Brookdale Garden Grove

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced Annual Required inspection of the facility. Upon arrival, LPA Tea was greeted by facility staff, granted entry, and explained the purpose of the visit. Executive Director (ED) Brisseth Arrellano and Business Operations Manager (BOM) Patricia Jimenez arrived shortly to assist with the inspection. The facility is licensed to serve 140 non-ambulatory residents, of which eight (8) may be bedridden, and has a hospice waiver for 15 residents. At the time of the visit, the facility had a census of 108 residents, of which 11 were receiving hospice services. LPA Tea reviewed eleven (11) resident files and five (5) staff files. The resident and staff files reviewed contained the required documentation. ED Arrellano's Administrator Certificate is valid through July 7, 2027. LPA Tea, accompanied by ED Arrellano and BOM Jimenez, toured the physical plant, including resident living areas, common areas, food service areas, and outdoor spaces. The facility is a two-story building with a memory care wing, known as "Clare Bridge," located on the first floor. The facility has a centrally located courtyard with shaded patio seating, as well as a separate Rose Garden courtyard available for residents. The memory care unit has its own secured private courtyard with ample seating. LPA tested the delayed-egress system around the memory care courtyard and found it to be operational. The facility's fire alarm system is monitored and maintained by a third-party company. Fire extinguishers throughout the facility were observed to be fully charged. LPA also observed evacuation chairs located in each stairwell for emergency use. The facility's most recent disaster drill was conducted on August 13, 2026. (Inspection Report continued on LIC809C) At the time of the visit, one of the facility's elevators was out of service and undergoing repair. The other elevator remained operational. While repairs are being completed, the facility is providing temporary complimentary escort and meal tray services to residents residing on the second floor. Resident bedrooms were observed to have the required furniture, bed linens, and adequate closet and drawer space to comfortably accommodate each resident. Resident bathrooms were inspected and observed to be clean and in good repair. Toilets and faucets were operational, grab bars were secure, and showers were free of visible mold and mildew. Hot water temperatures measured between 115.2 and 119.8 degrees Fahrenheit. LPA activated an emergency call pendant located in a resident bathroom, and staff responded in less than two (2) minutes. LPA also tested a resident push-button pendant, and staff responded in less than two (2) minutes. Common areas were observed to be clean and free of hazards, and doorways and passageways were free of obstructions. LPA inspected the kitchen and dining areas. The facility had an adequate supply of perishable and non-perishable food available at the time of the visit. Emergency drinking water was observed stored in the kitchen, and the facility's emergency food supply was stored in a nearby large storage closet adjacent to the kitchen. LPA Tea reviewed the facility's medication storage and administration practices. Medications are stored in locked medication carts in designated areas of the facility, including the memory care unit and the assisted living medication room. During the medication review, LPA observed that some PRN medications were listed on residents' medication records but did not have corresponding physician orders available for review. The facility was advised to ensure that current physician orders are obtained and maintained for all PRN medications, as applicable. Aside from the noted PRN medication order discrepancies, medications reviewed were being administered in accordance with physicians' orders. LPA also inspected the first aid kit located in the medication room. The first aid kit contained most of the required supplies; however, tweezers were not available at the time of the inspection. LPA advised facility that tweezers are required to ensure the first aid kit is complete. (Inspection Report continued on LIC809C) LPA interviewed residents regarding the quality of care and services provided at the facility and spoke with staff regarding resident care. During the visit, LPA observed residents eating lunch and engaging in leisure activities throughout the facility. Based on observations, interviews, and record reviews conducted during today's visit, no deficiencies were cited in the areas inspected pursuant to Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted with the facility. Copies of this LIC809, LIC809C, LIC858, LIC859, LIC9102TV were provided to the facility.the state’s words, verbatim · CDSS document, Aug 20, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Lack of care and supervision resulted in resident sustaining a fracture

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Wellness Director (WD) Ted Dawit on behalf of Administrator (AD) Brisseth Arrellano and explained the reason for today’s inspection. The investigation into the allegation of lack of care and supervision resulted in resident sustaining a fracture revealed the following: During the course of the investigation, Department staff inspected the facility, interviewed AD, residents, witnesses, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) hospice medical records, and R1’s facility care plan. It was alleged that R1, who is on hospice care, was complaining of pain in their left upper arm and was diagnosed with an impaction fracture on November 12, 2025. Unsubstantiated Review of R1’s hospice medical records revealed that an x-ray was taken on November 13, 2025, of R1’s left shoulder which revealed that the bones of R1’s shoulder are osteoporotic and there is an impaction of the surgical neck. When interviewed, AD and four additional facility staff denied witnessing or being aware of any recent falls by R1 at the facility. However, facility staff reported that R1 had a fall years ago and that R1’s left shoulder has had limited mobility for years. One facility staff noted that the bones in R1’s upper left arm seemed to make noises during changes, reported this to hospice in 2023, and was advised by hospice that the sounds were related to R1’s chronic arthritis. R1’s hospice medical records indicate R1 has been on hospice since July 28, 2023, and hospice staff give R1 sponge baths. An interview was attempted with R1, but R1 was unable to participate in the interview. When interviewed, R1’s family stated that R1 had pain in their shoulder for a month and a half prior to the x-ray. However, R1’s private caregiver, who is present with R1 four to five days a week for four to five hours a day and has been working with R1 since their admission, denied witnessing or being aware of any recent falls by R1 at the facility. The private caregiver further denied observing or hearing R1 report any recent complaints of pain in their arm or shoulder. When interviewed, three hospice staff also denied witnessing or being aware of any recent falls by R1 at the facility. While R1 sustained a fracture at the facility, it is unclear when R1 sustained the fracture and the information obtained did not corroborate that it was due to lack of care and supervision. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 22-AS-20251119151521

Allegation investigated: Resident sustained multiple falls while in care. Staff are not properly supervising residents who are a fall risk.

It was alleged that resident sustained multiple falls while in care and that staff are not properly supervising resident who is a fall risk. During the course of the investigation, the Department conducted interviews and attempted to interview R1 and R1’s responsible party; however, those attempts were unsuccessful. A review of facility records provided to LPA Lee on 3/23/2026 revealed no documentation identifying R1 as a fall risk, despite progress notes indicating that R1 experienced a total of 14 falls between 10/10/2024 and 01/08/2025. Documentation for these incidents reflects that R1 sustained injuries including head trauma, bumps, bleeding, bruising, and skin lacerations. Additionally, an After Visit Summary dated 01/08/2025 indicates that R1 was treated following a fall and diagnosed with a closed fracture of multiple ribs on the right side. Further review of R1’s Personal Service Plan dated 09/11/2024 indicates that fall prevention measures were not addressed. According to the facility’s Fall Management and Recovery Policy, a fall risk evaluation is to be completed upon move-in or as required by state regulation. Substantiated The policy also requires that all witnessed or unwitnessed falls be documented in the Brookdale Incident Reporting System (BAIRS), that a post-fall evaluation be conducted to identify interventions to prevent future falls, and that the service plan be reviewed and updated accordingly. Additionally, the policy requires that falls be tracked and trended for quality improvement purposes. Based on records provided by the facility, there was no documentation demonstrating that a fall risk assessment was completed upon R1’s admission. Furthermore, there was no evidence that post-fall evaluations were conducted following R1’s repeated falls, nor that interventions and or fall prevention plan were implemented or documented. The Personal Service Plan was not updated to reflect R1’s history of falls and related injuries. Overall, the facility did not follow its own policies and procedures regarding fall risk assessment, post-fall evaluation, care planning, and documentation for a resident with a history of falls. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. An Exit Interview was conducted with (FDA) Arrellano and a copy of this report was provided to the facility via email. A certified copy will be sent to the facility mailing address.the state’s words, verbatim · CDSS document, May 14, 2026 · control 22-AS-20241219203507

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: May 22, 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…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 evidence by: Based on the documents reviewed during the investigation, the facility did not ensure that the resident was reassessed despite multiple falls. There was no evidence that post-fall evaluations were conducted following R1’s repeated falls, nor that appropriate interventions or a fall prevention plan were implemented or documented. This condition poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 14, 2026

Plan of correction: As a plan of correction, the facility will also ensure that all residents who experience frequent falls are reassessed, and that appropriate fall prevention plans are developed and implemented in accordance with the facility’s Fall Management and Recovery Policy. In addition, the Administrator will review the cited regulation and submit a written statement to LPA Lee acknowledging understanding and compliance with the regulation due by 05/22/2026 end of day at 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 22, 2026

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by Based on the documents reviewed during the investigation, the facility did not ensure that R1 received appropriate care and supervision despite experiencing multiple falls, which resulted in injuries, including two rib fractures. This poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, May 14, 2026

Plan of correction: As a plan of correction (POC), the Administrator will review the cited regulation and submit a written statement to LPA Lee acknowledging understanding and compliance with the regulation due by 05/22/2026 end of day at 5:00 PM.

Allegation investigated: Staff did not provide appropriate care and supervision to resident.

On 05/05/2026, Licensing Program Analyst (LPA) Pang Lee conducted a Microsoft Teams meeting with Facility Designated Administrator (FDA) Brisseth Arrellano, for the purpose of delivering complaint findings for the allegations above. A brief interview with FDA Arrellano. It was alleged that staff did not provide appropriate care and supervision to resident. During the course of the investigation, the Department conducted interviews with facility staff, residents in care, and a resident’s responsible party. Based on interviews with five out of five residents, all reported no concerns regarding care and supervision. All residents also stated that they feel safe living in the facility. LPA Lee attempted to interview Resident 1 (R1); however, R1 is no longer residing at the facility and was not able to contact R1’s responsible party. CONTINUED LIC 9099-C Unsubstantiated In an interview with another resident’s responsible party, it was stated that staff are helpful and check on their mother several times a day, and that they “couldn’t ask for better care.” Based on a review of records, there was no documentation indicating that R1 was hospitalized and or any incident reports. LPA also attempted to obtain additional records/information regarding the allegation; however, further details could not be obtained from the facility, and current facility staff were not working at the time of the alleged incident. Based on interviews and records reviewed during the investigation, LPA Lee was unable to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did nor did not occur, therefore, the allegation is unsubstantiated. An Exit Interview was conducted with (FDA) Arrellano and a copy of this report was provided to the facility via email. A certified copy will be sent to the facility mailing address.the state’s words, verbatim · CDSS document, May 5, 2026 · control 22-AS-20210119160607

Allegation investigated: Staff neglect resulted in resident’s hospitalization Staff neglected resident’s calls for help multiple times

On 05/05/2026, Licensing Program Analyst (LPA) Pang Lee conducted a Microsoft Teams meeting with Facility Designated Administrator (FDA) Brisseth Arrellano, for the purpose of delivering complaint findings for the allegations above. A brief interview with FDA Arrellano. It was alleged that staff neglect resulted in the resident being hospitalized. During the course of the investigation, the Department conducted interviews with facility staff, residents in care, and a resident’s responsible party. Based on interviews with five out of five residents, all reported no concerns regarding care and supervision. All residents also stated that they feel safe living in the facility. LPA Lee attempted to interview Resident 1 (R1); however, R1 is no longer residing at the facility and was not able to contact R1’s responsible party. In an interview with another resident’s responsible party, it was stated that staff are helpful and check on their mother several times a day, and that they “couldn’t ask for better care.” CONTINUED LIC 9099-C Unsubstantiated Based on a review of records, there was no documentation indicating that R1 was hospitalized. LPA also attempted to obtain additional records/information regarding the allegation; however, further details could not be obtained from the facility, and current facility staff were not working at the time of the alleged incident. Based on interviews and records reviewed during the investigation, LPA Lee was unable to corroborate the allegation. It was alleged that staff neglected residents’ calls for help multiple times. During the course of the investigation, the Department conducted interviews with facility staff, residents in care, and a resident’s responsible party. Based on interviews with facility staff, it was reported that the typical response time to residents’ calls for assistance is approximately five minutes. However, depending on staffing levels and residents’ needs, response times may occasionally take longer, but no longer than 15 minutes. Interviews with five out of five residents indicated that they are provided pendant call necklaces and reported no concerns regarding staff not responding to call pendants. Residents stated that response times are usually immediate, and at the longest, within approximately 15 minutes. In an interview with a resident’s responsible party, it was stated that during one visit, their mother activated the pendant, and facility staff “came immediately.” LPA also attempted to obtain additional records, including pendant call logs related to the allegation; however, these documents could not be obtained from the facility, and current staff present were not working at the time of the alleged incident. Based on interviews and records reviewed during the investigation, LPA Lee was unable to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did nor did not occur, therefore, the allegation is unsubstantiated. An Exit Interview was conducted with (FDA) Arrellano and a copy of this report was provided to the facility via email. A certified copy will be sent to the facility mailing address.the state’s words, verbatim · CDSS document, May 5, 2026 · control 22-AS-20210623125429

Allegation investigated: Staff did not maintain a comfortable room temperature for residents. Staff does not treat resident with respect.

On 05/05/2026, Licensing Program Analyst (LPA) Pang Lee conducted a Microsoft Teams meeting with Facility Designated Administrator (FDA) Brisseth Arrellano, for the purpose of delivering complaint findings for the allegations above. A brief interview with FDA Arrellano. It was alleged that staff did not maintain a comfortable room temperature for residents. During the investigation, the Department conducted interviews with facility staff, residents in care, the assigned LPA Sean Haddad, a resident’s responsible party, and an outside agency representative. Based on interviews, it was learned that each resident has an individual thermostat in their room, allowing them to adjust the temperature to their preference. Five out of five residents interviewed reported no concerns regarding the facility’s temperature and stated they were able to regulate their room temperature to their liking. CONTINUED LIC 9099-C Unsubstantiated Additionally, LPA Haddad, a resident’s responsible party and the outside agency representative reported no concerns and indicated that during their visits, they did not observe any uncomfortable temperatures within the facility. A review of records, including LPA Haddad’s complaint investigation report dated 04/22/2025, indicated that temperatures and thermostats in 12 resident rooms were inspected. The air conditioning and heating systems were observed to be functioning properly, and all rooms were maintained at comfortable temperatures as selected by the residents. Furthermore, during the investigation on 04/22/2025, it was reported that although the air conditioning system has been properly maintained, it began intermittently shutting off a few months prior, with increasing frequency over time. However, maintenance staff reported that the issue did not impact residents or result in uncomfortable temperatures, as the system was promptly restarted each time and was never off for more than one hour. It was also noted that the facility engaged third-party air conditioning technicians immediately upon identifying the issue and has been actively working to diagnose and resolve the problem. A review of the facility’s maintenance records confirmed ongoing efforts to address and repair the air conditioning system. Based on interviews and records reviewed during the investigation, LPA Lee was unable to corroborate the allegation. It was alleged that staff do not treat residents with respect. During the investigation, the Department conducted interviews with facility staff, residents in care, the assigned LPA Sean Haddad, a resident’s responsible party, facility staff and an outside agency representative. Five out of five residents interviewed reported no concerns regarding staff not treating them with respect. Additionally, residents stated that they feel safe living in the facility and that staff treat them well. One resident stated, “I love it here, staff have been wonderful and respectful.” Interviews with two facility staff who denied the allegations. Furthermore, LPA Haddad, a resident’s responsible party, and the outside agency representative all reported no concerns and indicated they have not observed facility staff mistreating residents and not respecting residents in care. Moreover, the outside agency representative reported witnessing Resident 1 (R1) on multiple occasions not treating other residents with respect during resident council meetings. Based on interviews and records reviewed during the investigation, LPA Lee was unable to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did nor did not occur, therefore, the allegation is unsubstantiated. An Exit Interview was conducted with (FDA) Arrellano and a copy of this report was provided to the facility via email. A certified copy will be sent to the facility mailing address.the state’s words, verbatim · CDSS document, May 5, 2026 · control 22-AS-20240625165436

Allegation investigated: Facility did not administer medication as prescribed resulting in resident to be hospitalized.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Brisseth Arrellano and explained the reason for today’s inspection. The investigation into the allegation that facility did not administer medication as prescribed resulting in resident to be hospitalized revealed the following: During the course of the investigation, Department staff inspected the facility, interviewed AD, residents, witnesses, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Personal Service Plan dated April 25, 2025, R1’s Personal Service Plan dated July 3, 2025, R1’s Home Health Medical Records, R1’s Medication Administration Records, R1’s Garden Grove Hospital Medical Records, and R1’s Kaiser Permanente Medical Records. It was alleged that R1 was not given their prescribed dosage of Furosemide on July 5 and 6, 2025, experienced increased symptoms including hypotension and fluid on the lungs, and was hospitalized as a result. Substantiated When interviewed, R1 stated they moved into the facility in April 2025, initially handled their own medications, but that they were later reassessed to require medication management by the facility. Review of R1’s Personal Service Plan dated April 25, 2025, confirms that R1 initially handled their own medications and review of R1’s Personal Service Plan dated July 3, 2025, confirms the facility began managing R1’s medications on July 3, 2025. Per R1’s Home Health Medical Records, on May 28, 2025, R1 was prescribed Furosemide 40MG for congestive heart failure with instructions to take one and a half tablets daily and if there is a weight gain of two pounds or greater overnight, 5 pounds over one week, or if R1 experiences swelling or shortness of breath, then to take an additional one and a half tablets for one to three days then return to the previous dose. R1’s Home Health Medical Records also indicate that on July 1, 2025, R1’s doctor issued a new order for R1 to take two tablets of Furosemide 40MG daily on July 3, 4, and 5, 2025 for fluid retention. Interviews with AD and two facility staff revealed that there was confusion with R1’s new order for Furosemide, which was not properly clarified, resulting in a medication error by facility staff where R1 did not receive any Furosemide after the new order ended on July 5, 2025, when R1 should have returned to their previously prescribed dose. R1’s Medication Administration Records do not indicate that Furosemide was ever given to R1, except on July 3, 4, and 5, 2025, where on July 3, 2025, R1 was given two tablets as prescribed, but on July 4 and 5, 2025, R1 was actually given six tablets each day which is triple the prescribed dose. Per R1’s Garden Grove Hospital Medical Records, on July 8, 2025, R1’s nurse checked on R1 at the facility and noted R1 to be hypoxic, R1 was taken to the emergency room and diagnosed with pulmonary hypertension, hypotension which is likely caused by the pulmonary hypertension, dyspnea, urinary retention, pulmonary edema, and a urinary tract infection, as well as community acquired pneumonia and hyponatremia, R1 was hospitalized, and R1 was discharged to Kaiser Permanente hospital on July 10, 2025. Per R1’s Kaiser Permanente Medical Records, R1 was admitted on July 10, 2025, for acute on chronic hypoxemic respiratory failure, R1’s diagnoses included pulmonary hypertension, interstitial lung disease, cor pulmonale, coronary artery disease without angina, presence of stent diastolic heart failure, chronic hypoxemic respiratory failure, bronchiectasis, and R1 was discharged back to the facility on July 13, 2025. Per a witness from Kaiser Permanente, on July 7, 2025, R1’s home health nurse visited R1 at the facility and discovered that R1 had not received their prescribed dose of Furosemide. This witness also confirmed that R1’s doctor at Kaiser Permanente hospital determined that R1 not receiving their Furosemide as prescribed caused their hypotension and fluid on the lungs. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Apr 16, 2026 · control 22-AS-20250710150954

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 17, 2026

87465 Incidental Medical and Dental Care (a)… (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by :Based on interviews and documents, the licensee did not ensure R1 received assistance with medications by not giving R1 their Furosemide on multiple days and giving R1 triple their prescribed dose on two days resulting in hospitalization, which poses an immediate health risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Apr 16, 2026

Plan of correction: Licensee stated that they will retrain staff on medication administration and submit proof to LPA by POC due date.

Allegation investigated: Resident sustained unexplained injury while in care. Resident’s room has bed bugs. Resident’s room has pests. Toiletries not provided to resident. Staff not maintaining residents hygiene.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Administrator (AD) Brisseth Arrellano and explained the reason for today’s inspection. The investigation into the allegations that a resident sustained unexplained injury while in care, resident’s room has bed bugs, resident’s room has pests, toiletries not provided to resident, and staff not maintaining resident’s hygiene revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, staff. witnesses, and residents, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) service plan dated August 12, 2021, R1’s facility progress notes, pest control invoices, and the facility’s shower schedule. Unsubstantiated Regarding the allegation that resident sustained unexplained injury while in care: it was alleged that on May 11, 2021, R1 had a fall, was taken to the hospital with unknown injuries, stayed at a skilled nursing facility for three days, and then returned to the facility. It was also alleged that on July 27, 2021, blood was observed on the back of R1’s head, R1 was unable to recall what happened, and staff were unable to explain what happened. LPA interviewed the facility’s wellness director at the time who stated that R1 did have many falls, including one in May 2021 where R1’s head started bleeding, and R1 was sent to the hospital due to this fall. LPA attempted to interview R1, but R1 is no longer a resident of the facility. LPA interviewed four residents who reported no issues with the care they receive at the facility. LPA reviewed R1’s service plan dated August 12, 2021, which indicates R1 is on fall precautions. LPA reviewed R1’s facility progress notes which document that R1 had multiple falls, none of which resulted in fractures. Per R1’s facility progress notes, on May 10, 2021, R1 was found on the floor bleeding from their head and was taken to the hospital. R1’s facility progress notes do not contain an entry for the reported July 27, 2021, injury. LPA interviewed AD who stated that R1 did not have any fractures from these recent falls and, although R1 was sent to the hospital in relation to some falls, R1 was not hospitalized and was instead returned to the facility each time. LPA interviewed R1’s responsible party who stated that the facility took proper measures to address R1’s falls and that the most recent fall occurred around May 11, 2021, and resulted in a head laceration that was being treated by R1’s doctor. Although R1 had recent falls, the information obtained did not corroborate that R1 sustained any serious injuries or that the facility did not obtain timely medical care for R1. Regarding the allegation that resident’s room has bed bugs: it was alleged that R1’s room and mattress are infested with bed bugs and that on May 11, 2021, R1 was found on the floor by a caregiver due to bed bugs feeding on R1. LPA interviewed the administrator at the time who stated that the facility did have an issue with bed bugs which began in R1’s room and spread to nearby rooms, the facility immediately relocated R1 to another room with bed bug precautions, the facility then called a pest control company that treated the affected rooms for bed bugs, called in a second pest control company that treated the entire floor, and had a bed bug sniffing dog check for bed bugs. LPA interviewed the facility’s wellness director at the time who stated that there were bed bugs in R1’s room, but they were addressed. LPA attempted to interview R1, but R1 is no longer a resident of the facility. LPA interviewed four residents who reported no issues with bed bugs in their room, and two of the residents were aware that the facility had a bed bug issue that was addressed by the facility and one resident confirmed that a bed bug sniffing dog was used as reported by the administrator at the time. LPA and the administrator at the time used an ultraviolet flashlight to inspect six rooms in the area affected by bed bugs, including R1’s original room, and observed no evidence of continued bed bug infestation. LPA reviewed pest control invoices corroborating that two pest control companies provided bed bug treatments, a bed bug sniffing dog was also used, and one of the pest control companies cleared the facility of bed bugs on August 6, 2021. LPA interviewed R1’s responsible party who was concerned that the bed bugs were discovered in R1’s room, but provided no information corroborating that the facility did not handle the bed bug situation properly. Although bed bugs were found in R1’s room, the information obtained showed that the facility addressed the situation properly. Regarding the allegation that resident’s room has pests: it was alleged that R1’s room and bed have ants. LPA interviewed the administrator at the time who denied there are issues with pests or other ants, stating that the facility’s pest control company monitors the entire building for pests regularly. LPA attempted to interview R1, but R1 is no longer a resident of the facility. LPA interviewed four residents who reported no issues with pests in their rooms. LPA and the administrator at the time used an ultraviolet flashlight to inspect six rooms in the area around R1’s room and observed no evidence of pests of any kind. LPA reviewed pest control invoices corroborating that two pest control companies provided pest control services to the facility. LPA interviewed R1’s responsible party who stated that the ants were addressed as soon as they reported it to the facility. Regarding the allegation that toiletries not provided to resident: it was alleged that on May 25, 2021, R1’s room had no toiletries. LPA interviewed the facility’s wellness director at the time who stated that R1 was moved to a new room due to bed bugs in their old room, nothing was transferred from their old room to their new room due to bed bug precautions, so facility staff gave R1 toiletries that they had on hand as R1’s toiletries were left in their old room. LPA attempted to interview R1, but R1 is no longer a resident of the facility. LPA interviewed four residents who reported no issues with toiletries, with one resident confirming that the facility provides toiletries to residents. LPA interviewed R1’s responsible party who stated that when R1 was relocated to a new room, their toiletries and other belongings were not relocated with them, but stated this did not have a significant impact on R1. Although R1’s toiletries were not relocated to R1’s new room due to bed bug precautions, the investigation did not reveal that R1 went a long period without access to toiletries or that the facility did not provide toiletries to R1 when they were requested. Regarding the allegation that staff not maintaining residents’ hygiene: it was alleged that R1 went a week and a half without bathing. LPA interviewed the facility’s wellness director at the time who stated they were unaware of any issues with R1’s showers. LPA attempted to interview R1, but R1 is no longer a resident of the facility. LPA interviewed four residents who reported no issues with showers, with one resident confirming they get all the showers they need. LPA reviewed R1’s service plan dated August 12, 2021, which confirms R1 needed assistance with showers and they were scheduled for two showers a week. LPA reviewed the facility’s shower schedule which shows R1 was scheduled for two showers a week. LPA interviewed R1’s responsible party who stated that on one occasion they noticed that R1 had body odor and their hair was oily, they raised this concern to the facility, and R1’s showers were increased which addressed the problem. Per AD, the facility does not have shower logs from that period. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jan 26, 2026 · control 22-AS-20210806122628

Allegation investigated: Staff was rough with resident resulting in injury Failure to report

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with staff Ted Dawit and explained the reason for today’s inspection. The investigation into the allegations that staff was rough with resident resulting in injury and of failure to report revealed the following: During the course of the investigation, LPA inspected the facility, interviewed staff and residents, and obtained and reviewed copies of the resident roster, staff roster, an incident report dated July 27, 2021, the facility’s investigation, Staff #1’s (S1) staff file, Staff #2’s (S2) staff file, and the facility’s report of suspected dependent adult/elder abuse dated July 26, 2021. CONTINUED Substantiated Regarding the allegation that staff was rough with resident resulting in injury: it was alleged that Resident #1 (R1), a memory care resident, was handled roughly by staff resulting in bruises. LPA interviewed the facility’s wellness director who stated that R1 was a new resident and on July 22, 2021, S1 witnessed S2 trying to change R1, R1 kept refusing, and S2 forcefully grabbed R1 and changed them, but S1 did not report this incident and it was only discovered the next morning at which point a full investigation was conducted resulting in S1 and S2 being terminated. LPA reviewed an incident report dated July 27, 2021, which states that on July 22, 2021, at approximately 9:20PM, R1 was changed in a manner which caused bruising to their right forearm, R1 reported this incident on July 23, 2021, S1 and S2 were suspended pending investigation, and local law enforcement, the Long Term Care Ombudsman, and R1’s family were notified of the incident on July 26, 2021. The facility’s wellness director stated that there had been no prior incidents with S1 or S2 and after the incident was discovered, all other residents were checked and no similar injuries were discovered. Per the facility’s wellness director, the facility’s protocol for care refusal is to make multiple attempts, to notify management so other staff can make attempts, and if that does not work to reach out to the family and doctor to explore other options. The facility’s wellness director did not know why this protocol was not followed in this incident, but S2 may have been under pressure to change R1 before the shift ended as later shifts will sometimes complain to prior shifts if something is not done because later shifts will have to do it. Per the facility’s investigation, both S1 and S2 made multiple attempts to change R1, R1 refused both of them, it was S2 who insisted on changing R1 before end of shift, and S1 and S2 ultimately changed R1 together. LPA interviewed R1 who was confused as to why staff were trying to change their clothes, stated they were distraught during the incident, but that they are now doing fine. LPA interviewed three additional residents who reported that they have not experienced staff being rough. LPA confirmed that both S1 and S2 were background cleared. LPA reviewed S1’s staff file which shows that S1 was trained in mandated reporting requirements, had completed their training, and was terminated on July 31, 2021, for violating the facility’s mandated reporting policy when they did not report S2 being rough with R1. LPA reviewed S2’s staff file which shows that S2 was trained in mandated reporting requirements, had completed their training, and was terminated on July 31, 2021, for roughly handling R1. While the facility responded properly after the incident took place, the facility did not take proper measures to prevent incidents like this through sufficient staff oversight, especially in light of knowing that different shifts were pressuring each other to complete tasks prior to the end of their shift, which in this case resulted in forced care. Regarding the allegation of failure to report: it was alleged that the incident with R1 being handled roughly by staff resulting in bruises was not properly reported to R1’s responsible party. The incident report dated July 27, 2021, timely received in the Orange County Regional Office (OCRO), states that local law enforcement, the Long Term Care Ombudsman, the OCRO, and R1’s responsible party were notified of the incident on July 26, 2021, the same day the facility’s investigation into the incident was completed. However, while the incident report indicates that local law enforcement, the Long Term Care Ombudsman, and the OCRO were notified in writing, it does not indicate R1’s responsible party was notified in writing as required. The facility’s report of suspected dependent adult/elder abuse dated July 26, 2021, similarly, does not indicate that R1’s responsible party was notified in writing. While statements from R1’s responsible party, and the facility’s documentation, confirm that R1’s responsible party was told of the incident as of July 26, 2021, all of the information obtained indicates that this notification was only verbal, and not written, as required. Per staff interview, the facility’s policy is to provide only verbal reports to responsible parties and document the notification. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Dec 30, 2025 · control 22-AS-20210726164318

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Dec 31, 2025

87468.1 Personal Rights of Residents in All Facilities (a) … (3) To be free from punishment, humiliation, intimidation, abuse… This requirement was not met as evidenced by: Based on observation and interviews, the licensee did not ensure R1 was free from abuse when S1 and S2 forced care on R1 resulting in bruises, which poses an immediate personal rights risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Dec 30, 2025

Plan of correction: The licensee has already investigated the situation and terminated the staff involved. Licensee stated they will submit their training records on resident refusals and resident rights to LPA by POC due date.

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

87211 .. (a) … (1) A written report shall be submitted to … the person responsible for the resident within seven days of... (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse …This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R1’s responsible party received a written notification of R1’s rough handling by staff resulting in bruises, which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 30, 2025

Plan of correction: The licensee stated they will review section 87211 and submit a plan to ensure incidents are properly reported to LPA by POC due date.

Type of visit: Case Management - Other

This unannounced Case Management – Other inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering amended findings for Complaint Control Number 22-AS-20210726164318. LPA met with Staff #1 (S1) Patricia Jimenez and explained the reason for today’s inspection. During the inspection, LPA and S1 reviewed and discussed the previously delivered findings and the amended findings and LPA delivered the amended report to S1. An exit interview was conducted and copies of this report and the amended report were discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Dec 30, 2025

Type of visit: Case Management - Incident

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of concluding the investigation into the self-reported incident report received in the Orange County Regional Office (OCRO) on November 7, 2025, regarding Resident #1 (R1). LPA met with Staff #1 (S1) Ted Dawit and explained the reason for today’s inspection. Administrator (AD) Brisseth Arrellano appeared via telephone. During today’s inspection, LPA inspected the facility and interviewed AD. Per the incident report received in the OCRO on November 7, 2025, on November 6, 2025, R1 reported $850 in cash missing from their room and believes a certain staff took it. LPA previously interviewed AD and R1, and reviewed R1’s property log, and the information obtained did not corroborate that the money was present in R1’s room as stated and the information obtained regarding the alleged theft was conflicting, but R1 claimed they had recently found evidence proving a certain staff took the money, and stated that they would share this evidence with the police in the near future. LPA interviewed AD who stated that the police reviewed this new evidence on November 25, 2025, were unable to determine whether the money was present in R1’s room as stated, determined that the money was lost and not stolen, and will not investigate the matter further. There were no deficiencies observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Dec 4, 2025

Type of visit: Case Management - Incident

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on November 7, 2025, regarding Resident #1 (R1). LPA met with Administrator (AD) Brisseth Arrellano and explained the reason for today’s inspection. During today’s inspection, LPA inspected the facility, interviewed AD and residents, and requested and reviewed copies of the resident roster, staff roster, and R1’s property log. Per the incident report received in the OCRO on November 7, 2025, on November 6, 2025, R1 reported $850 in cash missing from their room and believes a certain staff took it. LPA interviewed AD who stated they investigated the situation, were unable to confirm that the money was ever present in R1’s room, questioned staff who denied taking the money, and searched the belongings of the accused staff and confirmed the money was not in the staff’s possession. Per AD, the facility reported the missing money to the police on November 6, 2025, but the police did not investigate. LPA reviewed R1’s property log which does not document the money. LPA interviewed R1 who stated the missing money was over $1,000, they believe they now have evidence proving a certain staff took the money, and they will share this evidence with the police in the near future. The information obtained did not corroborate that the money was present in R1’s room as stated and the information obtained regarding the alleged theft is conflicting. AD stated they will provide an update to LPA on December 8, 2025, regarding any new developments. There were no deficiencies observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Nov 24, 2025

Type of visit: Case Management - Incident

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on October 23, 2025, regarding Resident #1 (R1). LPA met with Administrator (AD) Brisseth Arrellano and Staff #1 (S1) Ted Dawit and explained the reason for today’s inspection. During today’s inspection, LPA inspected the facility, interviewed AD, staff, and residents, and requested and reviewed copies of the resident roster, staff roster, R1’s Medical Records dated October 18, 2025, R1’s Physician’s Report dated October 14, 2025, R1’s Personal Service Plan dated September 13, 2025, and R1’s Personal Service Plan dated October 23, 2025. Per the incident report received in the OCRO on October 23, 2025, on October 18, 2025, R1 had a fall at the facility and sustained a right toe fracture. LPA reviewed R1’s Medical Records dated October 18, 2025, which indicate R1 sustained a closed displaced fracture of the great toe. LPA interviewed AD who stated that R1 is a fall risk due to their multiple sclerosis which flares up and makes them unsteady, R1 does a good job keeping the facility informed of these flare ups and asking for extra care when necessary, and R1 has had multiple falls while at the facility but this is the first fracture R1 sustained. LPA reviewed R1’s Physician’s Report dated October 14, 2025, which indicates R1 has active progressive multiple sclerosis, Parkinson’s disease, and neuropathy, is non-ambulatory due to physical condition, but does not need assistance with bathing, dressing, eating, or toileting. LPA reviewed R1’s Personal Service Plan dated September 13, 2025, which indicates R1 is able to shower themselves but assistance was added for when R1 requests assistance, R1 is able to use the bathroom without assistance, escorts were temporarily added during a flare up of R1’s multiple sclerosis, and R1 is on the facility’s standard fall prevention plan. Per AD and facility staff, R1 was at a skilled nursing facility for over a month due to a multiple sclerosis flare up and returned to the facility on October 15, 2025, facility staff reassessed R1 to require additional care prior to R1 returning to the facility on October 15, 2025, and additional care was added to R1’s Personal Service Plan. LPA reviewed R1’s Personal Service Plan dated October 23, 2025, which documents the care services provided to R1 as of their return to the facility on October 15, 2025, and noted that assistance with emptying the commode and escorts were added. Per AD, R1 had a commode near their bed, R1 is able to get out of bed and to the commode on their own, but on October 18, 2025, R1 must have had a symptom of their multiple sclerosis and fallen on the way to the commode, injured their toe, and was taken to the hospital for treatment. Per facility staff, R1 has been receiving home health services three times a week for the toe injury and is not complaining of pain and R1’s room has been decluttered as clutter may have also played a role in R1’s fall. LPA interviewed R1 who raised no concerns over the care they receive at the facility. The information obtained did not corroborate lack of care and supervision causing R1’s fall as the facility regularly updated R1’s Personal Service Plans and added assistance where necessary to try to address R1’s chronic and evolving fall risk due to their multiple sclerosis. There were no deficiencies observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Nov 24, 2025

Allegation investigated: Staff stole money from resident Staff are going through residents personal belongings without consent

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. An initial investigation visit was conducted on June 06, 2025 by the Department. It was alleged staff stole money from resident and staff are going through resident's personal belongings without consent. During the investigation, the Department conducted interviews with residents in care and staff. LPA Arias reviewed records obtained. The investigation determined as follows: Regarding the allegation staff stole money from resident , it was reported staff stole $70 from resident 1 (R1). LPA interview with R1 stated $70 went missing from their money bag which was kept on their person in May 2025. R1 stated they found the money in their wallet located in the room later on and must have been misplaced. R1 stated they have more items than they need and is in process of decluttering their room. Unfounded LPA interviews with three out of five staff stated R1 has hoarding tendencies. Two out of five staff added R1 has had help to declutter R1's room. Physician's report for R1 stated diagnosis of compulsive hoarding. Regarding the allegation staff are going through residents personal belongings without consent, it was reported personal items have been moved in R1's room including hearing aids. LPA interview with R1 stated R1 had one of their two hearing aids missing for about 3 weeks. R1 stated they later found the second hearing aid on the floor next to the bed. R1 stated they did not witness a staff member move their hearing aids or other personal items. LPA interviews with two out of two additional residents stated they have not had any staff move their personal belongings without their consent. Based on Department interviews and record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed to be UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Oct 14, 2025 · control 22-AS-20250530152109

Allegation investigated: Facility did not maintain a clean and sanitary environment

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Brisseth Arrellano, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that facility did not maintain a clean and sanitary environment revealed the following: During the course of the investigation, LPA inspected the facility, conducted health and safety checks on residents, interviewed AD, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, and Resident #1’s (R1) Medical Records. CONTINUED Unfounded It was alleged that R1 has gastrointestinal issues causing odor, staff open R1’s door to air out their room into the hallway, and the odor goes into other resident’s rooms causing illness. LPA inspected the entire facility, including the memory care and assisted living sections, common areas, hallways, and 16 resident rooms, including the room of R1 and their neighbors, and noted no bad odors. LPA interviewed four neighboring residents and did not obtain information corroborating any issues relating to smell in the area around R1’s room. LPA interviewed AD who stated that R1 receives incontinence care, does not have any gastrointestinal issues and has regular bowel movements, receives incontinence care with the hallway door closed and the patio door open, and requests that the hallway door be opened after incontinence care is completed and the facility does not deny R1 this personal right. Per AD, there is nothing out of the ordinary about R1 or their incontinence care, the same type of care is provided throughout the facility with no issue, R1 has been out of the facility for almost a month and no complaints were received from other residents about the incontinence care provided to R1 while it was taking place at the facility, and the facility takes general steps to address odors from incontinence care including opening the patio doors, using sprays and diffusers, and running the central air conditioning system. AD stated that the facility was unaware of the alleged odor issue while R1 was in the facility, but if R1 had been at the facility, AD would have inspected their room and asked neighboring residents to gauge the impact of the smell and would have taken appropriate measures to try to mitigate the impact. LPA interviewed one staff who denied the allegation, claiming they never observed any out of the ordinary smells with R1 and that R1 had no gastrointestinal issues. LPA reviewed R1’s Medical Records which indicate that as of September 3, 2025, R1 was not noted to have any gastrointestinal concerns or diagnoses by their doctor. The investigation did not reveal any information corroborating that other residents contracted any gastrointestinal issues from R1. No information was obtained corroborating that there were out of the ordinary smells coming from R1’s room, that any residents were bothered by smells coming from R1’s room, or that the facility did not properly address odors relating to incontinence care. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 22-AS-20250924155802

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20250924155802. LPA met with Administrator (AD) Brisseth Arrellano and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, conducted health and safety checks on residents, interviewed AD, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, and Resident #1’s (R1) Medical Records. Per AD, R1 was sent to the hospital on September 5, 2025, due to change in condition and is still hospitalized, but this incident was not reported. Based on incident reports received at the Orange County Regional Office (OCRO) and AD’s admission, R1’s hospitalization on September 5, 2025, was not reported as required. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Sep 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Oct 21, 2025

87211 Reporting Requirements (a) … (1) A written report shall be submitted to the licensing agency … within seven days of the occurrence of … (B) Any serious injury… This requirement was not met as evidenced by: Based on documents and admission, the licensee did not ensure R1’s hospitalization on September 5, 2025, was reported to licensing, which poses a potential safety risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Sep 30, 2025

Plan of correction: Licensee stated that they will retrain staff on reporting requirements and submit proof to LPA by POC due date.

Allegation investigated: Staff did not adequately supervise resident resulting in resident's injury

Licensing Program Analyst (LPA) Celine Rodriguez conducted an unannounced continuation visit to the facility and to deliver the findings. LPA Rodriguez explained the purpose of today's visit, and met with Executive Director (ED) Brisseth Arrellano. It was alleged that staff did not adequately supervise resident resulting in resident's injury. 12 out of 12 resident interviews and 2 out of 2 staff interviews did not corroborate with the allegation. 7 out of the 12 resident interviews conducted specified that staff are well trained, knowledgeable, and that all basic needs are met, including support and supervision. Per documentation review, of resident 1’s (R1) physician report, R1 was diagnosed with dementia, and had a history of falls prior to admission, and was admitted to the facility only for medication management. On 11/4/2022, R1 sustained a fall while hospice nurse was conducting a visit, to which R1 was then prescribed medications to assist with pain, due to obtaining a bruise, however R1 sustained no wound, or injury from fall. Facility conducted checks on R1, despite R1 not being on 1:1 supervision. Unsubstantiated Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with ED Arrellano, and a copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Sep 17, 2025 · control 22-AS-20221108163825

Type of visit: POC

Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to follow up on the deficiency issued during the Annual Inspection on August 28, 2025. Based on the review of the Type B deficiency, 87303(a), facility has complied with the terms of the Plan of Correction (POC) as per inspection of the apartment unit of Resident #1 (R1) with Maintenance Supervisor Francisco Sarabia. An exit interview was conducted with Business Office Manager Patty Jimenez, and a copy of this report including the Letter of Deficiency Citations Cleared were provided at the end of this visit.the state’s words, verbatim · CDSS document, Sep 11, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Required 1-Year annual evaluation using the Care Inspection Tool. LPA was greeted and granted entry by the receptionist and explained the reason for the visit to Executive Director (ED) Brisseth Arrellano and Business Office Manager (BOM) Patricia Jimenez. LPA toured the physical plant with BOM Jimenez. Facility is clean, sanitary, and in good repair except for one out of twelve units. LPA observed the presence of mold on one panel of the ceiling caused by a small drip from the water pipe running through the ceiling. The ceiling panel was removed and replaced during the visit. All bedrooms had the required furnishings, and bathrooms were found to be in compliance, clean, and operational. The hot water temperature measured between the ranges of 110.8 and 119.6 degrees Fahrenheit in twelve bathrooms. All common areas were inspected including the kitchen, dining, and courtyards. LPA observed sufficient emergency food and water in the kitchen and storage. There were ample supply of clean towels and linens. Toxins, disinfectants, sharps, and medications were secured and inaccessible. The first aid kit had all necessary items. LPA observed ample supply of two-day perishables and seven-day non-perishable food in the kitchen. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction and there were sufficient seating and shading. The fire extinguishers were serviced on February 4, 2025. The smoke/carbon monoxide detectors were tested this year per maintenance director and proof of service will be submitted to LPA by August 29, 2025. Evac chairs were observed at each stairwell. The Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the correct size. Facility was advised on the following: to ensure the facility is clean, sanitary, and in good repair at all times. Based on the observations made during today's visit, a deficiency is being cited on the attached LIC809-D. An exit interview was conducted with Executive Director Brisseth Arrellano and Business Office Manager Patricia Jimenez, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Aug 28, 2025

Allegation investigated: AC units in disrepair

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Staff #1 (S1) Francisco Sarabia, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation of AC units in disrepair revealed the following: During the course of the investigation, LPA inspected the facility, conducted health and safety checks on residents, interviewed S1 and residents, and obtained and reviewed copies of the resident roster, staff roster, and the facility’s maintenance records. CONTINUED Unsubstantiated It was alleged that the facility’s AC system is not being properly maintained resulting in poor performance, outages, and uncomfortable temperatures. LPA inspected the facility and observed no health and safety issues. LPA interviewed 11 residents and did not obtain information corroborating the allegation. LPA inspected the temperatures and thermostats in 12 residents rooms, observed the air conditioning and heating working properly, and observed that all rooms were at comfortable temperatures that the residents had chosen using their thermostats. LPA interviewed S1, the facility’s maintenance supervisor, who stated that the air conditioning system is properly maintained, but began shutting itself off a few months ago and the frequency at which it shuts itself off has increased over time. S1 denied that this issue has impacted residents or created uncomfortable temperatures within the facility, stating they always restart the system immediately, the system was never off for more than one hour, and there have not been many hot days in the last few months. Per S1, as soon as the problem began, S1 and third-party air conditioning technicians have been working to diagnose and fix the problem. LPA reviewed the facility’s maintenance records which corroborate that the facility has been diligently working to diagnose and fix the issue with the air conditioning system. Although the air conditioning system has been having problems recently, the investigation revealed that the facility has been diligently working to fix the problem and that residents have not been impacted with uncomfortable temperatures. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 22-AS-20250415140543

Allegation investigated: Resident sustained a head injury due to lack of supervision Resident sustained multiple falls due to lack of supervision

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Brisseth Arrellano, discussed the purpose of the inspection, and explained the allegations. The investigation into the allegations that resident sustained a head injury due to lack of supervision and resident sustained multiple falls due to lack of supervision revealed the following: During the course of the investigation, LPA inspected the facility, conducted health and safety checks on residents, interviewed Administrator (AD) Jeri Miles, residents, staff, and witnesses, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Progress Notes, R1’s Physician’s Report dated November 29, 2023, R1’s Personal Service Plan dated January 1, 2024, R1’s Personal Service Plan dated August 30, 2024, R1’s Personal Service Plan dated January 1, 2024, R1’s Personal Service Plan dated September 18, 2024, Staff Training Records, R1’s Medical Records dated February 4, 2025, and the facility’s staff schedule. Unsubstantiated It was alleged that, due to lack of care and supervision, R1 had multiple falls at the facility that resulted in a head injury. LPA inspected the facility, conducted health and safety checks on R1 and other residents, and did not observe any health and safety issues. LPA reviewed R1’s Progress Notes which state that: on February 1, 2025, R1 had an unwitnessed fall, sustained a laceration to their head, was treated at a hospital, and returned to the facility the same day; on February 4, 2025, R1 had an unwitnessed fall, sustained a bruise to their head, was treated at a hospital, and returned to the facility the same day; and on February 5, 2025, R1 had an unwitnessed fall, did not sustain any injuries, and was seen by a nurse at the facility. LPA interviewed AD and one facility staff who reported that R1 moved in on December 9, 2023, was not a fall risk when they moved in, and had the facility’s basic fall prevention plan which includes encouraging residents to engage in the common area so they can be more closely monitored by staff and regular checks when they are in their rooms. LPA reviewed R1’s Physician’s Report dated November 29, 2023, which indicates R1 has Dementia, does not have any impairments relating to movement, is ambulatory, and can independently transfer to and from bed. Per R1’s Progress Notes, R1 had multiple falls in 2024. When interviewed, AD and facility staff stated that none of R1’s multiple falls in 2024 resulted in fractures or hospitalization, the facility reassessed R1 and noticed that R1’s balance issues were worsening, the facility held multiple care plan meetings with R1’s responsible party and updated R1’s care plan multiple times to address R1’s changing needs, and the facility conducted staff trainings on safe resident transfers, ergonomics, and gait belts. LPA reviewed R1’s Personal Service Plan dated January 1, 2024, R1’s Personal Service Plan dated August 30, 2024, and R1’s Personal Service Plan dated September 18, 2024, which corroborate that services were added to R1’s care plan as R1’s balance declined to ensure the facility was meeting R1’s needs with regards to their increasing fall risk. LPA also reviewed Staff Training Records that corroborated that the facility conducted additional staff training relating to falls. Per R1’s Progress Notes and interview with AD, R1’s falls in February 2025 did not result in hospitalization or fractures and R1’s laceration and bruise healed quickly with no issues. LPA reviewed R1’s Medical Records dated February 4, 2025, which indicate that R1 did not sustain any serious head injury from their fall on February 4, 2025. AD stated that in response to R1’s falls in February 2025, the facility took additional measures to address R1’s fall risk, including adding a fall mat, a wheelchair, and medication changes as facility staff had suspected one of R1’s medications was contributing to R1’s balance issues. Per AD and R1’s Progress Notes, R1 has not had a fall since February 5, 2025. LPA reviewed the facility’s staff schedule and did not note any staffing issues that may have contributed to R1’s falls. LPA interviewed R1’s responsible party who had no concerns about the care R1 was receiving at the facility. LPA interviewed two care staff and did not obtain information corroborating the allegations. LPA interviewed 12 residents and did not obtain information corroborating the allegations. Based on the information obtained, while R1 has sustained falls at the facility, the falls did not result in serious injury or hospitalization and the facility has diligently updated R1’s care plan to address R1’s changing needs. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Mar 24, 2025 · control 22-AS-20250205085503

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20250205085503. LPA met with Administrator (AD) Jeri Miles and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, conducted health and safety checks on residents, interviewed AD, and obtained and reviewed copies of the resident roster, staff roster, and Resident #1’s (R1) Progress Notes. LPA reviewed R1’s Progress Notes which state that: on February 1, 2025, R1 had an unwitnessed fall, sustained a laceration to their head, was treated at a hospital, and returned to the facility the same day; on February 4, 2025, R1 had an unwitnessed fall, sustained a bruise to their head, was treated at a hospital, and returned to the facility the same day; and on February 5, 2025, R1 had an unwitnessed fall, did not sustain any injuries, and was seen by a nurse at the facility. However, based on incident reports received at the Orange County Regional Office (OCRO) and AD’s admission, R1’s fall on February 1, 2025, was not reported as required. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Mar 3, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Mar 17, 2025

87211 Reporting Requirements (a) … (1) A written report shall be submitted to the licensing agency … within seven days of the occurrence of … (B) Any serious injury… This requirement was not met as evidenced by: Based on documents and admission, the licensee did not ensure R1’s fall on February 1, 2025, was reported to licensing, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 3, 2025

Plan of correction: Licensee stated that they will retrain staff on reporting requirements and submit proof to LPA by POC due date.

Allegation investigated: Facility staff falsified the resident's Physician Report Resident was unlawfully retained in Memory Care

Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Brandon Lopez conducted an unannounced visit to deliver findings on the above allegations received on June 05, 2024. LPAs were greeted and granted entry into the facility and met with Administrator (AD) Jeri Miles. LPAs explained the reason for the visit. This Department has investigated the complaint alleging that facility staff falsified the resident's Physician Report. Resident 1 (R1) was admitted to the facility on September 22, 2023. Documents reviewed included the Physician Report (LIC602) dated February 12, 2024, for R1. Per Physician report R1’s diagnoses are Hypertension and Major Depressive Disorder. Per Physician report dated February 12, 2024, R1 does not have a diagnosis of Dementia and is able to leave the facility unassisted. During the investigation LPA reviewed documents including the Physician Report dated February 11, 2024, for R1. Per Physician report dated February 11, 2024, R1 has a diagnosis of Dementia and is not able to leave the facility unassisted. During the course of the investigation LPA conducted interviews with witness 1 (W1), who is a Scan Associate General Counsel. CONTINUED ON LIC9099-C... Substantiated Per W1 Scan’s Nurse Practitioner (NP) was not working on February 11, 2024, and stated that the NP completed the Physician report for R1 on February 12, 2024. Regarding the allegation that Resident was unlawfully retained in Memory Care, the following was revealed: During the investigation LPA reviewed documents including the Personal Service Plan dated February 12, 2024, for R1. Per Personal Service Plan under comments, it states Resident with Scan as of move in. During the course of the complaint LPA reviewed documents including the Senior Doc New Provider orders dated February 10, 2024, for R1. Per New Provider orders it states patient may remain in the community in a locked/secured area/unit. LPA reviewed the Scan monthly visit dated February 12, 2024, for R1. Per Scan notes patient was seen and evaluated inside the Memory Care. During the course of the investigation LPA reviewed the Brookdale Garden Grove Progress Notes dated February 10, 2024, for R1. Per Progress notes is states R1 moved from Assisted Living to Memory Care same day and LIC602 to be completed today by provider to reflect change. Per Physician report dated February 12, 2024, R1 does not have a diagnosis of Dementia and is able to leave the facility unassisted. Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: facility staff falsified the resident's Physician Report and Resident was unlawfully retained in Memory Care are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with AD Miles and a copy of this report along with the Appeal Rights were provided at the time of this visit.the state’s words, verbatim · CDSS document, Feb 13, 2025 · control 22-AS-20240605094352

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Feb 14, 2025

87207 False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This regulation was not met as evidence by: Based on interviews conducted and records reviewed the Physician report dated 02/11/24 was not filled out by Scan's Nurse Parctitioner as Nurse Practitoner was not working on 02/11/24. This poses an immediately risk to resident’s health and safety.the state’s words, verbatim · CDSS document, Feb 13, 2025

Plan of correction: Licensee agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a) · Plan of correction due date: Feb 20, 2025

87468(a) Personal Rights. Residents in residential care facilities for the elderly shall have personal rights which include, but are not limited to, those listed in Sections 87468.1, Personal Rights of Residents in All Facilities, and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. This regulation was not met as evidence by: Based on interviews conducted and records reviewed the facility did not communicate with R1's Authorized Representative prior to placing R1 in Memory Care. CONT...the state’s words, verbatim · CDSS document, Feb 13, 2025

Plan of correction: Licensee agrees to read regulation and sign a statement of understanding, provide in-service training and forward proof to LPA by POC due date. Per Physician report dated 02/12/24, R1 does not have a diagnosis of Dementia and is able to leave the facility unassisted.

Allegation investigated: Staff do not ensure the facility is free from mold

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegation listed above. LPA was greeted and granted entry by facility administrator Jeri Miles after stating the purpose of the visit and listing the allegation investigated. An initial complaint investigation was conducted on November 18, 2024. During the visit, LPA accompanied by facility maintenance director Francisco Sarabia conducted a tour of the physical plant's both levels, including the main lobby, staff break room, laundry room, water heater closet, water softener room, television room and library, dwelling unit wings, hallways and staircases on both the ground level and upper level. Three occupied units were inspected during the visit on both levels. The facility's central courtyard and rose garden were also visited. The memory care was also inspected including the common area and four shared units and the secure courtyard. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 During the present visit, LPA requested the facility census and toured the premises again. A total of six resident interviews were conducted during the visit. Regarding the allegation that Staff do not ensure the facility is free from mold, the following has been concluded: Based on two tours of the physical plant, a review of a total seven units during the initial inspection and seven units on the present visit as well as interviews with six residents, LPA was able to corroborate the occurrence of a water damage incident in the facility's boiler room in November 2024. Adequate containment measures were observed and the room was observed to be dry upon a second visit. Regarding leaks along sprinklers or air conditioners, no instances of leaks or indications of the potential presence of mold were evidenced. Interviews conducted additionally failed to provide sufficient evidence of suspicion of mold on the premises either. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Feb 5, 2025 · control 22-AS-20241112102106

Allegation investigated: Facility did not provide all requested records to authorized representative Facility did not allow resident to participate in care planning Facility did not allow resident to choose healthcare provider

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on April 17, 2024. LPA was greeted and granted entry into the facility and met with Administrator (AD) Jeri Miles. LPA explained the reason for the visit. This Department has investigated the complaint alleging that facility did not provide all requested records to authorized representative. Resident 1 (R1) was admitted to the facility on September 22, 2023. Documents reviewed included the Physician Report (LIC602) dated February 12, 2024 for R1. Per Physician report R1’s diagnoses are Hypertension and Major Depressive Disorder. During the investigation LPA reviewed documents including the Progress Notes dated September 22, 2023 through March 01, 2024. During the visit on November 25, 2024 LPA reviewed additional Progress notes dated March 01, 2024 through April 03, 2024. R1 was discharged from the facility on April 03, 2024. CONTINUED ON LIC9099-C... Substantiated Per Witness 1 (W1) as of November 25, 2024 they have not received R1's records for March 2024. Regarding the allegation that facility did not allow resident to participate in care planning, the following was revealed: During the course of the complaint LPA reviewed documents including the Senior Doc New Provider orders dated February 10, 2024 for R1. Per Provider orders it states patient may remain in the community in a locked/secured area/unit. During the course of the interviews, W1 reported that she is the Authorized Representative for R1. W1 stated that on February 10, 2024 she was not notified regarding the updated care planning. Per W1 the Health and Wellness Director notified a family member but not the Authorized Representative. Regarding the allegation that facility did not allow resident to choose healthcare provider, the following was revealed: During the investigation LPA reviewed documents including the Personal Service Plan dated February 12, 2024 for R1. Per Personal Service Plan under comments it states Resident with Scan as of move in. Per Progress notes on February 10, 2024 R1 had a tele medicine visit with a provider from Senior Doc. LPA reviewed the Scan monthly visit dated February 12, 2024 for R1. Per Scan notes patient was seen and evaluated inside the Memory Care. Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegations: facility did not provide all requested records to authorized representative, facility did not allow resident to participate in care planning and facility did not allow resident to choose healthcare provider are deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with AD Miles and a copy of this report along with the Appeal Rights were provided at the time of this visit.the state’s words, verbatim · CDSS document, Nov 25, 2024 · control 22-AS-20240417072007

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(c)(1) · Plan of correction due date: Nov 29, 2024

(c)All information and records obtained from or regarding residents shall be confidential. (1)...The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidence by: the facility did not provide R1's records for March 2024. This poses a potential risk to persons in care.the state’s words, verbatim · CDSS document, Nov 25, 2024

Plan of correction: Licensee to provide R1's records to their Authorized Representative. Licensee to email POC to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87467(3) · Plan of correction due date: Nov 29, 2024

Resident Participation in Decisionmaking (3)The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident’s condition, or once every 12 months, whichever occurs first. This requirement was not met as evidence by the facility not arranging a meeting with R1 and their Authorized Representative prior to placing R1 in Memory Care. This poses a potential risk to persons in care.the state’s words, verbatim · CDSS document, Nov 25, 2024

Plan of correction: Licensee to read and sign a statement of understanding. Licensee to email a copy to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(7) · Plan of correction due date: Nov 29, 2024

Additional Personal Rights of Residents in Privately Operated Facilities (a)(7) To fully participate in planning their care, including the right to attend and participate in meetings or communications regarding care and services to be provided, according to Health and Safety Code section 1569.80 and involve persons of their choice in this planning. This requirement was not met as evidence by: On 02/10/24 R1 had a tele medicine visit by a Provider from Senior Doc.; however, R1's provider was from Scan Health Plan. This poses a potential risk to persons in care.the state’s words, verbatim · CDSS document, Nov 25, 2024

Plan of correction: Licensee to read and sign a statement of understanding. Licensee to email a copy to LPA by POC due date.

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad, Samer Haddadin, and William Vanegas for the purpose of conducting a Required – 1 Year Inspection. LPAs met with Administrator (AD) Jeri Miles and discussed the purpose of the inspection. LPAs reviewed Infection Control requirements. At about 9:00AM, LPAs and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a large commercial facility. Facility is composed of a single, two-story building with a delayed egress memory care unit on the first floor, a commercial kitchen and large dining room on the first floor, a medication room on the second floor, and resident rooms on all floors, along with multiple common areas, storage rooms, and a large central courtyard and a smaller courtyard dedicated to memory care with shaded seating for residents. There are a total of 115 resident rooms. Resident Bedrooms: the 12 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 12 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 107 degrees F and 120 degrees in the 12 resident bathrooms inspected, after corrections. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have been paid. At about 10:30AM, LPAs reviewed 6 resident files and 6 staff files, interviewed 6 residents and 6 staff, and inspected medications for 6 residents. Facility does not handle resident money. CONTINUED During the inspection, LPAs and AD observed the following: based on observation, the faucets in rooms 103, 104, 115, and 243 tested at 126, 133, 124, and 129 degrees F, respectively, and rooms 103, 104, and 115 are in memory care. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 9, 2024

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.

Type of visit: Case Management - Other

On today's date, LPA Quiroz called Administrator (AD) Jeri Miles via telephone to discuss amended report for complaint control #22-AS-20240226102932 dated 6/21/2024 on page 2 of 2. LPA Quiroz discussed amended report with AD Jeri Miles. An exit interview was conducted with AD Miles via telephone, and it was explained that a copy of amended report for complaint control #22-AS-20240226102932 and today's report would be emailed to facility. An electronic email read receipt confirms receiving of the report. AD Miles agreed to print the amended report and today's case management report, sign and email copy including signatures to LPA Quiroz.the state’s words, verbatim · CDSS document, Jun 24, 2024

Allegation investigated: -Staff did not provide adequate supervision, resulting in a resident wandering away from the facility. -Staff did not adequately notify resident’s authorized representative of a change in resident's placement. -Staff inappropriately placed resident in a locked unit.

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to deliver complaint findings regarding the allegations listed above. LPA was greeted and granted entry into the facility by front desk receptionist and met with Administrator (AD) Jeri Miles and Brisseth Rivera, Health Wellness Director and discussed purpose of the visit. The department received a complaint on 2/26/2024. LPA Quiroz conducted the initial 10 day visit on 03/06/2024 and follow up visit on 4/3/2024. During the course of the investigation LPA Quiroz interviewed staff, residents and other witnesses. LPA Quiroz obtained copies of resident records but not limited to physician reports, needs and services plans, progress notes, identification form, Admission agreement and Provider medical orders. Regarding the allegation that "Staff did not provide adequate supervision resulting in a resident wandering away from the facility,” the investigation revealed the following: Resident 1 (R1) physician report dated 4/7/2023 page 4 of 6 indicates R1 is not able to leave the facility unassisted and requires supervision. CONTINUED ON NEXT LIC 9099-C PAGE... Substantiated CONTINUED...During the course of the investigation, 4 of 4 interviewees indicated there were 2 staff working in Assisted living area and two staff working in the memory care unit during incident of R1s wandering behavior. Three of four interviewees indicated the need for additional staffing during the night shift. Regarding the allegation that “Staff did not adequately notify resident’s authorized representative of a change in resident's placement,” the investigation revealed the following: The Facility attempted to communicate with who the facility staff believed to be R1’s responsible party; however the facility contacted a Family member identified on the LIC 601-Identification and Emergency Form under Person(s) responsible for financial affairs, payment for care, legal guardian if any, but not the authorized representative. Regarding the allegation that “Staff inappropriately placed resident in a locked unit,” the investigation revealed the following: The facility did not provide the resident and responsible party with a 30 day notice, and did not communicate with Authorized representative prior to placing the resident in delayed egress memory care unit. Although, the facility was attempting to ensure R1s Health and Safety by placing R1 in delayed egress memory care unit, the facility attempted to substitute R1’s supervision needed to meet R1s need and provide necessary supervision. Therefore, based on evidence through records reviewed and interviews conducted the allegations “Staff did not provide adequate supervision, resulting in a resident wandering away from the facility,” “Staff did not adequately notify resident’s authorized representative of a change in resident's placement,” and “Staff inappropriately placed resident in a locked unit” are determined to be SUBSTANTIATED, meaning the complaint allegations are valid and that a violation has occurred. (SEE LIC 9099-D) The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted with (AD) Jeri Miles and (HWD) Brisseth Rivera, and a copy of this report, Appeal rights, LIC 9099-D page, and LIC 811- Confidential names were provided at exit. CONTINUED...responding paramedics and SCAN provider and by the SENIOR DOC provider on 2/10/2024 and reassessed by the SCAN provider on 2/11/2024 at 12:57am and 3/26/2024 at 1:57pm. Interview conducted with 1 of 1 witness reported that the assessment with SENIOR DOC on 2/10/2024 may have been inauthentic, multiple attempts were conducted to interview provider with SENIOR DOC, however, LPA Quiroz was unable to speak to SENIOR DOC provider. Interview with 1 of 1 witness reported that the assessment with SCAN on 2/11/2024 may have been inauthentic as the witness reported the SCAN provider was not on duty at the time of the reported assessment. Interview with 1 of 1 witness reported that the assessment dated 3/26/2024 may have been inauthentic as R1 was not present at the facility on the date and time of the reported assessment. Therefore based on the preponderance of evidence gathered through interviews, documentation review and observations conducted by LPA Quiroz, the allegation that the "Staff did not conduct a timely reappraisal following a change in resident’s condition," was found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator Jeri Miles and a copy of this report, LIC 811-Confidential names were provided at exit. ***THIS IS AN AMENDED REPORT***the state’s words, verbatim · CDSS document, Jun 21, 2024 · control 22-AS-20240226102932

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80072(a)(2)(3) · Plan of correction due date: Jun 26, 2024

80072:Personal Rights(a)each client shall have personal rights which include... (2) To be accorded safe, healthful and comfortable accommodations,...to meet his/her needs.(3)To be free from corporal or unusual punishment, infliction of pain, humiliation, CONTINUED... CONTintimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature...This requirement was not met as evidenced by: The facility did not provide the resident and responsible party with a 30 day notice, and did not communicate with Authorized representative prior CONT...the state’s words, verbatim · CDSS document, Jun 21, 2024

Plan of correction: AD Jeri Miles and HWD Brisseth Rivera agreed to read and understand CCR 80072, provide inservice to facility staff and submit proof of understanding to CCLD by 6/25/2024. to placing the resident in memory care. Although, the facility was attempting to ensure R1s Health and Safety by placing R1 in memory care unit, the facility attempted to substitute R1’s supervision needed to meet R1s need and provide necessary supervision. This poses a potential risk to residents in care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jun 24, 2024

87464(f)(1):Basic Services shall at a minimum include: (1) Care and Supervision as defined in Section 87101(c)(3) and Health & Safety Code 1569.2(C) "care and supervision means the facility responsibility for or provides or promises in future, ongoing assistance with activities CONT... assistance with activities of daily living without which the resident's physical, mental, health & safety, or welfare would be endangered. This requirement is not met as evidenced by the complaint investigation:The facility did not provide the resident and responsible party with a 30 day notice, CONTthe state’s words, verbatim · CDSS document, Jun 21, 2024

Plan of correction: AD Miles agreed to provide in-service training to facility staff regarding care and supervision and submit proof of udnerstading of CCR 87464 by POC due date of 6/25/2024. In addition, HWD Rivera indicated desire to enroll in AD certificate course to learn Title 22. and did not communicate with Authorized representative prior to placing the resident in delayed egress memory care unit. Although, the facility was attempting to ensure R1s Health and Safety by placing R1 in delayed egress memory care unit, the facility attempted to substitute R1’s supervision needed to meet R1s need and provide necessary supervision.This poses a potential risk to the residents in care.

Type of visit: Case Management - Deficiencies

On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz conducted a subsequent visit to cite deficiency discovered during the investigation of Complaint Control #22-AS-20240226102932. LPA met with Jeri Miles, Administrator and Brisseth Rivera, Health and Wellness Director and discussed the purpose of the visit. During the course of the investigation, based on interviews and file review, the facility did not provide 30 day written notice to Resident 1 (R1) and their responsible party prior to moving R1 from Assisted Living to Memory Care unit. This poses a potential risk to residents in care. An exit interview was conducted with AD Jeri Miles, and a copy of this report LIC 809 D, Appeal Rights and LIC 811- Confidential Names list were provided at exit.the state’s words, verbatim · CDSS document, Jun 21, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(16) · Plan of correction due date: Jun 25, 2024

87468.2(a)(16):Additional Personal Rights of Residents in Privately Operated Facilities (a)... residents...shall have...:(16) To written notice of any room changes at least 30 days in advance unless...agreed to...to fill a vacant bed, or...due to an emergency. This requirement was not met as evidenced by: The licensee failed to ensure this additional personal right was afforded to R1. Based on interviews and file review, the facility did not provide written notice to R1’s responsible party within 30 days of moving R1 to memory care unit. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Jun 21, 2024

Plan of correction: AD stated the facility will submit a statement of understanding of the regulation cited and will provide in service training to all staff and provide proof to CCL by POC due date of 1/25/2024.

Allegation investigated: Facility is not adhering to resident's Admission Agreement.

Licensing Program Analysts (LPAs) Jessica Cho and Edward Kim arrived at the facility unannounced to initiate the 10-day complaint investigation into the above allegation. LPAs stated the purpose of the visit to Business Office Manager (BOM) Patricia Jimenez, and Executive Director (ED) Jeri Miles was also adivsed of the visit upon arrival. During the course of the investigation, LPAs interviewed staff and obtained copies of pertinent documentation for Resident #1 (R1) which includes: Resident Roster, Personnel Report, Face Sheet, Physician's Report, Residency Agreement, Physician Certification Letter, March/April 2024 Rent Receipts, Visitor Sign-In/Out Sheets, and Notes. The following was determined: It is alleged that the facility is not adhering to the resident's admission agreement. Based on the review of the staff's notes, R1 was admitted to the hospital on March 27, 2024 and has not returned to the facility since. Two out of the two staff interviews revealed that R1's Responsble Person (RP) moved out R1's personal belongings on April 1, 2024, providing a certification letter to the facility written by a social worker dated April 1, 2024, and communicating their intent to move out R1. Substantiated Per review of the Residency Agreement docusigned and dated on April 12, 2023 by both parties, the agreement states on page 8, Section D, that the agreement will be immediately terminated "upon written notice if a physician certifies... in writing" due to reasons of health. As a result of the agreement, facility requested that the RP obtains a physician certified letter in lieu of a letter certified by a social worker. The physician certified letter dated April 16, 2024 was provided to the facility which is the effective date of R1's move. It is determined based on the evidence obtained that the facility is not adhering to the resident's admission agreement due to not issuing a prorated refund. Therefore, based on LPAs' interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. A deficiency is being cited on the attached LIC 9099D. An exit interview was conducted with Executive Director Jeri Miles, and a copy of this report including the LIC9099C, LIC9099D, LIC811, and the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Apr 23, 2024 · control 22-AS-20240417114300

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Apr 30, 2024

87507 Admission Agreement (f) "The licensee shall comply with all applicable terms and conditions set forth in the admission agreement..." This requirement was not met as evidenced by: Based on interviews and record review, facility did not adhere to the admission agreement pertaining to refunds which poses a potential Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 23, 2024

Plan of correction: Executive Director stated they will issue a refund to R1's responsbile party, and to submit an Acknowledgement of Understanding for the said deficiency to LPA via email by POC due date.

Allegation investigated: Facility did not provide requested records to authorized representative

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Jeri Miles, Executive Director, and explained the reason for the visit. It is alleged the facility did not provide requested records to authorized representatives. Based on interview with 2 of 2 staff revealed that they received a request on March 11, 2024, for copies of resident records that included from admission to current. Staff indicated that requestor was not the authorized presentative and facility did not receive an updated change of POA until March 14, 2024. Staff indicated that they started working on request the same day the update was received, and documents were forwarded to the legal department for processing. Copies of pertinent documents revealed that on March 15, 2024, there was Continued on LIC9099-C Unsubstantiated correspondence to update requestor and with information that records needed to be gathered and records would be available by Tuesday (March 19, 2024) of the following week. Records obtained reflect that on March 19, 2024, records were sent over via email to the requestor. As of today, the records request has been fulfilled and the requestor has obtained copies. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with Executive Director and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Mar 20, 2024 · control 22-AS-20240319093642

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) arrived unannounced for a Case Management visit. LPA met with Executive Director Jeri Miles and explained the reason for the visit. During today's visit, LPA interviewed Resident #1 (R1) in connection to Complaint Control Number: 22-AS-20230919083629 and obtained records. An exit interview was conducted with Executive Director Jeri Miles, and copy of this report and LIC811 were provided at the end of the visit.the state’s words, verbatim · CDSS document, Dec 7, 2023

Allegation investigated: -Resident was inappropriately pushed while in care -Residents sustained unexplained injuries while in care -Staff speak inappropriately towards a resident while in care -Residents sustains multiple falls while in care

On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to the facility to follow up on allegations listed above. LPA Quiroz was greeted and granted entry by Front Desk Receptionist and met with Patricia Jimenez, Business Office Manager and discussed purpose of today's visit. The 10 day visit was conducted by LPA Quiroz on 12/08/2020 virtually due to COVID-19 Pandemic. A follow up investigation visit was conducted by LPA Quiroz on 8/8/2023. During the course of this investigation, LPA Quiroz conducted interviews with interviewees consisting of staff, clients, witnesses and reviewed documentation but not limited to Personnel Report LIC 500, staff schedules,resident roster, Physician Reports, Identification Forms and Needs and Services Plans. It is alleged that “Resident was inappropriately pushed while in care,” “Residents sustained unexplained injuries while in care,” “Staff speak inappropriately towards a resident while in care” and “Residents sustains multiple falls while in care.” CONTINUED ON NEXT LIC 9099-C PAGE... Unsubstantiated CONTINUED...During the course of the investigation, the investigation revealed the following: Resident 1(R1) was admitted to the facility on 9/30/2017. (R1s) Physician report dated 11/10/2020 indicates primary diagnose as Parkinson’s disease and secondary diagnose as Progressive Supranuclear Disease (PSP). PSP is a condition that causes symptoms similar to those of Parkinson's disease involving damage to many cells of the brain including the part of the brainstem where cells that control eye movement are located and the area of the brain that controls steadiness when you walk is also affected. On 12/8/2020 while conducting 10 day visit, interviewee indicated that (R1) was noted to be wheelchair dependent stating “Staff have reported observing (R1) trying to get out of their wheelchair and confused and disoriented.” Documentation review of physician report dated 11/10/2020 indicates (R1) to be wheel chair dependent and confused and disoriented. Three of five staff interviewed indicated not knowing or meeting (R1) due to recent employment with the facility. Ten of ten interviewees consisting of staff, residents and other witnesses indicated staff speak appropriately to residents in care as evidenced by treating residents with dignity and respect. The department has investigated the allegations listed above. Therefore based on the preponderance of evidence gathered through interviews conducted, documentation review and observations conducted by LPA Quiroz, the allegations that the “Resident was inappropriately pushed while in care,” “Residents sustained unexplained injuries while in care,” “Staff speak inappropriately towards a resident while in care” and “Residents sustains multiple falls while in care” were found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Business Office Manager Patricia Jimenez and a copy of this report, along with LIC 811- Confidential Names were provided at exit. .the state’s words, verbatim · CDSS document, Nov 7, 2023 · control 22-AS-20201201100053