Brittany House

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

Allegation investigated: Staff verbally abused resident Staff did not report the incident to the appropriate agencies

*This report serves as an amendment to clarify findings. It supersedes the complaint investigation findings reflected on report created 8/17/26. On 8/17/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Esperanza Naaktgeboren, Executive Director 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 06/23/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Identification and Emergency Information, Medical Assessment for Residential Care facilities for the Elderly, Service Plan, Resident assessment, Incident report, dated 6/13/26, S5 Human Resource Status Change, S6 Resignation letter, 24 Hour Communication Log. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 8 (S1 – S8), and Resident 2 – Resident 6 (R2-R6). Resident 1 (R1) is hospitalized and cognitively impaired, not available to be interviewed. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff verbally abused resident It is being alleged that R1 was verbally abused by a caregiver at Brittany House. Per interviews on 6/24/26, S5 stated that R1 was having behaviors, screaming and trying to fall to the floor. S5 stated that she called S6 for advice on how to assist R1 as R1 was upsetting other residents. S5 stated that S6 told her that it was okay to let R1 fall out on the floor as it was the best way to assist her. LPA Shirley interviewed S2 on 6/23/26, per interview, the Long Beach Police Department was called but no one came out to take a report. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 3 out of 8 denied the allegation, 3 confirmed the allegation and 2 did not know. LPA interviewed resident 2 – resident 6 (R2 – R6). Of those who interviewed 5 out of 5 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff verbally abused resident,” therefore, the allegation is unsubstantiated. Allegation: Staff did not report the incident to the appropriate agencies It is being alleged that facility staff failed to report incident information to required agencies such as Licensing and to the local ombudsman office. On 6/23/26, LPA Shirley observed the incident report regarding R1, dated 6/13/26. LPA Shirley also reviewed the fax confirmation sheet dated 6/15/26 for Community Care Licensing (CCL) and also the fax confirmation sheet dated 6/15/26 for the local ombudsman. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 5 out of 8 denied the allegation, 2 staff confirmed the allegation and 1 was not sure. LPA interviewed resident 2 – resident 6 (R2 – R6). Of those who interviewed 5 out of 5 were not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not report the incident to the appropriate agencies,” 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. Allegation: Staff are not providing residents authorized representative with written incident reports It is being alleged that a family member requested that all incident reports and concerns be provided to them in writing and this request has not been fulfilled. The family member stated that they are only notified verbally. Per interview with S2 on 6/23/26, incident reports are confidential and internal only. Per S2, staff are required to notify family and responsible parties verbally only. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 3 out of 8 denied the allegation, 2 staff confirmed the allegation and 3 did not know. LPA interviewed resident 2 – resident 6 (R2 – R6). Of those who interviewed 2 out of 5 denied the allegation and 3 were not sure. According to the information gathered there is sufficient evidence to support the allegation “Staff are not providing residents authorized representative with written incident reports.” Based on interview and record review the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies are issued and an exit interview is conducted with the Executive Director, Esperanza Naaktgeboren. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 24, 2026 · control 11-AS-20260617125601

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 8, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Based on interview, S2 did not provide resident’s authorized representative with a copy of the written incident report. This violation poses as a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2026

Plan of correction: The Executive Director shall submit an in-service training informing and reminding the staff the importance of providing written reports to the responsible parties/authorized representatives of residents in care. Please provide the in-service training including date, time and participants names. Training must be submitted by due date: 10/8/26 to LPA's email: felisa.shirley@dss.ca.gov or fax attn: to LPA Felisa Shirley to 424-544-1016.

Allegation investigated: Resident was sexually abused while in care.

On 9/24/26, 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 9/14/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Incident Report, (9/1/26), Long Beach Police Department Card, Face sheet, AfterCare Instructions from Pipeline Health, Community Hospital of Huntington Park, Facility’s After Doctor Visit information, Resident Assessment, Identification and Emergency Contacts and Physician Report. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 5 (S1 – S5), and Resident 1 – Resident 5 (R1-R5). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Resident was sexually abused while in care. It is being alleged that R1 was sexually abused at this facility. On 9/8/26, LPA Felisa Shirley reviewed an incident report dated 9/1/26 indicating that R1 reported that they were involved in an argument during a consensual visit. Facility assessed R1 and were told that R1 talk to a man who is living inside a vent. R1 refused transport to a hospital. On 9/8/26, LPA Shirley reviewed a note attached to a card from the Long Beach Police Department dated 9/2/26, which indicated that the resident was not assaulted and that the sexual activity was consensual. The resident R1, was hospitalized at Pipeline Health, Community Hospital of Huntington Park on 9/3/26 and treated for a urinary tract infection (UTI) per R1’s AfterCare Instructions dated 9/3/26. Per interview on 9/8/26 with Esperanza Naaktgeboren, Executive Director, R1 reported to staff that a man inside the vent in their room was telling R1 that he wanted to have sexual relations with R1. R1 did not give a name and had not seen the man. During an interview with R2 on 9/8/26, R2 reported that R1 sits on their bed throughout the night and talks to the vent. LPA interviewed R1 on 9/8/26, during the interview R1 stated that the situation was a misunderstanding. LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 5 out of 5 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Resident was sexually abused 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, Esparanza Naaktgeboren.the state’s words, verbatim · CDSS document, Sep 24, 2026 · control 11-AS-20260904110900

Allegation investigated: Staff verbally abused resident Staff did not report the incident to the appropriate agencies Staff are not providing resident's authorized representative with written incident reports

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 6/25/26. On 8/17/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Esperanza Naaktgeboren, Executive Director 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 06/23/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Identification and Emergency Information, Medical Assessment for Residential Care facilities for the Elderly, Service Plan, Resident assessment, Incident report, dated 6/13/26, S5 Human Resource Status Change, S6 Resignation letter, 24 Hour Communication Log. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 8 (S1 – S8), and Resident 2 – Resident 6 (R2-R6). Resident 1 (R1) is hospitalized and cognitively impaired, not available to be interviewed. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff verbally abused resident It is being alleged that R1 was verbally abused by a caregiver at Brittany House. Per interviews on 6/24/26, S5 stated that R1 was having behaviors, screaming and trying to fall to the floor. S5 stated that she called S6 for advice on how to assist R1 as R1 was upsetting other residents. S5 stated that S6 told her that it was okay to let R1 fall out on the floor as it was the best way to assist her. LPA Shirley interviewed S2 on 6/23/26, per interview, the Long Beach Police Department was called but no one came out to take a report. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 3 out of 8 denied the allegation, 3 confirmed the allegation and 2 did not know. LPA interviewed resident 2 – resident 6 (R2 – R6). Of those who interviewed 5 out of 5 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff verbally abused resident,” therefore, the allegation is unsubstantiated. Allegation: Staff did not report the incident to the appropriate agencies It is being alleged that facility staff failed to report incident information to required agencies such as Licensing and to the local ombudsman office. On 6/23/26, LPA Shirley observed the incident report regarding R1, dated 6/13/26. LPA Shirley also reviewed the fax confirmation sheet dated 6/15/26 for Community Care Licensing (CCL) and also the fax confirmation sheet dated 6/15/26 for the local ombudsman. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 5 out of 8 denied the allegation, 2 staff confirmed the allegation and 1 was not sure. LPA interviewed resident 2 – resident 6 (R2 – R6). Of those who interviewed 5 out of 5 were not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not report the incident to the appropriate agencies,” therefore, the allegation is unsubstantiated. Con'd on 9099-C Allegation: Staff are not providing residents authorized representative with written incident reports It is being alleged that a family member requested that all incident reports and concerns be provided to them in writing and this request has not been fulfilled. The family member stated that they are only notified verbally. Per interview with S2 on 6/23/26, incident reports are confidential and internal only. Per S2, staff are required to notify family and responsible parties verbally only. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 3 out of 8 denied the allegation, 2 staff confirmed the allegation and 3 did not know. LPA interviewed resident 2 – resident 6 (R2 – R6). Of those who interviewed 2 out of 5 denied the allegation and 3 were not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not providing resident's authorized representative with written incident reports,” 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, Aug 17, 2026 · control 11-AS-20260617125601

Allegation investigated: Staff are not following infection control protocol

On 8/17/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Executive Director, Esparanza Naaktgeboren and explained the purpose of the visit is to investigate and deliver findings for the allegation mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 8/17/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, doctors Visit Notes, 8/7/26, clinical record, 8/5/26, and Scabies Prevention and Treatment instructions. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 5 (S1 – S5), and Resident 1 – Resident 5 (R1 - R5). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff are not following infection control protocol It is being alleged that a resident has been diagnosed with scabies and 5 other residents have symptoms. On 8/17/26, LPA Felisa Shirley conducted a review of current infection control practices and protocols at Brittany House, which included isolation, appropriate hand hygiene, use of personal protective equipment (PPE) when indicated, environmental cleaning and disinfection, and ongoing monitoring for signs and symptoms of communicable conditions. On 8/17/26, LPA Shirley reviewed Brittany House’s infection control training found within the Plans of Operation and observed that the facility’s infection control procedures are aligned with the requirements of Title 22. During review of the facility’s resident roster on 8/17/26, 1 resident was isolated. Per interview with S1 on 8/17/26, resident was isolated and evaluated for possible scabies; however, the resident did not test positive for scabies. At this time, no other residents are exhibiting signs or symptoms consistent with scabies. Staff will continue to monitor residents for any new or concerning symptoms and will promptly report and address any changes in condition in accordance with facility infection control procedures. LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation and 1 resident was not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not following infection control protocol,” 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, Aug 17, 2026 · control 11-AS-20260814110457

We haven’t transcribed this report yet. The complete document is on the state’s site.

We haven’t transcribed this report yet. The complete document is on the state’s site.

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

We haven’t transcribed this report yet. The complete document is on the state’s site.

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

Allegation investigated: Staff verbally abused resident Staff did not report the incident to the appropriate agencies Staff are not providing resident's authorized representative with written incident reports

On 6/25/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Esperanza Naaktgeboren, Executive Director 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 06/23/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Identification and Emergency Information, Medical Assessment for Residential Care facilities for the Elderly, Service Plan, Resident assessment, Incident report, dated 6/13/26, S5 Human Resource Status Change, S6 Resignation letter, 24 Hour Communication Log. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 8 (S1 – S8), and Resident 2 – Resident 6 (R2-R6). Resident 1 (R1) was not available to be interviewed. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff verbally abused resident It is being alleged that R1 was verbally abused by a caregiver at Brittany House. On 6/23/24 LPA Felisa Shirley reviewed an incident report dated 6/13/26 regarding R1 being mishandled. Per interviews on 6/24/26, S5 stated that R1 was having behaviors, screaming and trying to fall to the floor. S5 stated that she called S6 for advice on how to assist R1 as R1 was upsetting other residents. S5 stated that S6 told her that it was okay to let R1 fall out on the floor as it was the best way to assist her. S5 stated that she couldn’t believe that S6 suggested letting R1 fall out on the floor. S5 stated that this is the verbal abuse that she witnessed. During interview on 6/24/26, S6 stated that she witnessed S5 physically threw R1 on the bed in a violent aggressive way. S6 stated she reported the abuse to the Wellness Director. LPA Shirley interviewed S2 on 6/23/26, per interview, the Long Beach Police Department was called but no one came out to take a report. Per interview with S7, S5 was suspended on 6/14/26 and returned to work on 6/18/26, and S6 was suspended on 6/14/26 and per review of resignation letter dated 6/15/26, S6 submitted a Formal Grievance and Letter of Resignation. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 3 out of 8 denied the allegation, 3 confirmed the allegation and 2 did not know. LPA interviewed resident 2 – resident 6 (R2 – R6). Of those who interviewed 5 out of 5 denied the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff verbally abused resident,” therefore, the allegation is unsubstantiated. Allegation: Staff did not report the incident to the appropriate agencies It is being alleged that facility staff failed to report incident information to required agencies such as Licensing and to the local ombudsman office. On 6/23/26, LPA Shirley observed the incident report regarding R1, dated 6/13/26. LPA Shirley also reviewed the fax confirmation sheet dated 6/15/26 for Community Care Licensing (CCL) and also the fax confirmation sheet dated 6/15/26 for the local ombudsman. Con'd on 9099-C LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 5 out of 8 denied the allegation, 2 staff confirmed the allegation and 1 was not sure. LPA interviewed resident 2 – resident 6 (R2 – R6). Of those who interviewed 5 out of 5 were not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not report the incident to the appropriate agencies,” therefore, the allegation is unsubstantiated. Allegation: Staff are not providing residents authorized representative with written incident reports It is being alleged that a family member requested that all incident reports and concerns be provided to them in writing and this request has not been fulfilled. The family member stated that they are only notified verbally. Per interview with S2 on 6/23/26, incident reports are confidential and internal only. Per S2, staff are required to notify family and responsible parties verbally only. LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 3 out of 8 denied the allegation, 2 staff confirmed the allegation and 3 did not know. LPA interviewed resident 2 – resident 6 (R2 – R6). Of those who interviewed 2 out of 5 denied the allegation and 3 were not sure. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not providing resident's authorized representative with written incident reports,” 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 25, 2026 · control 11-AS-20260617125601

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).

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

Type of visit: Case Management - Deficiencies

Read the state’s words on page 2 of the record →

Allegation investigated: Staff are not following proper eviction procedures

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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.

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

Type of visit: Case Management - Deficiencies

Read the state’s words on page 2 of the record →

Allegation investigated: Facility unlawfully evicted resident

Read the state’s words on page 2 of the record →

Allegation investigated: Staff mishandle the residents medications.

Read the state’s words on page 2 of the record →

Type of visit: Case Management - Other

Read the state’s words on page 2 of the record →

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.

Read the state’s words on page 2 of the record →

Type of visit: Case Management - Other

Read the state’s words on page 2 of the record →

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.

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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.

Read the state’s words on page 2 of the record →

Type of visit: Case Management - Deficiencies

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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.

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

Type of visit: Case Management - Deficiencies

Read the state’s words on page 2 of the record →

Allegation investigated: Staff mismanaged resident's medication.

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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.

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

Type of visit: Required - 1 Year

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

Type of visit: Case Management - Incident

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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.

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

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

Read the state’s words on page 2 of the record →

Type of visit: Prelicensing

Read the state’s words on page 2 of the record →

Type of visit: Office

Read the state’s words on page 2 of the record →