuables list, staff and client rosters for 4/2025 and 6/2024, medication review report dated 7/5/2024, and outside service agency visit sheets date range of 7/11/2024 - 9/12/2024. LPA also conducted interviews with Staff 1- Staff 10 (S1–S10) and Residents 1 - Resident 10 (R1–R10), in addition to making observations during the tour of the facility. Unsubstantiated Investigation revealed the following: 1 Allegation: Staff handled residents in a rough manner which resulted in injuries On 5/12/2025 at 11:00 AM, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). Of all the staff interviewed 10 out of the 10 staff interviewed all stated that residents have not been handled in a rough manner that could have resulted in injuries. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members have not handled them in a rough manner. The remaining 8 residents were unable to engage in a clear conversation. 2 Allegation: Staff inappropriately restrained resident On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). Of all the staff interviewed 10 out of 10 staff members stated that residents have not been inappropriately restrained in any way including R1. LPA requested any special incident reports during the visit, and none could be provided because there has not been any incidents to report pertaining to restraining any residents. LPA also searched the Departments of Social Services (DSS) database to confirm if there were any unusual incident reports (UIR) submitted which could not be found. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members have not inappropriately restrained them in any way. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility LPA did not observe any residents being inappropriately restrained by the staff. Continued... 3 Allegation: Staff did not provide a safe and comfortable environment for residents On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated staff does provide a safe and comfortable environment for residents. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members have provide a safe and comfortable environment for residents. The remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility LPA observed the residents to be in a safe and comfortable environment and no health and safety concerns were observed. 4 Allegation: Staff did not provide residents with privacy On 5/12/2025, LPA conducted interviews with Staff 1 -Staff 10 (S1–S10), Residents 1 through Resident 10 (R1–R10). 10 of 10 staff members stated staff does provide a safe and comfortable environment for residents providing them privacy while conducting showers and any ADL's requiring privacy. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that staff members provide them with privacy the remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility LPA didn’t observe any residents’ rights being violated by not providing privacy. 5 Allegation: Staff mismanaged residents’ medication On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 of 10 staff members stated staff has not mismanaged residents’ medication. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated they don't believe their medication is mismanaged. The remaining 8 residents were unable to engage in a clear conversation. On 5/12/2025 and LPA observed R1 Medication Administration Records (MARS) and based on LPA observation it appeared that R1s medications had been administered as prescribed by their physicians. 6 Allegation: Residents are being left unattended for extended periods On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 of 10 staff members stated staff has not left residents unattended for extended periods of time. Staff stated there is no records of residents being changed however residents are checked on every 2-3 hours to ensure their incontinence issues are addressed. LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that they get help when they need it, and the remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were getting incontinence assistance from staff members. 7 Allegation: Staff did not provide adequate food service On 5/12/2025 LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 out of 10 staff members stated the residents are provided adequate food service. LPA observed the residents in care being fed and eating a balanced meal for breakfast -hot cereal, eggs, bacon and toast, Lunch- Baked pork chops, cornbread, mashed potatoes, and mixed veggies. On 5/22/2025 LPA toured the kitchen and observed there to be a 5-day supply of perishables and a 7-day supply of non-perishable food items. Lunch served tuna casserole, green salad, green beans and cornbread,water,juice and coffee. There was a menu available for review that reflected meals served. LPA conducted interviews with Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that they get three (3) meals and snacks daily the remaining 8 residents were unable to engage in a clear conversation. 8 Allegation: Medications are not being stored properly On 5/12/2025 LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), 10 out of 10 staff members stated the medication room is locked when not in use and LPA observed the residents medications to be stored properly in the medication room locked in drawers inaccessible to the residents. LPA also observed the Medication Technicians (MEDTECHS) using their keys to open the medication drawers during the random audit of records. 9 Allegation: Residents are not being changed in a timely manner. On 5/12/2025, LPA conducted interviews with Staff 1 - Staff 10 (S1–S10), Residents 1 - Resident 10 (R1–R10). 10 of 10 staff members stated they have not left residents unattended for extended periods of time. Staff stated there is no records of residents being changed however residents are checked on every 2-3 hours to ensure their incontinence needs are met. Continued.... LPA also attempted to interview Residents 1 – Resident 10 (R1–R10). Of the 10 residents, 2 stated that they get help when they need it, and the remaining 8 residents were unable to engage in a clear conversation. During the tour of the facility, it appeared that residents were getting assistance from staff members addressing their incontinence needs. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Joel Niblett-Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 22, 2025 · control 11-AS-20240719115501

Allegation investigated: Lack of supervision resulting in resident being assaulted by another resident while in care.

On 05/08/2025 at 1:10pm Licensing Program Analyst (LPA) Zina Brown conducted a subsequent complaint visit at this facility to deliver the complaint findings. During today’s visit, LPA met with Marcus Falanai Resident Care Coordinator and the explained the purpose of the visit. The investigation consisted of the following:On 04/03/2025, LPA interviewed Administrator (A1), Staff #1 - Staff #6 (S1 - S6) and Resident #1- #6 (R1 – R6). LPA requested copies of the staff roster (dated 01/31/2025) and resident roster, centrally stored medication record (for R7), Service Plans (for R6 - R7), Physician's Order (List of Medication for R6-R7), LIC 602: Physician Report for RCFE, and LIC 601 Identification and Emergency Information. The investigation revealed the following: Allegation: Lack of supervision resulting in resident being assaulted by another resident while in care. Report continues LIC 9099-C Unsubstantiated On 04/03/2025 between the hours of 12:18pm - 12:28pm, LPA interviewed the Administrator (A1), regarding the above allegation. A1 stated she was unaware of the allegation. On 04/03/2025 between the time of 9:31am - 12:28pm, LPA interviewed Staff # 1 (S1)– Staff 6 (S6) and on 04/23/2025 between the hours of 9:21am – 9:38am, LPA interviewed Staff (7) regarding the allegation. 2 out 7 staff interviewed confirmed an incident occurred between Resident #6 (R6) and Resident #7 (R7), but Staff had different various of the incident that occurred between R6 and R7. 5 out 7 staff interviewed had no knowledge of the incident that occurred between R6 and R7. On 04/03/2025 between the hours 1:17pm - 2:26pm, LPA interviewed Resident #1(R1) – Resident #5 (R5). On 04/03/2025 LPA attempted to interview Resident# 6 (R6) but due to the communication barriers, the resident was unable to answer interview questions. On 04/03/2025 LPA attempted to interview Resident #7 (R7) who declined to be interviewed. 5 out of the 5 residents interviewed were unaware of the incident. On 05/06/2025 between the hours of 2:30pm – 3:30pm, LPA conducted a records review for Resident #7 (R7) records and observed the following: No history of aggravation per the resident’s physicians report (dated 09/29/2023) and need and service plan (dated 10/30/2024) No history and or record of LIC 624: Unusual incident/Injury Report (from December 2024 – April 2025) Based on the information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is unsubstantiated Exit interview conducted with Marcus Falanai Resident Care Coordinator & copy of the report was provided.the state’s words, verbatim · CDSS document, May 8, 2025 · control 11-AS-20250401131451

Allegation investigated: staff do not meet resident's dietary needs. staff do not meet resident's dental hygiene needs. staff do not provide outdoor activities to residents. staff do not provide comfortable accommodations to residents. staff do not provide refunds to responsible parties. staff do not keep the facility in a sanitary condition.

On 04/30/2025 the department conducted a subsequent complaint visit to the facility listed above. LPA met with the administrator Marcus Fulanai and the purpose of today’s visit was explained. LPA was given access to the facility. The investigation consisted of the following: On 12/20/2024 Licensing Program Analyst (LPA) Watson requested, reviewed, and obtained copies of the Staff Roster, Client Roster, and Face Sheets. The department interviewed Staff#1-Staff#4 (S1-S4) and Residents #1-Residients #5 (R1-R5). CONTINUED ON LIC-9099C Unsubstantiated The investigation revealed the following: Allegation: Staff do not meet resident's dietary needs. It is being alleged that staff do not meet residents’ dietary needs. On 12/20/2024 the department conducted interviews with Residents #1- Residents #5 (R1-R5). The department asked the residents if staff did not meet their dietary needs. Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 the department interviewed Staff #1- Staff #4 (S1-S4). The department asked the staff if they did not meet residents’ dietary needs? Of those interviewed, 4 out of 4 staff denied the above allegation. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. Allegation: staff do not meet resident's dental hygiene needs. It is being alleged that staff do not meet residents’ dental hygiene needs. On 12/20/2024 the department conducted interviews with Residents #1- Residents #5 (R1-R5). The department asked the residents if staff did not meet their dental hygiene needs. Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 the department interviewed Staff #1- Staff #4 (S1-S4). The department asked the staff if they did not meet residents’ hygiene needs? Of those interviewed, 4 out of 4 staff denied the above allegation. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not provide outdoor activities to residents. It is being alleged that staff do not provide outdoor activities to residents. On 12/20/2024 the department conducted interviews with Residents #1- Residents #5 (R1-R5). The department asked the residents if staff did not provide outdoor activities to residents. Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 the department interviewed Staff #1- Staff #4 (S1-S4). The department asked the staff if they did not provide outdoor activities to residents? Of those interviewed, 4 out of 4 staff denied the above allegation. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. Allegation: staff do not provide comfortable accommodations to residents. It is being alleged that staff do not provide comfortable accommodations to residents. On 12/20/2024 the department conducted interviews with Residents #1- Residents #5 (R1-R5). The department asked the residents if staff do not provide comfortable accommodations to residents? Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 the department interviewed Staff #1- Staff #4 (S1-S4). The department asked the staff if they do not provide comfortable accommodations to residents? Of those interviewed, 4 out of m4 staff denied the above allegation. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. CONTINUED ON LIC9099-C Allegation: staff do not provide refunds to responsible parties. It is being alleged that staff do not provide refunds to responsible parties. On 12/20/2024 the department conducted interviews with Residents #1- Residents #5 (R1-R5). The department asked the residents if staff do not provide refunds to responsible parties? Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 the department interviewed Staff #1- Staff #4 (S1-S4). The department asked the staff if they do not provide refunds to responsible parties? Of those interviewed, 4 out of m4 staff denied the above allegation. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. Allegation: staff do not keep the facility in a sanitary condition. It is being alleged that staff do not keep the facility in a sanitary condition. On 12/20/2024 the department conducted interviews with Residents #1- Residents #5 (R1-R5). The department asked the residents if staff do not keep the facility in a sanitary condition? Of those interviewed, 5 out of 5 residents denied the above allegation. On 12/20/2024 the department interviewed Staff #1- Staff #4 (S1-S4). The department asked the staff if they do not keep the facility in a sanitary condition? Of those interviewed, 4 out of 4 staff denied the above allegation. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with the Resident Care Coordinator Marcus Fulanai and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2025 · control 11-AS-20241216112039

Allegation investigated: Resident sustained unexplained injuries while in care Staff do not meet a resident's grooming need while in care Staff did not timely address a resident's change in medical condition

On 4/28/25, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Resident Care Coordinator, Marcus Falanai and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 4/28/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA Shirley requested and received copies of the following: Staff Roster, Resident Roster, incident reports for April 2025, reviewed client’s facility files and toured the facility. LPA interviewed Staff 1 – Staff 9 (S1 – S9) and Resident 1 – Resident 7 (R1 - R7). The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Resident sustained unexplained injuries while in care The details of the complaint allege that R1 was observed with bandages on both hands and did not remember what happened or was choosing not to say. LPA Felisa Shirley requested and received copies of all incident reports for April 2025. LPA Shirley observed an Unusual incident/Injury report, stating date occurred 4/18/25. Per interview with S9, R1 was agitated, had a suitcase packed and was trying to leave. LPA interviewed S2 and she stated that R1 was agitated that morning and S2 observed R1 sitting and scratching her wrist and observed that R1 was bleeding. R1’s wristed were treated and wrapped up by S9 and 911 was called and the family was notified. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, has there been any reports of a resident with unexplained injuries. Of those interviewed, 9 out of 9 staff answered no. LPA interviewed Resident-1 thru Resident-7 (R-1 thru R-7). LPA asked, have you reported any unexplained bruises to staff. Of those interviewed, 7 out of 7 answered no. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff do not meet a resident’s grooming need while in care On 4/28/25, LPA Shirley observed R1’s Physician Report dated, 9/1/23. The report stated that R1 has the capacity to groom herself. LPA Shirley reviewed R1’s Service Plan dated, 11/5/24, stating that R1is independent with grooming and would monitor for changes in condition and conduct a reappraisal as appropriate. During file review, LPA observed R1’s Comprehensive Geriatric Assessment dated, 9/14/23, which stated, always well-groomed without assistance, can cut and clean fingernails. LPA Shirley interviewed R1 and she stated that she likes her nails. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff meet residents grooming needs while in care. Of those interviewed, 9 out of 9 staff answered yes. LPA interviewed Resident-1 thru Resident-7 (R-1 thru R-7). LPA asked, does staff meet all of your grooming needs. Of those interviewed, 5 out of 7 answered yes, 1 did not answer and 1 groom themselves. Con'd on 9099-C Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Staff did not timely address a resident’s change in medical condition LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff address change in medical condition in a timely manner. Of those interviewed, 9 out of 9 staff answered yes. LPA interviewed Resident-1 thru Resident-7 (R-1 thru R-7). LPA asked, have you ever been ill and staff did not report your change in condition. Of those interviewed, 6 out of 7 answered no, and 1 did not answer. On 4/18/25, R1 had bandages on her wrist. S9 was notified by S2 and S8 that R1 was bleeding. S2 observed R1 sitting and scratching herself with her nails. R1 was treated by S9, 911 was called and the family was notified. Per S9, the paramedics rebandaged the wound with the original bandages and did not take R1. The family arrived later and took R1 to the hospital. LPA observed the unusual incident/injury report which stated in the comments area, will have a meeting with family about updated service plan. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Regarding the allegations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies were cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Resident Care Coordinator, Marcus Falanai.the state’s words, verbatim · CDSS document, Apr 28, 2025 · control 11-AS-20250418155530

Type of visit: Case Management - Deficiencies

On 04/03/2025 at 9:22am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced case management deficiencies. The purpose of the visit is to issue a citation observed during the complaint investigation - Control 11-AS-20250401131451. During the complaint investigation, LPA learned of an incident that occurred around December 2024 - January 2025. The facility failed to report the incident as required. Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. Exit interview conducted with Marcus Falanai Resident Care Coordinator and copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Apr 3, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 7, 2025

Each licensee shall submit serious incident reports to the licensing agency such as the Department may require, including the following: (1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence of any of the eventsthe state’s words, verbatim · CDSS document, Apr 3, 2025

Plan of correction: The facility need submit a serious incident report of the incident that occurred with Resident #6 & Resident #7. Also facility need to review Title 22 Regulations for Reporting Requirements and self certify that all staff read Title 22 Regulations.

Allegation investigated: Staff mismanaged resident's medication.

On February 19, 2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) conducted a subsequent, unannounced complaint visit. The Resident Service Coordinator Marcus Falanai greeted the Department. The Department explained that the purpose of this visit was to investigate the allegation mentioned above. The investigation included interviews, collection of records and tour of the facility. Interviews were conducted with staff members #1 to #5 (S1-S5), resident members #1-#6 (R1-R6), and witness #1-#6 (W1-W6). The Department reviewed several documents, including the Personnel Report LIC 500, the Resident Roster, Resident #1 (R1)'s Face Sheet; Identification and Emergency Information; Service Plan; Resident Assessment; Preplacement Appraisal Information; Admissions Agreement; Physicians Report; Los Alamitos Medical Center Medical Records, Home Health Plus Service Medical Records, and other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #4: Staff mismanaged resident's medication. The complaint detailed allegation of mismanagement regarding Resident #1's (R1's) medications by the staff. It has been reported that the facility issued pain medications and antifungal cream that were not authorized by R1's primary physician. Additionally, the facility authorized refills for medications from R1's former primary physician instead of the current physician. On November 2, 2024, R1 was admitted to the hospital, where it became evident that the facility had failed to administer necessary diabetic medications. This oversight raised significant concerns, especially since R1's blood glucose levels were not being consistently monitored, which is critical for effective diabetes management. On November 2, 2024, R1 was admitted to Los Alamitos Medical Center for altered mental status caused by low blood sugar. An Unusual Incident Report from November 6, 2024, noted that R1 was feeling lightheaded in the dining area at 8:30 PM, just moments before the observation. On January 10, 2025, between 9:15 AM and 10:20 AM, the Department interviewed five staff members (Staff #1 through Staff #5). All of them acknowledged that Resident #1 (R1) had been hospitalized due to general weakness. Staff #2 (S2) claimed that no one from the hospital inquired about R1's diabetic diagnosis. S2 was uncertain whether there had been any miscommunication regarding R1's prescribed medications with the pharmacy. Staff members S2 through S5 were aware that R1 had been receiving diabetic medications daily since their admission to the facility. They indicated that R1 was only receiving medications prescribed by R1's physician. Staff members S3 through S5 stated that the medication technicians were responsible for monitoring R1's blood glucose levels and that there should be a chart log documenting the daily results. However, Staff #1 (S1) claimed that R1’s service plan did not include care staff to monitor R1’s blood glucose levels. On February 13, 2025, between 3:00 PM and 5:00 PM, the Department interviewed five family representatives (Witness #1 through Witness #5) regarding the allegation. One out of the five witnesses reported some discrepancies with medications being refilled, discontinued, or continued to be administered. Evaluation Report continues LIC 9099-C INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Facility staff did not safeguard resident’s personal items. The complaint alleged that the facility failed to safeguard the personal items of Resident #1 (R1). It was reported that R1's tooth retainer and hearing aids went missing, for which the facility has since provided reimbursement. However, R1's wheelchair, which was labeled with R1's name, also went missing and was replaced with a wheelchair that did not belong to R1. No further details were provided about this issue. On January 30, 2025, between 9:35 AM and 11:50 AM, the Department interviewed five staff members, identified as Staff #1 through Staff #5, regarding the allegation. Staff #1 and Staff #2 (S1 and S2) confirmed that the facility reimbursed R1 for the retainer and hearing aids. Staff #2, along with Staff #3 to Staff #5 (S3 to S5), claimed they had never seen R1 with a personalized manual wheelchair. Rather, they mentioned observing R1 with multiple wheelchairs in R1's room. Staff #5 described R1 using a walker-wheelchair combination, while Staff #2 to Staff #4 described a regular manual wheelchair. Staff #2 stated that all personal items belonging to R1 were documented on a Facility Resident Inventory List and disputed the existence of a personalized wheelchair for R1, asserting that it was never listed on R1's inventory and should have been identified by a serial number. On February 13, 2025, between 3:00 PM and 5:00 PM, the Department interviewed five family representatives, identified as Witness #1 through Witness #5, regarding the allegation. All five witnesses (W1 to W5) could not corroborate the claim, stating personal items were never reported missing or lost. They confirmed that residents completed an individual property and valuables inventory list upon admission. On February 19, 2025, between 9:00 AM and 11:00 AM, the Department interviewed five residents, identified as Resident #2 through Resident #6, regarding the allegation. All five residents indicated that they had not experienced any missing or lost items while in care at this facility. A review of R1's service records included an Inventory of Personal Effects dated January 25, 2019, which listed 19 items, including a walker wheelchair, but did not provide a serial number for description. Based on the information gathered, there is insufficient evidence to support the stated allegation. Evaluation Report continues LIC 9099-C Allegation #2: Staff did not ensure that resident's dental hygiene was met. The complaint stated that the facility staff did not ensure that Resident #1 (R1) received adequate dental hygiene. It was reported that R1 had not received brushing and cleaning for four or five months. Additionally, it was noted that the staff was unaware that R1 had a partial front tooth retainer, which had not been removed for cleaning. No further details were provided regarding this issue. On January 30, 2025, between 9:35 AM and 11:50 AM, the Department interviewed four staff members (Staff #2 to Staff #5) regarding the allegation. They indicated that R1 was assisted daily with dental hygiene. Staff members S3 and S4, who were the primary caregivers for R1, explained that R1 preferred to perform hygiene care independently but received assistance from staff through verbal cues or contact guard support. Staff members (S2 to S5) were unaware that R1 had partial retainers, only learning of this information years later. (S2) reported that R1 had been receiving home health services from August to November 2024, with weekly visits from home health staff for healthcare services. On February 13, 2025, between 3:00 PM and 5:00 PM, the Department interviewed five family representatives (Witness #1 to Witness #5) regarding the allegation. All five witnesses stated they could not support the claim, asserting that residents had never faced any oral hygiene issues or concerns. On February 19, 2025, between 9:00 AM and 11:00 AM, the Department interviewed five residents (Resident #2 to Resident #6) about the allegation. All five residents indicated that they had not experienced any issues with their oral hygiene care. Three out of five stated they received daily assistance from care staff, while the other two preferred to manage their oral hygiene independently. On February 2, 2025, between 12:02 PM and 12:29 PM, the Department interviewed the Case Manager at Home Health Plus, identified as Witness #6. They explained that R1 was receiving home health care services with weekly visits from a Licensed Vocational Nurse (LVN), although these visits did not include grooming or dental care. A review of R1's Physician's Report (LIC 602A) dated January 24, 2019; January 11, 2020; January 27, 2021; and January 19, 2022; as well as the Facility Service Plan dated November 6, 2024; and the Preplacement Appraisal Information dated January 25, 2019, revealed that R1 required assistance with personal hygiene. Medical assessment reports indicated that R1 did not have dentures or retainers until 2022. The facility decisively failed to maintain progress notes for Resident #1, resulting in a significant gap in their care documentation. Based on the information gathered, there is insufficient evidence to support the stated allegation. Evaluation Report continues LIC 9099-C Allegation #3: Staff did not ensure that resident was adequately fed. The complaint states that the staff did not ensure that Resident #1 (R1) is adequately fed. It is reported that R1 lacked nutrition due to not eating enough, which is attributed to R1's recent hospitalization. Further reports indicated that after hospitalization, the physician ordered R1 to be given Ensure drink supplement twice daily. However, an inventory surplus showed that this was not carried out according to the doctor's orders. Los Alamitos Medical Center Medical Records indicated that on November 2, 2024, R1 was hospitalized with altered mental status due to hypoglycemia. An Unusual Incident Report dated November 6, 2024, noted that R1 was observed at 8:30 PM on November 2, 2024, in the dining area, feeling lightheaded just minutes before. On January 10, 2025, between 9:15 AM and 10:20 AM, the Department interviewed five staff members (Staff #1 - Staff #5). None of them could corroborate the complaint. They stated that R1 was on a mechanical soft diet and received three meals and snacks in between. According to Staff #1 to Staff #5, the nutritional drink Ensure was provided to R1 twice daily, as prescribed by the physician after hospitalization. Staff #2 reported that R1 was under home health services, receiving weekly visits from a Licensed Vocational Nurse (LVN), and there were no concerns regarding R1's nutrition. Staff #3 and Staff #4 indicated that the meals served to residents meet health standards, are of good quality, and provide adequate portions. They further noted that the facility offers meal substitutes and can accommodate residents with special dietary restrictions. They observed that R1 was a "light eater" who consumed smaller portions of food. On February 13, 2025, between 3:00 PM and 5:00 PM, the Department interviewed five family representatives (Witness #1 – Witness #5) regarding the allegation. All five witnesses attested that the residents enjoyed an ample selection of nutritious meals that fully met their dietary requirements. They reported no concerns whatsoever regarding the quality or appropriateness of the food provided. On February 19, 2025, from 9:00 AM to 11:00 AM, the Department interviewed five residents (Resident #2 - Resident #6) about the allegation. Evaluation Report continues LIC 9099-C They expressed that they had no issues with the meals provided, stating that the portions were sufficient and that there was no shortage of food, including ample snacks. On February 2, 2025, between 12:02 PM and 12:29 PM, the Department interviewed the Case Manager at Home Health Plus (Witness #6). The witness confirmed that there were no notable medical concerns regarding R1's nutritional status. (W6) elaborated that R1 was currently taking a variety of multivitamins, along with prescribed medications, which could potentially diminish appetite. The Department reviewed R1's Physician's Report (LIC 602A) dated January 24, 2019, January 11, 2020, January 27, 2021, and January 19, 2022; the Facility Service Plan dated November 6, 2024; and the Preplacement Appraisal Information dated January 25, 2019. These documents revealed that R1 can self-feed and is on a mechanical soft diet. Records from Home Health Plus Services dated August 13, 2024, through November 2, 2024, showed no observations of R1 being undernourished. R1 is prescribed 18 medications and nine out of 18 had side effects for causes of loss appetite (ref: National Institute of Health). Based on the gathered information, there is insufficient evidence to support the stated allegation. The Department could not conduct an interview with Resident #1 because R1 was unwilling to participate. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are deemed unsubstantiated. An exit interview was conducted with Marcus Falanai, and copies of the reports were provided. All five witnesses concurred that the facility faced significant communication challenges with the authorized parties involved. On February 19, 2025, from 9:00 AM to 11:00 AM, the Department interviewed five residents (Resident #2 through Resident #6) about the same allegation. The residents collectively stated that they had no issues with their medications and that medications were being administered in a timely manner as prescribed. On February 2, 2025, between 12:02 PM and 12:29 PM, the Department interviewed the Case Manager at Home Health Plus (Witness #6). This witness indicated that the LVN nurse was aware of Resident #1's prescribed medications and followed the physician's orders. Witness #6 stated that there were no issues with the facility's administration of medications and that the care staff was monitoring Resident #1’s glucose levels. According to this witness, the LVN nurse it was not needed to monitor during visits since the facility staff had already completed the necessary procedures. An examination of R1's medical documentation, including the Physician's Reports (LIC 602A) dated January 24, 2019, January 11, 2020, January 27, 2021, and January 19, 2022, along with the Facility Service Plan dated November 6, 2024, and Preplacement Appraisal Information from January 25, 2019, was conducted. Additional records from Los Alamitos Medical Center covering the period from November 2, 2024, to November 5, 2024, were also reviewed. Noteworthy documents included an Incident Report LIC 624 dated November 6, 2024, Physicians’ Medication Orders spanning from January 26, 2019, to December 2, 2021, a Medication Administration Record from January 26, 2019, to March 1, 2019, and further Physicians’ Medication Orders dated January 17, 2024, along with the Residential Admission Agreement dated January 25, 2019. The analysis revealed that R1 is diagnosed with a range of diabetic health issues, necessitating careful management. Since admission in 2019, R1 has been consistently prescribed diabetic medications, specifically "Glipizide 5mg & 10mg," to be taken twice daily. However, it was concerning to note that the service care plan did not incorporate any monitoring for blood glucose levels, which is critical for effective diabetes management. A significant deficiency in record-keeping was identified, as vital Medication Administration Records (MAR) were absent for the entire duration from 2020 through 2024. Evaluation Report continues LIC 9099-C Furthermore, R1 had been prescribed PRN (as needed) medications, yet there were no accompanying (MAR) Physician Medication Orders recorded for the years 2022 and 2023. There were no detailed charts available to monitor the ups and downs of blood sugar levels, which raises significant concerns about proper care. Furthermore, the absence of staff notes, or progress reports left important gaps in R1’s care documentation, making it difficult to understand their health changes over time. The Department could not conduct an interview with Resident #1 because R1 was unwilling to participate. Based on observations, interviews, and record reviews, there is substantial evidence indicating that "Neglect and Lack of Care and Supervision" has been substantiated. This finding is cited under California Code of Regulations, Title 22, Division 6, Chapter 8, as noted on the attached LIC 9099-D. An exit interview was conducted with Marcus Falanai, the Resident Care Coordinator, during which a hard copy of the report and information on appeal rights was provided.the state’s words, verbatim · CDSS document, Feb 19, 2025 · control 11-AS-20250124134130

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 11, 2025

87465(a)(4) Incidental Medical and Dental Care 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... When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observations and a review of records, the licensee failed to comply with the aforementioned section. The LPA observed inconsistencies and gaps in the medication administration records, which posed a potential risk to the health, safety, or personal rights of the individuals in care.the state’s words, verbatim · CDSS document, Feb 19, 2025

Plan of correction: The licensee will ensure that facility staff consistently use medication administration records (MARs) accurately. As part of the correction plan, a retraining program will be implemented to reinforce proper documentation procedures. Proof of this training will be submitted to the License Program Analyst (LPA) before the deadline for the plan of correction (POC). *CIVIL PENALTY ISSUED*

Allegation investigated: Staff do not report incidents to residents' responsible parties.

On 12/31/24 the department conducted a subsequent complaint visit regarding the allegations above. LPA met with Resident care coordinator Marcus Falanai as the purpose of the visit was explained. The investigation consisted of the following: On 07/31/2024 at 9:30 am Licensing Program Analyst (LPA), David España conducted an initial complaint visit. On 07/31/2024 as part of the LPA España investigation, LPA requested documents for Resident #1-#6 (R1-R6), Staff #1-#6 (S1-S6), and a staff and resident roster. On 12/04/24 LPA Villegas obtain copies of the staff and resident rosters, and between 9:30am-1pm LPA conducted interviews with residents #3-5 (R3-R5), Staff #1 (S1), and Witness#1 (W1). On 07/31/2024 as part of the LPA España interviewed staff 5-7 (s5-s7) . On 12/19/24 between 9:30am-11:30 am LPA Villegas conducted interviews with S2-S4. On 12/31/24 LPA Villegas conducted a medication review for 4 residents, and a review of trainings for 3 caregivers, and 3 med-techs. The investigation revealed the following: Unsubstantiated Allegation: Staff do not report incidents to residents' responsible parties. It is being alleged that the facility consistently fails to report fall incident or notify families of their loved ones' deteriorating conditions. On 12/04/24 between 9:30am-1pm LPA conducted interviews with (R3-R5) regarding the allegation above, 3 of 3 residents interviewed denied the allegation and denied experiencing a fall or injury while in care. On 12/04/24 LPA Villegas was unable to interview R1 as R1 is no longer receiving care at Brittany House. On 12/04/24 LPA conducted over the phone interview with POA for R1, per POA facility did notify POA of fall as R1 was being transported to hospital by ambulance. On 12/04/24 LPA Villegas was unable to interview R2 due to communication barrios. On 12/04/24 LPA interviewed S1 regarding the allegation above, 1 of 1 staff interviewed denied the allegation above and reported S1 will review the written report before faxing it to CCLD and obtaining a fax confirmation number. On 07/31/2024 and 12/19/24 between 9:30am-11:30 am LPA Villegas interviewed S2-S7 regarding the allegation above, 3 of 6 staff interviewed denied the allegation above and reported documenting when responsible parties are notified in the communication folder, 3 of 6 staff interviewed stated being unaware of the reporting procedures are after incidents are reported to the med room staff on shift. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided. Allegation: Staff do not administer medications as prescribed. It is being alleged medications are frequently administered late or improperly. On 12/04/24 LPA Villegas interviewed S1 regarding the allegation above, 1 of 1 staff interviewed denied the allegation above and reported documenting if there is a medication error. On 07/31/2024 and 12/19/24 between 9:30am-11:30 am LPAs Espana and LPA Villegas interviewed S2-S7 regarding the allegation above 3 of 6 staff denied the allegation above, 3 of 6 staff interviewed reported they do not assist with medication therefore are unaware of the medication administration process. On 12/04/24 between 9:30am-1pm LPA conducted interviews with (R3-R5) regarding the allegation above, 2 of 3 residents interviewed denied the allegation above, 1 of 3 residents interviewed reported not taking any medications. On 12/04/24 LPA Villegas was unable to interview R1 as R1 is no longer receiving care at Brittany House. On 12/04/24 LPA conducted over the phone interview with POA for R1, per POA facility did not administer antibiotics are prescribed to R1. On 12/04/24 LPA Villegas was unable to interview R2 due to communication barrios. On 12/31/24 at 11:30am LPA Villegas conducted review of MAR for 4 residents, LPA Villegas observed that the MARs weren’t checked off and observed med tech was checking off meds that were passed during the AM during the review. On 12/31/24 1 of 7 overall staff interviewed disclosed medications errors are currently being worked on in order to correct discrepancies previously cites by LPA Brown on 12/10/24 and LPA Iniguez on 12/16/24. Allegation: Staff are not properly trained. It is being alleged that the facility has staff members who fail to complete mandatory annual training. On 12/04/24 LPA Villegas interviewed S1 regarding the allegation above, 1 of 1 staff interviewed denied the allegation above and reported training is ongoing. On 07/31/2024 and 12/19/24 between 9:30am-11:30 am LPA Villegas interviewed S2-S7 regarding the allegation above, 1 of 3 staff denied the allegation above and reported shadowing for 2 weeks, 1 staff reported shadowing for 1 week, 1 staff reporting not having much training, and 3 of 6 staff reported training is upon hire with in-services as needed. On 12/04/24 between 9:30am-1pm LPA Villegas conducted interviews with (R3-R5) regarding the allegation above, 3 of 3 residents interviewed denied the allegation above and reported feeling safe when assisted by staff. On 12/04/24 LPA Villegas was unable to interview R1 as R1 is no longer receiving care at Brittany House. On 12/04/24 LPA conducted over the phone interview with POA for R1, per POA all the “good caregivers” are no longer employed at the facility. On 12/04/24 LPA Villegas was unable to interview R2 due to communication barrios. On 12/31/24 LPA Villegas conducted a review of training records for 3 caregivers and observed completed required trainings in the personnel file. On 12/31/24 LPA requested copies of training for 3 meds techs however, LPA was not provide with training and was informed there is not documented training's for med techs on file. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8)are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 31, 2024 · control 11-AS-20240725125526

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6)(A-H) · Plan of correction due date: Jan 14, 2025

87465 Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored: The licensee shall be responsible for assuring that a record of centrally stored prescription medications.... The name of the resident for whom.... Based on interviews and record reviews, the licensee and Administrator did not comply with the section cited above as medications passes were not properly documeted which is a potential a potentila health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Dec 31, 2024

Plan of correction: Licesee and Administrator will develope a plan detailing how the facility will ensure all medications are properly administered and documented. Plan to be submitted to LPA by POC due date. Lizeth.villegas@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c)(1-2) · Plan of correction due date: Jan 14, 2025

87412 personnel records Licensees shall maintain in the personnel records verification of required staff training and orientation. The following staff training and orientation shall be documented: For staff who assist with personal activities of daily living.... Based on interviews and record reviews, the licensee and Administrator did not comply with the section cited above as there was no documentation confirming Staff 5-7 have obtained and passed required training(s).the state’s words, verbatim · CDSS document, Dec 31, 2024

Plan of correction: Licesee and Administrator will enure all staff have required training by an appropriate skilled professional and provide the department with training sign in sheets, and instructures contact info and crendials by POC due date. LPA provided a copy of section 87412 for refrence.

Allegation investigated: Residents are forced to using facility's medical care provider. Facility does not appropriately provided enough staff to meet the residents' needs. Staff falsify records.

On 12/19/24 at 9am the department conducted a subsequent complaint visit regarding the allegations above. LPA met with (S1) Marcuc Falanai as the purpose of the visit was explained. The investigation consisted of the following: On 07/31/2024 at 9:30 am Licensing Program Analyst (LPA), David España conducted an initial complaint visit. On 07/31/2024 as part of the LPA España investigation, LPA requested documents for Resident #1-#6 (R1-R6), Staff #1-#6 (S1-S6), and a staff and resident roster. On 12/04/24 LPA Villegas obtain copies of the staff and resident rosters, and between 9:30am-1pm LPA conducted interviews with residents #3-5 (R3-R5), Staff #1 (S1), and Witness#1 (W1). On 12/19/24 LPA Villegas conducted a tour of the facility, there were no immediate health or safety concerns. On 12/19/24 between 9:30am-11:30 am LPA Villegas conducted interviews with S2-S4. The investigation revealed the following: Unsubstantiated Allegation: Residents are forced to using facility's medical care provider. It is being alleged that residents are denied their right to choose healthcare providers and are being compelled to use a preferred agency contracted by the licensee. On 12/4/24 between 9:30am-1pm LPA conducted interviews with (R3-R5) regarding the allegation above, 1 of 3 residents interviewed confirmed the allegation above, 2 of 3 residents interviewed reported having no recollection if they were provided with options upon admission. On 12/4/24 LPA Villegas was unable to interview R1 as R1 is no longer receiving care at Brittany House, On 12/4/24 LPA Villegas was unable to interview R2 due to communication barrios. 12/4/24 LPA interviewed S1 regarding the allegation above, 1 of 1 staff interviewed denied the allegation above and reported that some residents come in with a medical provider and report wanting to keep them and if not, the facility has a lot of pamphlets for medical providers, home health and hospice agencies to chose from. On 12/19/24 between 9:30am-11:30 am LPA Villegas LPA interviewed S2-S4, regarding the allegation above, 3 of 3 staff interviewed denied the allegation above and reported having no knowledge of the admission process. Allegation: Facility does not appropriately provide enough staff to meet the residents' needs. It is being alleged that the turnover rate among staff is high. On 12/4/24 between 9:30am-1pm LPA conducted interviews with (R3-R5) regarding the allegation above, 1 of 3 residents denied the allegation above, 2 of 3 residents interviewed reported the facility is short staff at times. On 12/4/24 LPA Villegas was unable to interview R1 as R1 is no longer receiving care at Brittany House, On 12/4/24 LPA Villegas was unable to interview R2 due to communication barrios. 12/4/24 LPA interviewed S1 regarding the allegation above, 1 of 1 staff interviewed denied the allegation above and reported that there are 7 caregivers per shift. On 12/4/24 LPA conducted a review of the staff roster and per staff roster, there are (11) caregivers scheduled between 6:30am-5pm, (2) med techs scheduled between 6:30 am-2:30pm, (6) caregivers scheduled between 2:30pm--10:30pm, (1) LVN scheduled between 2:30pm--10:30pm, (2) caregivers scheduled between 10:30pm- 6:30am. On 12/19/24 between 9:30am-11:30 am LPA Villegas LPA interviewed S2-S4, regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. Allegation: Staff falsify records. It is being alleged that the facility is attempting to modify physician's report to remove a dementia diagnosis to facilitate transfer to assisted living. On 12/4/24 between 9:30am-1pm LPA conducted interviews with (R3-R5) regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. On 12/4/24 LPA Villegas was unable to interview R1 as R1 is no longer receiving care at Brittany House, On 12/4/24 LPA Villegas was unable to interview R2 due to communication barrios. On 12/4/24 LPA interviewed S1 regarding the allegation above, 1 of 1 staff interviewed denied the allegation above and reported that if the allegation above was observed it would be report to supervisor for further investigation. On 12/19/24 between 9:30am-11:30 am LPA Villegas LPA interviewed S2-S4, regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 11-AS-20240725125526

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: Staff did not dispense resident’s medication as prescribed.

On 12/16/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Mandy Taylor/ Executive Director. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (S#1-S#4) and Resident’s interviews (R#1-R#5). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#5) Identification and Emergency Information, (R#1-R#5) Physicians Assessment or LIC 602A, (R#1-R#5) Inventory List or LIC 621, (R#1-R#5) Medication Administration Record (MARs) from October, November, and December 2024… Evaluation Report continues LIC 9099-C Substantiated Evaluation Report continues LIC 9099-C Allegation: Staff did not dispense resident’s medication as prescribed. The details of the complaint alleged that facility staff is not dispensing residents’ medications as prescribed by their physician. During the records review, LPA Iniguez reviewed (R#1-R#5) Medication Administration Records (MARs) from October through November 2024; LPA Iniguez observed discrepancies During the records review, LPA Iniguez examined the Medication Administration Records (MARs) for residents (R#1-R#5) from October to November 2024. LPA Iniguez identified discrepancies in the medication documentation for all five residents.in all (5) residents' medication documentation. In addition, LPA reviewed (R#1-R#5) Physicians assessment or LIC 602A, LPA noted that all (5) residents are not able to administer their own medications. During this investigation, LPA found sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D. ) An exit interview was conducted, and a copy of the Complaint Report was given to Mandy Taylor/Executive Director. Investigation Revealed the Following: Allegation: Staff spoke to resident in an inappropriate manner. The details of the complaint alleged that facility staff spoke to a resident in care in an inappropriate manner. During an interview with the administrator (A#1), she and other facility staff never spoke inappropriately to a resident in care. Also, (A#1) stated that facility staff, including her, treat residents with dignity and respect. During interviews with residents (R#1-R#5), (4) out of (5) stated that they have never spoken inappropriately. During interviews with staff (S#1-S#4), (4) out (4) stated that they have never inappropriately spoken to residents in care and they treat all residents with dignity and respect. Allegation: Staff did not allow resident to have private phone calls. The details of the complaint alleged that facility staff is not allowing residents in care to have private phone calls. During a health and safety check of the facility, LPA Iniguez observed that the telephone is located in one of the common areas. The place has the ability to close the door for more private conversations. During an Interview with the Administrator (A#1), she stated that the residents can make and receive private phone calls, and she and the facility staff have never listened to their private conversations. During interviews with residents (R#1-R#5), (4) out of (5) stated that they can have private phone call conversations. Evaluation Report continues LIC 9099-C During interviews with staff (S#1-S#4), (4) out of (4) stated that the residents are able to have private phone conversations, and they have never been listed to them. Allegation: Staff did not safeguard resident's personal belongings. The details of the complaint alleged that facility staff is throwing away resident’s personal belongings. During the records review, LPA Iniguez reviewed (R#1) 's Client/Resident's Personal Property and Valuables or LIC 621; LPA observed that (R#1) refused to have their personal belongings listed. In addition, LPA reviewed (R#1) 's Physicians Assessment or LIC 602A dated 11/3/2024; LPA noted that it is listed that (R#1) has a cognitive impairment. Moreover, LPA observed that (R#2-R#5) had their inventory list on file. During an Interview with the Administrator (A#1), she stated that the facility is safeguarding residents' belongings and is not throwing them away. During interviews with residents (R#1-R#5), (4) out of (5) stated that the facility is safeguarding their personal belongings. During interviews with staff (S#1-S#4), (4) out (4) stated that the facility is safeguarding residents' belongings and is not throwing them away. Allegation: Staff did not provide resident with prescribed medical garment. The details of the complaint alleged that facility staff is not providing prescribed medical garment to resident in care. During the records review, LPA Iniguez reviewed (R#1)’s medical file, and there was no doctor’s order for a medical garment. Evaluation Report continues LIC 9099-C During an Interview with the Administrator (A#1), she stated that they provide prescribed medical garments if a medical order (R#1) does not have one on file. During interviews with residents (R#1-R#5), (4) out of (5) stated that the facility provides the items prescribed by their physician. Allegation: Staff did not ensure facility floors were maintained in clean condition. The details of the complaint alleged that facility is not clean and sanitary. During a health and safety check of the facility, LPA Iniguez observed that it was clean and sanitary. During an Interview with the Administrator (A#1), she stated that the facility is clean and sanitary. During interviews with residents (R#1-R#5), (4) out of (5) stated that the facility is clean and sanitary. During interviews with staff (S#1-S#4), (4) out (4) stated that the facility is clean and sanitary. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Mandy Taylor / Executive Director.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 11-AS-20241209150447

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 30, 2024

87465(a)(4) Incidental Medical and Dental Care 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: When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as during medication reviews, LPA observed discrepancies in all 5 residents medication administration records which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: Licensee will ensure facility staff use correctly medication administrator records at all time. As plan of correction, licensee will re-train facility staff on the importance on how to document properly on the resident's MARs. proof of training will be sent to LPA before POC due date.

Allegation investigated: Staff did not post notice for residents council meetings

*This finding supersedes the findings written on 10/31/24. On 12/16/24, Licensing Program Analyst, (LPA) Felisa Shirley conducted a subsequent unannounced visit to this facility. LPA was met by Administrator, Mandy Taylor and explained the purpose of the visit is to deliver amended findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 10/31/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA Shirley requested and received copies of the following: Staff Roster, Resident Roster, Activity schedules, and reviewed client’s facility files and admission agreements. The investigation revealed the following: Con'd on 9099-C Substantiated Allegation: Staff did not post notice for resident council meetings On 10/31/24, LPA Shirley reviewed facilities activity board and observed that there is no Resident Council information, meeting dates nor locations. LPA Shirley interviewed facility Administrator, Mandy Taylor and learned that this facility formerly only focused on Memory Care and just recently began offering services in July of 2024 to residents for Assisted Living. LPA Shirley spoke with the Activities Director who is new to the position who stated that she is in the process of curating a calendar of events, which includes a Resident Council. The Activities Director stated that she will meet with residents and inform them that they have a right to form a committee. Resident Councils meetings are not posted as Brittany House does not have a Resident Council. There should’ve already been a Resident Council in place. LPA Shirley interviewed staff-1 thru staff-7 (S-1 thru S-7). LPA asked, does staff post notices for Resident Council meetings? Of those interviewed, 6 out of 7 answered no. One employee stated that they did not know. LPA interviewed Client-1 thru Client-6 (C-1 thru C-6). LPA asked, does staff post notices for Resident Council meetings?” Of those interviewed, 6 out of 6 did not know anything about the Resident Counsel. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. An exit interview was conducted, and a copy of this report was provided to Receptionist, Stephanie Rubio.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 11-AS-20241022210327

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87221 · Plan of correction due date: Dec 30, 2024

87221 Resident Councils The facility shall permit the formation of a resident council by interested residents, provide space and post notice for meetings, and provide assistance in attending meetings for those residents who request it. In order to permit a free exchange of ideas, at least part of each meeting shall be allowed to be conducted without the presence of any facility personnel. Residents shall be encouraged, but shall not be compelled to attend. The purpose of such an organization shall be to work with the administration in improving the quality of life for all residents by enriching the activity program and to discuss the services offered by the facility and make recommendations regarding identified problems. This requirement was not met as evidenced by: Based on interviews and record reviews, facility staff did not assist residents in the formation of a resident council. This poses a possible personal rights violation to all residents in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: Please provide provide proof that there is a Resident Council in place by Plan of Correction date of 12/30/24. Please send to LPA Felisa Shirley at felisa.shirley@dss.ca.gov or fax to 424-544-1016 by POC date.

Type of visit: Required - 1 Year

On 12/10/2024 at 8:18am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection (due February 2025). LPA met with Marcus Falanai, Resident Care Coordinator and the purpose of the visit was discussed. Facility is licensed to serve age range 60 and over which is approved for 170 non-ambulatory of which 24 may be bedridden (bedroom 301 - 303, 307 - 308, 311-314 may have 2 bedridden) and bedroom #304-306 and 309 may have 1 bedridden only with a waiver granted for hospice care for ten (10). There are (50) residents are diagnosed with dementia, (9) residents receiving home health, (10) residents receiving hospice care services and (1) resident receiving palliative care. The last fire inspection was completed on 05/08/2024. The facility does not handle any of the residents’ money. The facility annual fee is $$2,311.00 which is due on 02/09/2025. LPA provided pin #773699 if facility choose to make facility annual payment online. The facility a single story building consisting of: (142) resident bedrooms, (43) Full bathrooms, kitchen, (4) dining area, laundry room, medication room and (10) outdoor shaded patio areas. LPA toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 108.0F -112.3.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Report continues on LIC 809-C A review of (10) residents service files, (10) staff personnel files and (10) Medication Administration Records (MAR) and did observe discrepancies at the time of visit. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. -Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8); LPA observed the following deficiencies: On 12/10/2024 at 1:45 pm while LPA was conducting a tour of the physical plant, LPA reviewed and observed: 4 out 10 staff (Staff #1, Staff #4 - Staff #6) with no CPR/First Aid Certification. 8 out of 10 staff did not have a LIC 503 Health Screening with TB Test results. 10 out of 10 residents medication was not listed on the MAR, empty and or not check off by staff on consecutive days. LPA conducted a file review of the 5 out of 10 residents files and did not observe an Needs and Services Plan within 30 days after admission date. An exit interview was conducted, and a copy of Report and Appeal Rights provided.the state’s words, verbatim · CDSS document, Dec 10, 2024

Allegation investigated: Staff are not properly reporting incidents involving the residents.

On 11/06/24, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted an initial complaint visit to the facility and was greeted by Mandy Taylor, Executive Director, and Marcus Falanai, Service Coordinator. LPA explained the purpose of this visit is to conduct interviews, gather facility files, and render findings in the complaint. The investigation consisted of the following: LPA investigated the allegation mentioned in this complaint and conducted interviews with staff (S1-S8). Additionally, LPA obtained the following documents: Resident Roster (No Date), Staff Roster (Dated: 10/28/2024), and Incident Reports (Dated: 09/14/24, 09/16/24, 10/14/24, 10/15/24, 10/18/24, 10/21/24, 10/22/24, 10/28/24, 11/6/24) from the facility. The investigation revealed the following: Staff are not properly reporting incidents involving the residents. The details of the complaint alleged that the facility does not send in incident reports for residents when they are injured or pass away at the facility. Complaint Investigation Report Continued on LIC9099-C Unsubstantiated On 11/06/24, from 09:20am-2:00pm, LPA interviewed staff (S1-S8) regarding the allegation. 8 of 8 staff (S1- S8) denied the allegation that the facility Staff are not properly reporting incidents involving the residents. All staff (S1-S8) stated that the facility does send in timely incident reports. S1 stated that since S1 has been in charge, the facility has sent in all reports involving a death or an injury. Staff (S3-S8) further state that when an injury or death occurs, they alert the med-Techs, caregivers, and the nurses and they either report it to the hospice agency, the family, call 911 and then write an incident report. The department reviewed the Incident reports for the residents dated 09/14/24, 09/16/24, 10/14/24, 10/15/24, 10/18/24, 10/21/24, 10/22/24, 10/28/24, and 11/6/24 for the residents and did not observe any discrepancies in the reports or when they were sent. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff are not properly reporting incidents involving the residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued for this complaint. An exit interview was conducted with Marcus Falanai, Service Coordinator, and a copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Nov 6, 2024 · control 11-AS-20241031111836

Allegation investigated: Staff did not post notice for residents council meetings

On 10/31/24, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Administrator, Mandy Taylor and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 10/31/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA Shirley requested and received copies of the following: Staff Roster, Resident Roster, Activity schedules, and reviewed client’s facility files and admission agreements. The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Staff did not post notice for resident council meetings On 10/30/24, LPA Shirley reviewed facilities activity board and observed that there is no Resident Council information, meeting dates nor locations. LPA Shirley interviewed facility Administrator, Mandy Taylor and learned that this facility formerly only focused on Memory Care and just recently began offering services in July of 2024 to residents for Assisted Living. LPA Shirley spoke with the Activities Director who is new to the position who stated that she is in the process of curating a calendar of events, which includes a Resident Council. The Activities Director stated that she will meet with residents and inform them that they have a right to form a committee. Resident Councils meetings are not posted as Brittany House does not have a Resident Council. LPA Shirley interviewed staff-1 thru staff-7 (S-1 thru S-7). LPA asked, does staff post notices for Resident Council meetings? Of those interviewed, 6 out of 7 answered no. One employee stated that they did not know. LPA interviewed Client-1 thru Client-6 (C-1 thru C-6). LPA asked, does staff post notices for Resident Council meetings?” Of those interviewed, 6 out of 6 did not know anything about the Resident Counsel. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not post notice for Resident Council meetings,” therefore the allegation is unsubstantiated. A copy of this report is being signed and copies given to Administrator, Mandy Taylor.the state’s words, verbatim · CDSS document, Oct 31, 2024 · control 11-AS-20241022210327

Allegation investigated: Staff do not report incidents to Community Care Licensing.

On 10/02/24 at 9:00 am, Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegation above. LPA met with Executive Director (ED) Mandy Taylor as the purpose of today’s visit was explained. The investigation consisted of the following: On 10/02/24 LPA obtained copies of staff and resident rosters, and the following documents for R1: Emergency ID from, facesheet, admission agreement, durable power of attorney, physicians report, POLST, and needs and service plan. On 10/02/24 LPA conducted interviews with ED and staff #1 (S1). The investigation revealed the following: Allegation- Staff do not report incidents to Community Care Licensing. It is being alleged that the facility does not submit incident reports for the death of R1. Substantiated On 10/02/24 LPA conducted interview with Executive Director (ED) regarding the above allegation, ED confirmed the allegation above. Per ED, an employee who is no longer employed at the facility was in charge of submitting SIRs and ED is unsure why the SIR was not submitted. On 10/02/24 LPA conducted interview with staff #1 (S1) regarding the allegation above, 1 of 1 staff interviewed confirmed that there was no incident report submitted for the death of R1 as a previously employed staff who was in charge of submitting reports to the licensing department did not complete the required report. S1 continued to report that S1 is now the employee responsible for submitting incident reports to the licensing department. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 2, 2024 · control 11-AS-20240924105844

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(B)(D) · Plan of correction due date: Oct 16, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...(B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety, or health of any resident...This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report associated with the death of (R1) . The facility did not have proof of certified confirmations LIC 624 was faxed to CCL. This violation poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: Licensee/Administrator will review Title 22 Sec. 87211 and agreed to provide training to staff pertaining to CCL Reporting Requirements. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC date Lizeth.villegas@dss.ca.gov

Type of visit: Case Management - Incident

On October 2, 2024 at 9:40am Licensing Program Analyst (LPA) Zina Brown and Licensing Program Manager (LPM) Janae Hammond conducted an unannounced case management to follow up on a incident that occurred on September 20, 2024 between Resident #1 and Resident #2 that engaged in inappropriate sexual activity. During today visit we met with Mandy Taylor, Administrator and explained the purpose of the visit. During today's visit, LPA conducted a tour of the physical and reviewed residents file, conducted interview with Administrator, Staff #1 - Staff 3, Resident #1 - Resident #2. Due to insufficient information at this time, a further investigation is needed at this time. LPA Brown will return at a later date to complete further investigation. A exit interview was conducted with Mandy Taylor, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 2, 2024

Allegation investigated: Staff did not notify authorized representative of incident.

Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Med-Ted (S6:Laurie Riffel). LPA stated the purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation. The investigation consisted of the following: A health and safety visit was conducted 08/21/24 and 08/23/24. A toured the facility’s physical plant. A review of documents: Residents’ Roster (dated: 08/21/24); Staff Roster & Work Schedules (dated: 08/21/24); Admissions Agreement (dated: 08/10/20); Physicians Report LIC 602A (dated: 07/30/20 and 08/29/23); Resident Pre-Assessment (dated: 07/20/20); Resident Assessment (dated: 08/07/20); Admission Body Check (dated: 08/10/20 and 12/18/21); Service Plans (dated: 08/10/20); Functional Assessment Stating Tool (dated: 08/07/20); and (Evaluation Report continues LIC 9099-C) Substantiated Nurses Notes (dated: 08/10/20 – 11/12/23); Shower Scheduled (dated: 08/01/24-08/231/24); Vital Sings Records; Weight Records; and Podiatric Evaluation and Treatment (dated: 11/02/20 – 06/21/23); Los Alamitos Medical Center Medical Records (dated: 08/26/24), and other documents associated with this complaint. INVESTIGATION REVEALED THE FOLLOWING: Allegation #2: Resident sustained injury while in care. The details of the complaint alleged resident #1 (R1) sustained injury while in care. Information provided claimed while (R1) was examined at Los Alamitos Medical Center it revealed (R1) had pressure ulcers. On 08/21/24 between 09:30 am to 03:56 pm, the Department interviewed (6) out of (6) administrator #1 (A1) and staff #1-#5 (S1-S5) who denied (R1) had pressure injuries. (A1) stated when (R1) was admitted on 08/10/20 an examination of the body was performed and it indicated that old scars on the buttocks, otherwise skin was clear and intact. Whatever sore that (R1) had from the skilled nursing facility Broadway by the Sea had healed. (S3-S5) who had direct contact with (R1) as primary caregivers refuted this claim. (S3-S5) claimed body checks are performed daily and there were no indications of skin tears, lacerations, or bed sores during (R1) care at this facility. (A1-S1-S5) verified that (R1) did not have any injuries due to falls or accidents. On 08/23/24 and 08/29/24 between 01:15 pm - 03:05 pm, the Department interviewed (3) out of (6) residents #1-#6 (R1-R6) who verified to have had no pressure injuries while being cared for at this facility. On 08/23/24 and 08/29/24 between 01:35 pm to 04:45 pm, the Department interviewed (4) out of (6) witnesses #3-#6 (W3-W6), claimed that residents have not sustained pressure injuries while in care at this facility. (W1) claimed Los Alamitos Medical Center made no mention of a bed sore on (R1), however, Kaiser Permanente did specify (R1) had pressure injuries. A review of the Los Alamitos Medical Center Medical Records (dated: 08/26/24) (R1) was examined and it indicated skin had no rashes or redness. There was no indication of pressure ulcers in the gluteal region. Medical records indicated examination consisted of the gluteal area for a colonic diverticulosis procedure that may have later been attributed to a skin tear in the gluteal region. (Evaluation Report continues LIC 9099-C) A result of the Department review of (R1’s) service records included: Physicians Report LIC 602A (dated: 07/30/20 and 08/29/23); Resident Pre-Assessment (dated: 07/20/20); Resident Assessment (dated: 08/07/20); Admission Body Check (dated: 08/10/20 and 12/18/21); Service Plans (dated: 08/10/20); Functional Assessment Stating Tool (dated: 08/07/20); and Nurses Notes (dated: 08/10/20 – 11/12/23) made no mention of an active pressure ulcers were being treated. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Allegation #3: Staff did not provide a safe environment for resident. The details of the complaint alleged the facility staff did not provide a safe environment for resident #1 (R1) while in care. Information provided indicated on 06/06/24, (R1) was left in bed asleep in the room while the area was cleared of residents for construction. The result of the construction left an overwhelming smell of tar and construction noises taking place near (R1’s) room. On 08/21/24 between 09:30 am to 03:56 pm, the Department interviewed (6) out of (6) administrator #1 (A1) and staff #1-#5 (S1-S5) verified that some type of remolding was being constructed in unit 4 where (R1) had a room. (A1) S1-S5) all indicated that all residents were moved to the unit 5 area on time. (A1) indicated that all current residents and their representatives were notified Units 3 and 4 were being repurposed for assisted living and memory care will remain in units 1, 2, and 5 in writing. (S1) verified to have notified authorized representatives of the move from unit 4 to unit 5 and construction of unit 4. (S1-S5) said that (R1) remained in the room while the other residents were moved to unit 5. (S1-S4) claimed on 06/06/24, (R1) refused to cooperate and did not want to be relocated to another room. (S1-S5) claimed that (R1) was left in the room for no more than an hour between 11:30 am to 12:30 pm. (R1) eventually agreed to be relocated into a room in unit 5. (S1-S5) stated that (R1) was not abandoned and was not left in unit 4 for more than an hour. (S1-S5) stated the renovation consisted of securing several protections plastic covered to prevent noise, smell, and dust as barriers. (S1-S5) claimed that the renovation of the facility was intended to ensure the safety and health of all residents. On 08/23/24 and 08/29/24 between 01:15 pm - 03:05 pm, the Department interviewed (3) out of (6) residents #1-#6 (R1-R6) able to recall some of the remolding and were removed from the area timely. (R4-R6) claimed they did feel safe and did not feel any discomfort during the renovation. (Evaluation Report continues LIC 9099-C) On 08/23/24 and 08/29/24 between 01:35 pm to 04:45 pm, the Department interviewed (4) out of (6) witnesses #3-#6 (W3-W6) verified notification from staff was received by telephone. (W3-W6) reported not having any concerns for the health and safety of residents while reconstruction was conducted. Based on the information collected, there is insufficient evidence to corroborate the allegation mentioned above. Allegation #4: Staff left resident in soiled clothing/bedding. Allegation #5: Staff are not ensuring resident's hygiene needs are met. The details of the complaint alleged the facility staff were negligent in resident #1 (R1’s) care. It was reported the attention (R1) receives is a concern. (R1) has been seen in dirty and stained clothing. (R1) does not appear clean and unkempt. On multiple occasions, (R1) has been seen in wet clothing and bedding. On 08/21/24 between 09:30 am to 03:56 pm, the Department interviewed (6) out of (6) administrator #1 (A1) and staff #1-#5 (S1-S5) stated these allegations are not accurate. (S1-S5) who have direct care with (R1) reported, (R1) is monitored for repositioning and diaper changes every two hours or as needed. All three shifts regularly perform incontinent services after meals. (R1) is scheduled to shower weekly on Sunday and Thursday. (S3-S5) are primary caregivers to (R1), denied (R1) has been left in stained or soiled clothing and bedding. According to (S1-S5), maintaining good personal hygiene is vital to prevent ill health, and (R1) was provided the care and services daily. (S1-S5) claimed that there were occasions when it was challenging to care for when (R1) refused to receive assistance with hygiene and grooming care services from staff. The staff will attempt to redirect the (R1) or return with a different staff to assist with basic care services. (S1-S5) claimed they are respectful of (R1’s) rights and (R1) has the right to refuse services as well. (S1) stated Progress Notes (aka Nurses Notes) were used to document and track the progress of the resident’s condition over time. (S1) claimed progress notes were only available for (R1) from 08/10/20 – 11/12/23. The Brittany House's new management has not mandated the facility to continue with Progress/Nurse charting and does not have current records. On 08/23/24 and 08/29/24 between 01:15 pm - 03:05 pm, the Department interviewed (3) out of (6) residents #1-#6 (R1-R6) claimed not to have concerns with their clothing appearance nor have been left in soiled diapers or bedding. (Evaluation Reports continue LIC 9099-C) On 08/23/24 and 08/29/24 between 01:35 pm to 04:45 pm, the Department interviewed (4) out of (6) witnesses #3-#6 (W3-W6) reported having no issues or concerns with the resident’s hygiene. The residents were found in presentable conditions and appearance in clothing when visits were conducted at the facility. A result of the Department review of (R1’s) service records included: Physicians Report LIC 602A (dated: 07/30/20 and 08/29/23); Resident Pre-Assessment (dated: 07/20/20); Resident Assessment (dated: 08/07/20); Admission Body Check (dated: 08/10/20 and 12/18/21); Service Plans (dated: 08/10/20); Functional Assessment Stating Tool (dated: 08/07/20); and Nurses Notes (dated: 08/10/20 – 11/12/23); Shower Scheduled (dated: 08/01/24-08/231/24); Vital Signs Records; Weight Records; and Podiatric Evaluation and Treatment (dated: 11/02/20 – 06/21/23) revealed that hygiene practices were included in daily living activities and services. Based on the information collected, there is insufficient evidence to support the allegations mentioned above. Between 08/23/24 - 08/29/24, the Department made several attempts to interview resident #1 (R1) by telephone who is now recovering at Heritage Rehabilitation Center. (R1) refused to engage in full conversation. Based on the evidence gathered interviews conducted, and analysis of records, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations of NEGLECT/LACK OF CARE AND SUPERVISION: “Resident sustained injury while in care", “Staff did not provide a safe environment for resident", “Staff left resident in soiled clothing/bedding”, and “Staff are not ensuring resident's hygiene needs are met” are found to be UNSUBSTANTIATED. An exit interview was conducted with Laurie Riffel, and a hard copy of the report was provided. Nurses Notes (dated: 08/10/20 – 11/12/23); Shower Scheduled (dated: 08/01/24-08/231/24); Vital Signs Records; Weight Records; and Podiatric Evaluation and Treatment (dated: 11/02/20 – 06/21/23); Los Alamitos Medical Center Medical Records (dated: 08/26/24), and other documents associated with this complaint. INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not notify authorized representative of incident. The details of the complaint alleged facility staff failed to notify the authorized representative of an incident involving resident #1 (R1) on 08/05/24. Information provided stated (R1) was transported by Emergency Medical Services (EMS) to Los Alamitos Medical Center at 06:00 pm. (R1's) authorized representatives were notified by the hospital's medical physician at 9:30 pm that (R1) needed a medical procedure. Investigation revealed resident #1 (R1) was admitted at Brittany House on 08/10/20, according to the Admission Agreement (dated: 08/10/20). (R1) was a former resident at Broadway by the Sea. (R1) remained as a resident at Brittany House from 08/10/20 through 08/21/24. On 08/05/24, (R1) was admitted to Los Alamitos Medical Center through 08/08/24 and was transferred to Kaiser Permanente South Bay Medical Center and then to Heritage Rehabilitation Center where (R1) is currently a resident. On 08/21/24 between 09:30 am to 03:56 pm, the Department interviewed (6) out of (6) administrator #1 (A1) and staff #1-#5 (S1-S5) who verified to know about (R1’s) emergency admission at Los Alamitos Medical Center. Four (4) out of six (6) admitted (R1’s) hospitalization on 08/05/24 did not account for notifying the authorized representatives. (2) two out of six (6) admitted to the facility failed to notify Community Care Licensing (CCL) with an Unusual Incident/Injury Report LIC 624 of (R1’s) hospitalization on 08/05/24. (S1) claimed the staff responsible for dispatching (EMS) was a new staff and unintentionally failed to follow proper procedures. On 08/23/24 and 08/29/24 between 01:15 pm - 03:05 pm, the Department interviewed (3) out of (6) residents #1-#6 (R1-R6) who verified that they were informed of any changes in health condition. (Evaluation Report continues LIC 9099-C) On 08/23/24 and 08/29/24 between 01:35 pm to 04:45 pm, the Department interviewed (4) out of (6) witnesses #3-#6 (W3-W6), confirmed to have received notice of any changes in the resident’s condition. Based on the evidence gathered interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF CARE AND SUPERVISION resulted in " Staff did not notify authorized representative of incident" is found to be SUBSTANTIATED. Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted with Laurie Riffel, and a hard copy of the report along with appeal rights.the state’s words, verbatim · CDSS document, Aug 31, 2024 · control 11-AS-20240816151317

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(1) · Plan of correction due date: Sep 14, 2024

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia…(1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator…when a resident’s behavior or condition changes. This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to notify the responsible person/conservator for (R1) when (R1) was hospitalized on 08/05/24. This violation poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 31, 2024

Plan of correction: Licensee/Administrator will review Title 22 Sec. 87705 and agreed to provide training to staff pertaining caring for resident with dementia. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC date via email: ernand.dabuet@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(B)(D) · Plan of correction due date: Sep 14, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...(B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety, or health of any resident... This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report associated with an incident with (R1) change in condition and hospitalization on 08/05/24. The facility did not have proof of certified confirmations LIC 624 was faxed to CCL. This violation poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 31, 2024

Plan of correction: Licensee/Administrator will review Title 22 Sec. 87211 and agreed to provide training to staff pertaining to CCL Reporting Requirements. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC date via email: ernand.dabuet@dss.ca.gov

Allegation investigated: Licensee is not isolating COVID positive resident(s).

**This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 7/15/24. On 7/15/24 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit. LPA met with the Resident Services Director, Neil Chandra and explained the purpose of today's visit and was granted entry. The investigation consisted of the following: On 7/15/24 LPA Shirley toured first floor of facility for resident interviews. LPA also requested and reviewed copies of the following records: Staff Roster, Resident Roster, Resident file, Face Sheet, Id and Emergency Info, Id card & Medical ID info, Preplacement Appraisal, Physician’s Report, MAR’s, Physician’s Orders, ActiveCare Living – admissions Disclosure Statement, House Rules, Emergency In-House Doctor Authorization, and Order Summary Report. Investigation revealed the following: Con’d on 9099-C Unsubstantiated Allegation: Licensee is not isolating COVID-19 positive resident(S) It is being reported that this facility is not properly isolating Covid-19 positive residents. There were visitors to this facility on 7/4/24 who later tested positive for Covid –19. Facility staff was notified on 7/5/24. During visit on 7/15/24 LPA Shirley interviewed residents who were exposed to the visitors and observed that they were masked, in their room and learned that they had been asked to remain in their room and not to join other residents in the dining room until their PCR test results were returned and reviewed. LPA observed that the exposed residents were more than 6 feet apart. LPA Shirley learned that they had been in their room for at least a week. The Resident Services Director stated during interviews that their protocol was to isolate the resident, notify the family and follow the physician’s orders. LPA Shirley interviewed staff 1-8 (S1-S8), and asked, does this facility staff isolate covid-19 positive resident(s)? Of those interviewed, 5 out of 8 answered yes. LPA Shirley interviewed residents 1-7 (R1-R7). R-8 was not available for interview. LPA ask, does this facility staff isolate Covid-19 positive residents. Of those interviewed, 2 out of 7 answered No. Based on information gathered, the department did not find sufficient evidence to support allegation of, "License is not isolating COVID-19 positive resident(s)”. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted and a copy of the LIC 9099 was provided to Receptionist, Stephanie Rubio.the state’s words, verbatim · CDSS document, Jul 15, 2024 · control 11-AS-20240711155146

Allegation investigated: Staff did not safeguard resident's personal belongings.

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 7/10/24. On 07/10/24 Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent complaint visit to the address listed above. LPA was greeted by Office Manager, Yessica Martinez. LPA was granted access to the facility. The investigation consisted of the following: On 6/13/24, LPA toured the facility to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. LPA requested copies of the following records: Staff Roster, Resident Roster, Staff and Resident interviews, reviewed resident files, and a copy of a delivery receipt from Ideal Home Care, dated 4/25/24. The investigation revealed the following: Con'd on 9099-C Substantiated Allegation: Staff did not safeguard resident’s personal belongings This facility recently moved residents from one unit to another unit and management received notice that a resident was transferred without their personal belongings. LPA Shirley reviewed the copy of delivery receipt that was provided for missing items and learned that a medical bed, Inner Spring mattress, half bedrails, hoyer lift and wheelchair were delivered to the Brittany House facility on 4/25/24 and was accepted by staff at 7:38pm. On 6/13/24, LPA Shirley went to the resident’s room and took pictures of the equipment that was there. A standard bed, walker, a wheelchair with a pedal leaning against the wall and the other pedal missing, and no hoyer lift. LPA Shirley checked residents closet to verify that the correct clothing were in the residents closet. LPA Shirley checked the laundry room to confirm labeling for residents clothing and was told that the clothes are labeled by families or representatives before the resident moves in. Labeling prevents residents clothing and personal belongings from being separated from the resident or in other residents rooms. LPA spoke with S-1 on 6/17/24. LPA discussed the delivery and acceptance by staff. S-1 stated that they would look into the matter and get back to me. On 6/17/24, S-1 forwarded a video of all of the missing equipment that was now in R-1’s room. LPA was told that missing items were in the storage room #211 and were not being used by another resident. LPA Shirley interviewed staff S1-S5, (S-1 – S-5.) LPA ask, Does the staff here safeguard the resident’s personal belongings? Of those interviewed, 5 out of 5 answered, yes. LPA interviewed residents R-1 – R-7, (R-1 – R-7.) LPA ask, does staff here safeguard your personal belongings. Of those interviewed, 6 out of 7 answered, yes, there was 1 resident whose response did not answer LPA’s question. Based on interviews, the preponderance of evidence has been met therefore the allegation is Substantiated. Deficiencies were issued for this allegation. An exit interview was conducted and plans of correction developed with the Administrator Susie Fuentes. A copy of this report and appeals rights was reviewed and left with the Office Manager, Jessica Martinez.the state’s words, verbatim · CDSS document, Jul 9, 2024 · control 11-AS-20240611084549

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Jul 24, 2024

87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not as evidenced by: Based on document review and interviews, facility staff did not take appropriate measures to safeguard residents belongings. This poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 9, 2024

Plan of correction: The Office Manager shall submit in writing a better plan and training for all staff to safeguard residents personal belongings and provide receipts for all such articles to CCLD via fax or email by POC due date of 7/24/24. Proof of correction can be emailed to felisa.shirley@dss.ca.gov.

Allegation investigated: Staff does not have adequate staffing to meet resident's needs. Staff does not ensure resident's are provided quality food. Staff does not ensure facility is free of odor. Staff moved resident's out of facility without notifying resident's responsible party.

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Monday, July 01, 2024, Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Executive Director (ED) Mandy Taylor. LPA Bunker explained the purpose of today's visit. LPA Bunker conducted interviews with staff members 1-3 (S1-S3) and residents 1-4 (R1-R4), asking questions relevant to the nature of the complaint. S1-S3 and R1-R4 stated the facility has adequate staffing to meet residents' needs, residents are provided quality food, staff ensures the facility is free of odor and does not move residents out of the facility without notifying the resident's responsible parties. S1-S3 and R1-R4 stated that the building offers a comfortable living environment for residents. During the visit, ED Mandy Taylor and LPA Bunker toured the facility, receptionist area, lobby, executive office, kitchen, 2 dining rooms, and the memory care unit. The following rooms were also observed 101, 107, 114, 204, 210, 215, 302, 304, 307, 308, 310, 311, 312, 313, 314, 407, 408, 410, 412, 413, 414, and 415. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 LPA Bunker reviewed staff and residents' records and requested copies of Identification and Emergency Information, Personnel Reports, Resident's Roster, Monthly Food Menus, and Ongoing In-Service Training. Allegation #1: Staff does not have adequate staffing to meet resident's needs. Staff members 1-3 (S1-S3) and residents 1-4 (R1-R4) interviewed stated the facility is fully staffed and staff is always available to provide assistance to residents. S1-S3 stated this is a 24-hour care facility that operates, 7 days a week, 365 days a year. Residents are never left at the facility alone without supervision. The facility operates in three shifts 6:00 A.M. - 2:30 P.M., 2:00 P.M.- 10:30 A.M.; and 10:00 P.M. – 6:30 A.M., Sunday through Saturday. S1 stated the Executive Director and Resident Services Director are on call 24 hours a day. S1-S3 stated several residents were not screaming and were confused about their whereabouts. S1-S3 stated this is a memory care facility where residents have Dementia. S1-S3 ensures sufficient and competent staff are available to provide the necessary services to meet residents' needs. S1-S3 and R1-R4 denied the allegation. Allegation #2: Staff does not ensure residents are provided quality food. Staff members 1-3 (S1-S3) and residents 1-4 (R1-R4) interviewed stated residents are provided with a variety of quality food to eat. S1-S3 and R1-R4 stated the residents receive an ample supply of perishable and non-perishable food, including three (3) meals and 3 snacks per day, breakfast, lunch, dinner, and snacks daily. The staff serves well-balanced meals with a variety of food options to choose from each week. R1-R4 stated that they had no complaints about the food. S1-S3 stated every day the food menu changes and residents can select something different if they prefer. S1-S3 stated residents are not served the same food every week. The food menu for weeks 1-4, reviewed by the LPA, shows a variety of food choices. S1-S3 stated residents' food is not served on inexpensive styrofoam plates or with plastic utensils. S1-S3 and R1-R4 denied the allegation. Allegation #3: Staff does not ensure the facility is free of odor. Staff 1-3 (S1-S3) and residents 1-4 (R1-R4) interviewed stated the facility is free of odor. S1-S3 stated the facility does not smell like urine or feces and is cleaned, sanitized, and disinfected daily. S1 stated the facility has scent air throughout the facility. S1-S3 denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation #4: Staff moved residents out of the facility without notifying the resident's responsible party. Staff members 1-3 (S1-S3) interviewed stated residents were never moved out of the facility without notifying the resident's responsible parties. S1 stated residents' responsible parties are always notified of any changes. S1-S3 denied the allegation. Investigation revealed the following: Staff members 1-3 (S1-S3) interviewed stated the facility is fully staffed and staff is always available to provide assistance to residents. S1-S3 ensures sufficient and competent staff are available to provide the necessary services to meet residents' needs. S1 and LPA Bunker observed the food in the kitchen refrigerators, freezers, kitchen cabinets, and pantry. The facility had plenty of meat, chicken, beef, steak, ground beef, hamburger patties, pork loins, pork roast, meatballs, fish, ground turkey, hot dogs, pizza, sausages, lunch meat, cold cuts, variety of frozen vegetables, green beans, sweet potatoes, chili beans, mixed vegetables, stir fry vegetables, peas, corn, French fries, variety of canned vegetables, fruit mix, diced beets, fruit cups, apple sauce, peanut butter, jelly, milk, eggs, cheese, variety of breads, white & wheat bread, hot dog buns, hamburger buns, cereals, rice, noodles, pasta, macaroni & cheese, potatoes, fresh fruits, oranges, bananas, watermelons, tomatoes, fresh vegetables, onions, garlic, potatoes, carrots, sweet potatoes, broccoli, lettuce, celery, red peppers, bell peppers, variety of canned fruits, cookies, chips, crackers, desserts, cake mix, sugar, flour, coffee cream, beverages, coffee, juice, milk, sodas, water, a variety of seasoning and sauces, ketchup, mustard, mayonnaise, tomato sauce, ripe olives, mushrooms, and etc. LPA Bunker observed an ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. S1-S3 stated residents are getting enough food to eat. During the visit, LPA Bunker observed residents in the dining room who were not eating from styrofoam plates or using plastic utensils. There was no foul odor detected throughout the facility, and it did not smell of urine or feces. Staff members 1-3 (S1-S3) also stated that residents were never moved out of the facility without notifying the resident's responsible parties. S1-S3 denied all the allegations. See continued LIC9099-C page 4 Continued LIC9099-C page 4 Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. Copies of the Complaint Investigation Report LIC9099 and LIC9099-Cs were provided to Executive Director Mandy Taylor. There were no deficiencies cited Exit interview conductedthe state’s words, verbatim · CDSS document, Jul 1, 2024 · control 11-AS-20240624084818

Allegation investigated: Staff violated residents' personal rights. Staff did not provide a safe and comfortable environment .

On 06/14/24, at 10:00am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-day complaint visit to the facility and was greeted by Yessica Martinez, Office Manager. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings for the allegation mentioned above. The investigation consisted of the following: LPA investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S7), (W1-W3) and residents (R1-R5). Resident Roster (No Date), Staff Roster (Dated 06/10/2024), Admission Record for all residents (Dated 06/14/2024) and Call Sheet (No Date) were obtained from the facility. The investigation revealed the following: Allegation #1- Staff violated residents' personal rights. The details of the complaint alleged that staff are moving residents from two units in the facility to unit 1 without notifying the residents or the family beforehand of the move; thereby violating their personal rights, leaving them confused and upset. Report continued on LIC 9099-C Substantiated On 06/14/24, from 10:00am-2:00pm, LPA interviewed staff (S1-S7) witnesses (W1-W3), and residents (R1-R5) regarding the allegation. 3 of 7 staff denied the allegation that the Staff violated residents' personal rights. 3 of 7 staff interviewed stated that the residents and family members were notified that the residents would be moved to another unit because of construction. They state that the family members were notified by phone or email. Whereas 4 of 7 staff were not sure if the residents’ or family were notified but received complaints from family members that they were not notified. LPA interviewed W1-W3 about the allegation and 3 of 3 witnesses denied that the facility reported to them or the residents of the relocation to another unit. Witnesses state that their family members were confused and upset about the move and did not know what was going on in the facility. LPA interviewed R1-R5 about the allegation and 4 of 5 residents that were interviewed corroborated the allegation that Staff violated residents' personal rights. A majority of the residents interviewed stated that they and their family members were not notified of the move and felt confused about it and did not know why they were moving. They further state that some of the residents that were moved into their room were not compatible with them. They complained that some of the residents kept screaming that they didn’t know what was going on. LPA reviewed the call sheet provided (No Date) but it did not specify the date, time, or who was notified and that either the resident or family member acknowledged the notification. Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation: Staff violated residents' personal rights, is found to be Substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. Deficiencies are issued and plans of corrections were discussed. The investigation revealed the following: Allegation #2- Staff did not provide a safe and comfortable environment. The details of the complaint alleged that because of construction and relocation of the residents with no attempt to make sure the residents are compatible and knowledgeable of what’s going on in the facility. It has become very crowded and chaotic, and it appears they are warehousing the residents, with no regard for their feelings, their emotional well-being, or their safety. Report continued on LIC 9099-C On 06/14/24, from 10:00am-2:00pm, LPA interviewed staff (S1-S7), witnesses (W1-W3), and residents (R1-R5) regarding the allegation. 3 of 7 staff denied the allegation that the Staff did not provide a safe and comfortable environment. 3 of 7 staff stated that the residents and their family members were notified about the construction that would take place in the facility causing the residents to be relocated. Whereas 4 of 7 staff stated that they were not sure if the residents or their family members were notified that construction would be taking place in the facility. They further state that some family members and residents were upset and confused that construction was taking place causing the residents to be subjected to loud noises, chemical smells, and overcrowded spaces. LPA interviewed W1-W3 about the allegation and 3 of 3 corroborated that Staff did not provide a safe and comfortable environment. They state that no one notified them that construction would be taking place and when they visited, they found the facility had strong odors from construction, too many residents in a small place with not enough caregivers to provide effective care, and they feared that the residents would be hurt in this environment. LPA interviewed R1-R5 about the allegation and 4 of 5 corroborated that Staff did not provide a safe and comfortable environment. They stated that no one advised them that construction was going to take place. They further state that during construction there were loud noises, dust, debris, and chemical smells that caused some to wear masks because of the fumes and they did not want to get sick. They state that it was very chaotic and could have been handled better. Based on interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation: Staff did not provide a safe and comfortable environment, is found to be Substantiated. California Code of Regulations, Title 22, Division (6) and chapter (8) are being cited on the attached LIC 9099D. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. * Deficiencies are issued and plans of corrections were discussed. An exit interview was conducted with Yessica Martinez, Office Manager, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 20, 2024 · control 11-AS-20240607142431

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 28, 2024

87468.1(a)(2) Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews conducted, the administrator failed to ensure a resident's personal rights due to the facility not letting them know that they would be relocated to a different unit in the building, causing confusion and feeling unsafe in the facility, which posed a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jun 20, 2024

Plan of correction: Administrator to review Personal Rights of Residents 87468.1(a)(2) and submit a statement acknowledging understanding of Title 22 Regulations by POC due date of 6/28/24 and email it to LPA Perry Scott at perry.scott@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Jun 28, 2024

87468.1(a)(8) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations... This requirement is not met as evidence by: Based on interviews conducted and records reviewed the administrator failed to inform the responsible parties about the construction of the facility and movement of the residents. Which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jun 20, 2024

Plan of correction: Administrator to review Personal Rights of Residents 87468.1(a)(8) and submit a statement acknowledging understanding of Title 22 Regulations by POC due date of 6/28/24 and email it to LPA Perry Scott at perry.scott@dss.ca.gov

Allegation investigated: Staff are not administering resident's medications as prescribed. Staff are mismanaging resident's medications.

On 05/22/2024, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit to this facility to conclude complaint investigation and deliver findings. LPA met with Resident Services Director Neio Chandra, and the purpose of today’s visit was explained. The investigation consisted of the following: On 03/25/24, LPA Gonzalez conducted a tour of the medication room, interviewed staff #1-#5 (S1-S5), reviewed resident files, received documents pertinent to the investigation, and requested additional documents which were provided to LPA via email on 03/28/24. On 04/09/24, LPA Gonzalez interviewed residents #2-#7 (R2-R7), LPA was unable to interview resident #1 (R1) due to medical conditions. LPA also reviewed resident file and requested copies of documents. On 05/22/24, LPA interviewed staff #6-#8 (S6-S8). Continued on LIC9099-C Substantiated The documents received and reviewed are the Staff Roster, Resident Roster, resident’s Physician’s Reports, Residents Physicians Orders, and Resident Appraisals, and residents MARs (Medication Administration Records). INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff are not administering resident's medications as prescribed. It is alleged that staff failed to administer medications to a resident as prescribed. It is also alleged that a resident has had extended times without vital medications which have led to the resident experiencing extreme anxiety and hallucinations. 0n 05/22/24, the department audited residents MAR (dated: 02/01/24 - 02/29/24 and 03/01/24 - 03/31/24) and revealed that a Not Applicable note was noted for 18 out of 29 days in February and 11 out of 31 days in March. On 05/22/24 at 10:30 AM, (1) out of (8) staff that were interviewed by the Department were aware of the error. S8 admitted to knowing about the medication not being dispensed as prescribed to the resident. LPA Gonzalez asked S8, what happened on 03/15/24 and 03/16/24 with R1? S8 stated they couldn’t give the resident their medication those days because they were waiting on the refills. S8 stated that they wrote not applicable on the QuickMAR note section but forgot to note the reason for not applicable. LPA then asked S8 if the not applicable noted on the rest of the days in the MAR meant the same thing, and S8 stated that it did mean that the resident was not given their medication(s) as prescribed and said this won’t happen again. On 04/09/24, LPA Gonzalez interviewed residents #2 - #7 (R2 -R7). Five (5) out of six (6) residents interviewed stated that the staff at this facility dispense their medication as prescribed by their physician, and (6) out (6) residents interviewed stated they have not missed any medication dosage. Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Continued on LIC9099-C Allegation: Staff are mismanaging resident’s medications. It is alleged that staff are mismanaging resident’s medications. It is also alleged that a resident had not had their Memantine medication in a week, because the medication was ordered but it had not arrived yet. On 04/09/24 LPA interviewed witness #1 (W1), R6’s daughter. Interview communicated that they feel there is not enough staff at this facility to provide for the needs of the residents. W1 stated that R6 does not get their medications on time or when needed. W1 stated that staff has advised them on several occasions that R6 did not get their medication because of the facility waiting for the medication to be refilled. On 05/22/24 at 10:30 AM, (1) out of (8) staff that were interviewed by the Department were aware of the error. S8 stated that they are aware the resident missed their medications on numerous times because they were out of medicine and were waiting on the medication to be refilled. S8 stated that in the past they have made the mistake of advising the nurse (which is responsible for refilling the resident’s medication) last minute or when the resident did not have any more medication, and that would cause a delay in receiving the new medication timely, which would cause the resident to go days without their medication(s). Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8) the following deficiencies have been observed and citations issued (ref. LIC 9099D). An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights was provided to Resident Services Director Neil Chandra.the state’s words, verbatim · CDSS document, May 22, 2024 · control 11-AS-20240318111845

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jun 5, 2024

87464(f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This was not met as evidence by based on records reviewed and interviews, med tech failed to give medication to resident which poses a potential health, safety risk to persons in care.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: Licensee will provide a training for all med techs to attend regarding policies and procedures for medications. Licensee will send LPA Gonzalez the sign in sheet and description of the type of training given by POC due date 06/05/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jun 5, 2024

87465(a)(2) Incidental Medical and Dental Care - 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: The licensee shall provide assistance in meeting necessary medical and dental needs… This was not met as evidence by based on records reviewed and interviews, med tech admitted to LPA that he was notifying the nurse about refilling medications last minute and that would cause a delay, where resident would go days without medication.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: Licensee will provide a training for all med techs to attend regarding policies and procedures for medications. Licensee will send LPA Gonzalez the sign in sheet and description of the type of training given by POC due date 06/05/24.

Allegation investigated: The facility admitted a resident with prohibited health condition. The facility operates beyond conditions and limitations specified on the license.

On 03/21/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit to the facility listed above. LPA met with Administrator, Mandy Taylor, and the purpose of today’s visit was explained. During today's visit, LPA toured the facility, interviewed Staff (S1-S8), interviewed Residents (R2-R7), and received documents pertinent to the investigation. The documents received and reviewed are the Staff Roster, Resident Roster, Plan of Operation, resident Physicians Report, visitor logs, Preplacement Appraisal, and Resident Admission Agreement. The investigation revealed the following: Continued on LIC9099-C Substantiated Allegation: The facility admitted a resident with a prohibited health condition. It is alleged a resident was admitted and moved into the facility, in the beginning of March 2024, with a communicable disease prohibited health condition. During interviews with staff (S1-S8), they were asked if a resident with a prohibited condition was admitted, seven (7) out of eight (8) stated Resident R1 was admitted to the facility with a prohibited health condition. During an interview with the Administrator (S1) stated they were unsure if an exemption was submitted to Community Care Licensing (CCL). Additionally, S1 stated when they became employed at the facility, on March 18,2024, they had R1 placed on home health for the care of the condition, and since that time R1 has been cleared, by a physician, of the prohibited health condition. During an interview with S2 stated that once they found out R1 had a prohibited health condition, staff took precautions such as isolating R1, placing a PPE cart outside the room for staff to use. During file review of Resident R1, LPA observed the facility was informed of R1’s diagnosis of the prohibited health condition via fax on March 12, 2024, at 8:37AM PDT. R1 was admitted to the facility on March 12, 2024, after a diagnosis of the prohibited health condition. During interview with residents (R2-R7) six (6) out of six (6) stated they were unsure if the are any residents with a prohibited condition. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. Allegation: The facility operates beyond condition and limitations specified on the license. It is alleged a client has come to the facility and uses it as a daycare and is participating in activities and meals then is picked up at 5:30pm. During interviews with staff (S1-S8), they were asked if there is a client who comes in and participates in daily activities and has meals, four (4) out of eight (8), stated C1 has been at the facility a few times and participated in activities. During an interview with S2, stated C1 has been in the facility twice when C1’s spouse has things they need to do. Additionally, S2 stated C1 will be a resident at the facility eventually but the family is not ready to place them here yet. S2 stated C2 receives minimal assistance while here and has been charged for the days they participated in the program. During file review, LPA observed on the Visitor Log, C1 was signed in on 03/06/24 at 8:30am, and on 03/15/24 at 8:25am till 6pm. During interviews with residents (R2-R7), six (6) out of six (6) stated they have no knowledge or concern of C1 coming in to participate in activities or meals. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. Two deficiencies were cited on the attached LIC9099-D. An exit interview was conducted with Maintenance Director, Juan Talavera, and a copy of this report and the appeals rights were provided.the state’s words, verbatim · CDSS document, Mar 21, 2024 · control 11-AS-20240315115358

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(4) · Plan of correction due date: Apr 4, 2024

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not ve admitted or retained in a residental care faclity for the elderly: (4) Staphylococcus aureus ("staph") infection or other serious infection. This regulation was not met based on evidence by: Record review and interviews, the licensee failed to ensure resident R1 did not have a phohibited health conditionthe state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: Administrator will review Tittle 22, Division 6 Chapter 8 Article 11 Health Related Services and conditions. Adminsitrator will submit a signed letter to LPA upon completion stating it was reviewed. Administrator will submit an excemption request to CCL and a Care Plan for the R1 by the POC.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87204(a) · Plan of correction due date: Apr 4, 2024

87204Limitations-Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum numbe of persons who my receive sedrvice at any one time. An exceptio my be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity, This regeulation was not met based on: Interviews and file review, C1 has paid to come and stay at the faclitily during the day, meals and services are porvided.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: Administrator will review Title 22, 87204 Limitations and submit a signed letter stating it has been reviewed by POC. Administrator will ensure C1 no longer being left at the facility unless a resident.

Type of visit: Prelicensing

On 1/19/24 Licensing Program Analysts (LPAs) Socorro Leandro and Alfonso Iniguez conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with authorized administrator: Ruth Tistoj. The licensee has applied for a license to serve (170) elderly residents ages 60 and older. The fire clearance is approved for (146) non-ambulatory residents and (24) bedridden. A complete tour of the facility was performed: residents rooms, medication room, kitchen, patio, dinning room, public restrooms and common areas. The following was observed during this visit: MEDICATIONS There is a locked centralized storage area for Resident medications. PHYSICAL PLANT Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 73°F. degrees. Open porches, and areas of potential hazard are well-lit. Smoke alarms operate properly. Carbon monoxide detectors operate properly. Report continues LIC 809C. BEDROOMS There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair. Mattresses and pillows are flame-retardant. There is dresser and closet space for each client that includes at least two (2) drawers or eight (8) cubic feet of dresser space per client. There is a chair and lamp for each client and at least one (1) nightstand per two (2) clients. BATHROOMS There is at least (1) toilet and washbasin per six (6) clients, family, and personnel. There is at least (1) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is 113° Fahrenheit. Bathroom is located near client bedrooms. There are nightlights in the hallways outside non-private bathrooms. SUPPLIES There are client personal hygiene supplies to include soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths. FOOD SERVICE Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0° Fahrenheit. Refrigerator is a maximum of 45° Fahrenheit. A seven (7) day supply of non-perishable food is present. There are enough tableware, tables, dishes, and utensils. There is enough equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. Report continues LIC 809C. RECORDS There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility. ADMINISTRATION The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. ACTIVITIES There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. MISCELLANEOUS There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. During this pre-licensing inspection, LPA did not find corrections are needed. LPA conducted the Component III Orientation with the Licensee and copy of this report was provided. A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with their assigned CAU Analyst. Exit interview conducted with Ruth Tistoj/Administrator.the state’s words, verbatim · CDSS document, Jan 19, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 170 Census (if any clients in care): 69 Interview Method: Telephone interview On 11/16/2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Nov 16, 2023