Cambridge Court

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Office Assistant Jaritza Carmona and the purpose of the inspection was discussed. Supervisor Lupe Jaime arrived at approximately 10:00 a.m. Administrator (AD) Lauren Chon arrived at approximately 3:00 p.m. During the inspection, LPA and Supervisor conducted a physical tour of the facility. LPA observed select resident bedrooms. Bedrooms were observed to have the required furnishings, with the exception of Resident 1 (R1), who did not have a bed or bed frame. Per Supervisor, R1 prefers to sleep in their recliner and does not want a bed. LPA observed all other residents’ beds had linens and blankets. Residents were observed having lunch, consisting of chow mein, orange chicken, and steamed cabbage. Bathrooms were observed to be free of debris and mildew and faucets and toilets were operational. Water temperature tested between 114.8 – 120.0 degrees Fahrenheit. The facility has a 2-day supply of perishables and a 7-day supply of non-perishable food. Smoke detectors and carbon monoxide detectors tested operational. A fire extinguisher was observed in every facility hallway. Fire extinguishers were observed to be fully charged with service tags dated December 9, 2025. Gas stove, microwave, laundry washer and dryer were all observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication was observed to be centrally stored and locked. LPA reviewed select resident medication and Medication Administrator Records (MARs) and observed three residents' MARs were incomplete. LPA reviewed eight resident files and three staff files. Three of three staff files did not include required training. LPA interviewed select residents and staff. Based on the observations made during today’s inspection, 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 and appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Aug 26, 2026

Allegation investigated: Staff do not respond to residents' requests for assistance in a timely manner.

Licensing Program Analyst (LPA) Nancy Guillen conducted an unannounced complaint visit to finalize the investigation into the above allegation. Upon arrival, the LPA was greeted and granted entry into the facility. The LPA explained the purpose of the visit. It was alleged that facility staff did not respond to residents' requests for assistance in a timely manner. To investigate the allegation, the LPA conducted interviews with residents and facility staff, reviewed relevant records, and made observations of the facility, residents, and staff interactions. Continued on LIC9099C Unsubstantiated The LPA interviewed eight residents regarding their experiences with requesting assistance from facility staff and the facility's response times. Two of the eight residents stated that they had never needed assistance from staff and did not need to use the call light/pull cord. Four of the eight residents interviewed stated that staff generally responded to their requests for assistance in less than five minutes. However, five of the eight residents stated that response times were significantly delayed during nighttime hours or on weekends. LPA tested the call switches in three resident bedrooms. In each instance, a staff member responded within one to three minutes. The LPA also interviewed facility staff regarding the response to resident call lights. Three caregivers were interviewed. The caregivers interviewed had all been employed by the facility within the previous six months. The caregivers stated that caregiver call buttons are responded to in less than five minutes. A medication technician (Med Tech) was also interviewed and stated that Med Techs assist with responding to call lights when caregivers are unable to respond. The Office Assistant stated there is no log record for response times however , they had personally not observed a call light switch remain unanswered for longer than the approximately two to three minutes expected for staff to reach a resident. The Administrator was interviewed by telephone and acknowledged that the facility does receive complaints concerning response times. The Administrator stated that staff are being trained regarding the facility's required response time of approximately two to three minutes. The LPA's review of the available records and observations did not identify sufficient evidence to establish that facility staff consistently failed to respond to residents' requests for assistance in a timely manner. Although some residents reported experiencing longer response times during nighttime hours and on weekends, the information obtained through interviews was not sufficient to establish that the facility routinely failed to respond to resident requests within the required time frame. The evidence obtained during the investigation was also inconsistent with the LPAs testing of the call system. Resident statements regarding response times varied, while staff interviewed reported that call lights were generally answered within the expected time frame. The facility's Administrator acknowledged receiving complaints regarding response times and reported that staff are receiving training to reinforce the required response time. Based on interviews, record review, and LPA observations, there was insufficient evidence to support the allegation that the facility did not respond to residents' requests for assistance in a timely manner. Therefore, the allegation is determined to be UNSUBSTANTIATED, meaning that although the allegation may have occurred or may be valid, there is insufficient evidence to prove or disprove the allegation. An exit interview was conducted with the facility representative. A copy of the LIC 9099 was left at the facility.the state’s words, verbatim · CDSS document, Aug 24, 2026 · control 22-AS-20240531102854

Type of visit: Case Management - Deficiencies

On Monday August 24, 2026 Licensing Program Analyst (LPA) Nancy Guillen conducted an unannounced Case Management- Deficiencies visit. The visit is being conducted in conjunction with complaint control number 22-AS-20240531102854. Administrator(AD) Lauren Chon was notified via telephone and appointed Office Assistant Jaritza Jaime to assist with the visit. During the investigation into the complaint, LPA toured the facility, requested documentation and did a health and safety check on the residents in care. At approximately 9:12am, LPA observed the first floor laundry room open with a full gallon of bleach on the floor, a 945 ml bottle of cleaner with bleach on the shelf and a half gallon of powerful cleaning formula dish soap on the commercial washer. LPA did not observe a house keeper in sight. Staff 1 happened walk by, LPA asked Staff 1 if it was okay to lock laundry room. Staff 1 stated the housekeepers have a key and proceeded to lock the door for the laundry room. At approximately 9:16 am on the second floor, LPA observed the a gallon of bleach and a 945 ml bottle of cleaner with bleach that had about an inch left of product remaining. No staff in sight, LPA proceeded to lock and close the door to make items inside inaccessible to residents in care. Based on the information gathered during the visit, deficiencies are being cited on the attached LIC809-D page. An exit interview was conducted and a copy of this report and appeal rights were left at the facility at time of visit.the state’s words, verbatim · CDSS document, Aug 24, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Aug 25, 2026

87309(a)... the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...and other similar items which could pose a danger to residents are in locked storage and are not left unattended... This requirement is not met as evidence by: Based on observation, the licensee did not ensure toxic chemicals and cleaning solutions were inaccessible to residents in care which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 24, 2026

Plan of correction: Licensee did not ensure the facility keeps toxic chemichals and cleaning solutions inaccessible to residents in care. Facility stated they will review the regulation and provide CCLD with a signed statement of understanding by August 25, 2026.

Allegation investigated: Facility did not report power outage to the Department Facility did not have emergency lighting available during power outage Facility is not conducting quarterly emergency drills Facility is not following their emergency disaster plan

On July 15, 2026, Licensing Program Analysts (LPAs) Brandon Lopez and Tran Nguyen made an unannounced visit to the facility to deliver the complaint findings. LPAs were greeted and granted entry into the facility by staff after explaining the purpose for the visit. Executive Director Lauren Chon was present and assisted on today's visit. During the course of the investigation, the Department interviewed eight residents and five staff. The Department also reviewed and obtained pertinent documents to the complaint such as the facility's emergency disaster drill training's and the facility's emergency disaster plan. Regarding the allegation, facility did not report power outage to the Department, the following has been concluded: During the investigation, the Department conducted eight resident interviews. Eight out of the eight residents interviewed confirmed the facility experienced a power outage on June 19, 2026. The Department conducted five staff interviews, including with the facility's Executive Director. Five out of the five staff interviewed also confirmed that the facility experienced a power outage on June 19, 2026. CONTINUED ON LIC9099-C Substantiated California Code of Regulations, Title 22 Section 87211(a)(1)(d) states the following: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." LPAs observed that the facility submitted an Unusual Incident/Injury Report to the Orange County Regional Office regarding the facility's power outage on July 2, 2026, which is thirteen days after the incident occurred, and therefore six days past the required time frame. Regarding the allegation, facility did not have emergency lighting available during power outage, the following has been concluded: During the investigation, the Department confirmed that the facility experienced a power outage on June 19, 2026. The Department conducted eight resident interviews. Eight out of the eight resident interviews corroborated the allegation. The eight residents interviewed reported that the facility did not have sufficient flashlights available during the power outage. Resident interviewed reported that staff present during the outage had to rely on their personal cell phones for lighting. Resident interviewed reported that residents also allowed staff to borrow their own personal flashlights so that the staff could perform their job duties. The Department conducted five staff interviews. Three out of the five staff also corroborated the allegation and reported that the facility did not have sufficient flashlights available for the power outage. The staff interviewed confirmed that they had to rely on their personal cell phones, and they had to borrow flashlights from residents, in order to complete their job duties. Regarding the allegation, facility is not conducting quarterly emergency drills, the following has been concluded: Per Health & Safety Code Section 1569.695(c), it states: "(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill." During the course of the investigation, LPAs reviewed the facility's quarterly emergency drill training's. CONTINUED ON LIC9099-C LPAs observed that the facility conducted an emergency disaster drill in the second quarter of 2026, however, the facility only conducted the training with the overnight staff. The facility did not conduct the training with the morning or afternoon shift staff as required per regulations. The Department conducted five staff interviews. Three staff interviewed confirmed that they did not participate in an emergency disaster drill in the second quarter of 2026. Regarding the allegation, facility is not following their emergency disaster plan, the following has been concluded: During the investigation, the Department reviewed the facility's emergency disaster plan. Per the facility's emergency disaster plan on page six, it states" If there is a need for more power the facility is prepared to rent an additional generator from Home Depot. It states that if the emergency call system becomes inoperable, staff will implement a manual check-in and visual monitoring. It further states that caregivers will perform request safety rounds 15-30 minutes or as needed. Lastly, it states that during power outages or emergencies, battery operated and back-up oxygen tanks will be made available for residents using concentrators." The Department conducted five staff interviews. Five out of the five staff interviewed confirmed that the facility did not rent a generator from Home Depot as stated in their emergency disaster plan. Three staff interviewed confirmed that facility was also unable to complete safety rounds every 15-30 minutes as stated in their emergency disaster plan due to lack of staffing. Staff interviewed also confirmed that the facility did not have back-up oxygen tanks available for the four residents of the facility that require oxygen. The staff interviewed reported that the four residents went without oxygen and were just monitored during the approximate nine hour power outage. The Department conducted eight resident interviews. Eight out of the eight resident interviewed also corroborated the allegation. The eight resident confirmed that the facility did not have a generator present during the power outage. The eight residents confirmed that staff did not complete safety rounds every 15-30 minutes. The residents interviewed reported that staff only checked on them one or twice during the entire power outage which lasted approximately nine hours. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the four allegations listed above. The preponderance of evidence standards has been met; therefore, the above allegations are SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D pages. An exit interview was conducted with Executive Director Lauren Chon. A copy of the report and appeal rights were provided at time of visit.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 22-AS-20260622113246

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

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports.. (1) A written report shall be submitted to the licensing agency .. within seven days..(D) Any incident which threatens the welfare, safety or health of any resident.. This requirement is not evidenced by: Based on records reviewed, the Licensee did not ensure that the facility submitted a written report for the power outage that occurred on June 19, 2026, within seven days. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: The Executive Director stated that she will complete a written statement that the facility will abide by the regulation cited. The Executive Director agreed to provide LPA the written statement via email or fax by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(h) · Plan of correction due date: Jul 27, 2026

87303 Maintenance and Operation: (h) Emergency lighting shall be maintained. At a minimum this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff... This requirement is not evidenced by: Based on interviews conducted, the Licensee did not ensure that the facility had sufficient emergency lighting available during the power outage that occurred on June 19, 2026. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: The Executive Director stated that she has already purchased additional emergency lightings for the facility after the power outage. The Executive Director stated that she will conduct a training with the staff regarding the locations of emergency lighting. The Executive Director agreed to provide LPA proof of the training via email or fax by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Jul 27, 2026

§1569.695 Emergency Plans: (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. Based on records reviewed, the Licensee did not ensure that the morning or afternoon shifts conducted an emergency disaster drill in the second quarter of 2026. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: The Executive Director stated that she will have the two remaining shifts complete an emergency disaster drill. The Executive Director agreed to provide LPA proof of the emergency disaster drill via email or fax by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87212(a) · Plan of correction due date: Jul 27, 2026

87212 Emergency Disaster Plan: (a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available. This requirement is not evidenced by: Based on records reviewed and interviews conducted, the Licensee did not ensure that the facility followed the emergency disaster plan during the power outage that occurred on June 19, 2026. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: The Executive Director stated that she will complete a written statement that the facility will follow the emergency disaster plan. The Executive Director stated that she will also conduct a training with all staff regarding the facility's emergency disaster plan procedures. The Executive Director stated that she will provide LPA the written statement and the training via email or fax by POC due date.

Allegation investigated: Staff administered wrong medication dosage to resident

On May 8, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to continue the investigation into the allegation listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Office Assitant Teresa Mejia was notified via telephone and later arrived to assist with the inspection. During the course of the investigation, the Department interviewed staff, interviewed residents, reviewed and obtained pertinent documents to the complaint such as the current resident roster, current staff roster, and resident medication records. Regarding the allegation, staff administered wrong medication dosage to resident, the following has been concluded: It was alleged that staff administered the wrong medication dosage to Resident #1 (R1). The Department was unable to conduct an interview with R1 or review R1's medication, due to R1 moving out of the facility in December 2024. The Department conducted eight resident interviews. The facility currently manages the medication for seven out of the eight residents interviewed. CONTINUED ON LIC9099-C Substantiated Two residents reported that they have had previous issues with their medication, such as not receiving their medication and not receiving the right amount of their medication. Five residents reported not having any issues with receiving their medication. The Department reviewed the medication and medication administration records for the seven residents. The Department observed that the facility did not have Resident #2's (R2's) Alendronate 70 MG tablet, despite R2 currently having active orders for the routine medication. The Department also observed the facility did not have Resident #3's (R3's) Amlodipine Besylate 10 MG tablet, despite R3 currently having active orders for the routine medication. Based on the evidence gathered during this investigation, the Department obtained sufficient evidence to substantiate the allegations that, staff administered wrong medication dosage to resident. The preponderance of evidence standards has been met; therefore, the above allegation is SUBSTANTIATED. A deficiencies is being cited on the attached LIC9099-D page. An exit interview was conducted with Office Assistant Teresa Mejia. A copy of the report and appeal rights were provided at time of visit. The eight residents interviewed also confirmed that medication technicians and wellness coordinators are the only staff that have assisted them with their medication. The Department reviewed the training records for the five medication technicians and two wellness coordinators currently employed by the facility. The Department observed that the seven staff have received the initial, and annual medication training as required per regulations. Regarding the allegation, staff shoved medication into resident's mouth, the following has been concluded: It was alleged that staff shoved medication into Resident #1 (R1) mouth. The Department was unable to conduct an interview with R1 for this complaint due to R1 moving out of the facility in December 2024. The Department conducted eight resident interviews. Eight out of the eight residents interviewed denied the allegation and reported that they have never been forced to take any medication. The Department conducted six staff interviews. Six out of the six staff interviewed also denied the allegation and denied ever observing a staff forcing a resident to take medication. Regarding the allegation, facility has a rodent infestation, the following has been concluded: During the investigation, the Department inspected the facility's kitchen, dining area, laundry rooms, medication room, two staff offices, eight resident bedrooms, and the center courtyard area. During the Department's visits conducted to the facility on May 3, 2023, July 15, 2025, and May 8, 2026, the Department did not observe any rodents or any signs of rodents being present at the facility. The Department observed that the facility has consistently received pest control services twice a month to prevent any rodents. The Department observed the facility received pest control services on May 2, and May 16, 2023, which was the month the Department originally received the complaint. The Department additionally conducted eight resident interviews. Eight out of the right residents interviewed denied the allegation and denied ever observing a rodent present at the facility. The Department conduced six staff interviews. Six out of the six staff interviewed also denied the allegation and denied ever observing a rodent present at the facility. Based on the evidence gathered during the investigation, the Department is unable to ascertain if the allegations 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, the three allegations are deemed UNSUBSTANTIATED. An exit interview was conducted with Office Assistant Teresa Mejia and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 8, 2026 · control 22-AS-20230501113154

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 9, 2026

87465 Incidental Medical and Dental Care :(a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not evidenced by: Based on records reviewed, the Licensee did not ensure that R2 and R3 had their routine medications present at the facility, despite having active orders for the medications. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2026

Plan of correction: The Executive Director stated that she will conduct an in service training with all staff regarding medication management and orders. The Executive Director agreed to provide LPA proof of training via email or fax by POC date.

Type of visit: Case Management - Health Checks

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check and to follow up on a self-reported incident report received in the Orange County Regional Office (OCRO) on April 3, 2026, regarding Resident #1 (R1). LPA met with staff Laura Padilla and explained the purpose of the inspection. During the inspection, LPA inspected the facility, conducted health and safety checks on residents, including R1, observed no health and safety issues, conducted interviews, and requested and reviewed the resident roster, staff roster, resident files, and staff files. During the inspection, LPA observed that Staff #1 (S1), who was present at the facility and per interviews has worked more than five days, is not background cleared or associated to the facility. Facility representative stated they will notify LPA prior to S1 returning to the facility and when the results of the investigation into the incident involving R1 are known. 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. Immediate civil penalties are being assessed. See LIC421BG. 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 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Apr 9, 2026

87355 Criminal Record Clearance … (e) All individuals subject to a criminal record review … shall prior to working… (2) Obtain a California clearance… This requirement was not met as evidenced by: Based on admission and records, the licensee did not ensure S1 was background cleared prior to working at the facility for more than five days, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Apr 8, 2026

Plan of correction: During the inspection, the licensee had S1 removed from the facility and LPA confirmed. Licensee stated they will have S1 background cleared and submit proof to LPA by POC due date.

Allegation investigated: Facility staff did not ensure the resident's medication is being administered as prescribed. Facility staff mismanaged the resident's medication. Facility did not provide the medication log to the responsible party as requested. Facility did not inform the representative of the missing medication.

On 03/24/2026, Licensing Program Analyst (LPA) Cassandra Mikkelson contacted the licensee via phone and email to deliver final findings regarding a complaint that was received on 10/31/2024. The department conducted interviews and reviewed records relating to allegations of this complaint. **Report continued on 9099-C page Unsubstantiated Facility staff did not ensure the resident's medication is being administered as prescribed And Facility staff mismanaged the resident's medication The department conducted a records review of resident's Medication Administrator Record (MAR) which showed that the facility administered the medication as prescribed. Therefore, the allegations facility staff did not ensure the resident's medication is being administered as prescribed and the allegation facility staff mismanaged the resident's medication is unsubstantiated. Facility did not provide the medication log to the responsible party as requested LPA reviewed messages sent between Resident #1(R1s) responsible party and facility Executive Director (ED). Per text messages on 10/25/2024, R1s responsible party received the medication log from the facility for R1. Therefore, the allegation facility did not provide the medication log to the responsible party as requested is unsubstantiated. Facility did not inform the representative of the missing medication The department conducted a review of Resident #1 (R1s) most recent Medication Orders from the Skilled Nursing Facility R1 previously resided at. The resident had four separate orders for the medication Vancomycin HCI Oral Capsule 125MG. One order was for 10 days with a start date of 10/08/2024. Another order was for seven (7) days and to be taken on Monday, Wednesdays and Saturday with a start date of 11/02/2024. The last two orders were for seven (7) days. One with a start date of 10/25/2024 and the other with a start date of 10/18/2024. The department cannot prove or disprove if the medications were started on those set dates and/or if the facility received those medications. Therefore, the allegation facility did not inform the representative of the missing medication is unsubstantiated. Based upon the information obtained during investigation, the above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means 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. Exit interview conducted a copy of the report and appeal rights were mailed to the facility .the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 22-AS-20241031084119

Allegation investigated: Facility has insufficient staff to provide care and supervision to residents

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) Hannah Choe, discussed the purpose of the inspection, and explained the allegation. Administrator (AD) Lauren Chon appeared via telephone. The investigation into the allegation that the facility has insufficient staff to provide care and supervision to residents revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, the facility’s staff schedule, and the facility’s payroll records. CONTINUED Substantiated It was alleged that the facility does not have enough staff, when the elevator was temporarily down recently the facility did not have enough staff to help residents get up and down the stairs, and during a recent weekend there was only one medication technician and one caregiver on duty. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. Per the facility’s resident roster, the facility has 82 residents. LPA interviewed AD who stated the facility is always trying to improve staffing, and although there are callouts, the facility has always had enough staff to meet residents’ needs. LPA interviewed the facility’s wellness coordinator who stated that the staff schedule provides for one medication technician for each shift and three caregivers for the day shift, two or three caregivers for the afternoon shift, and two caregivers for the overnight shift. Per the facility’s wellness coordinator, two caregivers plus a medication technician is sufficient to meet the needs of the residents. LPA reviewed the facility’s staff schedule which generally shows there is one medication technician scheduled per shift, three caregivers scheduled for the day shifts, and two caregivers scheduled for the overnight shift. LPA reviewed the facility’s payroll records which shows that on Saturday, February 28, 2026, both caregivers that were scheduled for the afternoon shift of 2:30PM to 10:30PM called out, one of the three caregivers that were scheduled for the morning shift stayed late to cover until 6:30PM, and a backup staff was called to cover from 5:00PM until 10:30PM. Based on these payroll records, in addition to the medication technician, there was only one caregiver between 2:30PM and 5:00PM and again from 6:30PM to 10:30PM on Saturday, February 28, 2026, which is lower than the two care staff that would be sufficient to meet residents’ needs per the facility’s wellness coordinator and lower than the three care staff planned for by the staff schedule. LPA interviewed 10 residents and obtained corroborating information that staffing at the facility is sometimes short, particularly on weekend evenings, leading to staff being spread too thin and rushing care for residents and not providing enough individual attention. The resident interviews provided conflicting information regarding staff helping residents up and down the stairs during the period the elevator was down and did not provide information indicating that short staffing led to any injuries or incidents involving residents. The information obtained corroborated that the facility did not have sufficient staff to meet residents’ needs, but did not corroborate any immediate threat or harm to residents in this instance. 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. 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 9, 2026 · control 22-AS-20260302125450

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 23, 2026

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure the facility had sufficient staff, including by having only one caregiver on February 28, 2026, resulting in rushed care for residents, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 9, 2026

Plan of correction: Licensee stated they will create a plan to improve staffing, including a contingency plan for staff callouts, and submit proof to LPA by POC due date.

Allegation investigated: Staff mishandled a resident's personal belongings

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) Hannah Choe, discussed the purpose of the inspection, and explained the allegation. Administrator (AD) Lauren Chon appeared via telephone. The investigation into the allegation that staff mishandled a resident's personal belongings revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD and residents, and obtained and reviewed copies of the resident roster and staff roster. CONTINUED Unfounded It was alleged that money and personal items have gone missing from a resident’s room. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed AD who denied the allegation, stating that there have been no recent reports of lost or missing items, residents are encouraged to not bring money or valuables to the facility or to secure them if they do decide to bring them, and that any reports of theft are investigated. LPA interviewed the resident at issue who denied that any of their money or personal items were lost or stolen. LPA interviewed an additional nine residents and did not obtain any information corroborating theft or properly loss issues at the facility. 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, Mar 9, 2026 · control 22-AS-20260302152212

Allegation investigated: Staff did not follow proper eviction protocol

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) Lauren Chon and Staff #1 (S1) Lupe Jaime, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that staff did not follow proper eviction protocol revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, and obtained and reviewed copies of the resident roster, staff roster, and a facility incident report dated January 5, 2026. It was alleged that Resident #1 (R1) was taken to the hospital by police for alleged violent behavior and after R1’s hospitalization ended the facility refused to accept R1 back without following eviction protocols resulting in R1 moving to another facility. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. Substantiated Per a facility incident report dated January 5, 2026, on January 3, 2026, R1 was intoxicated, threatened staff and themselves with a knife, and police were called and took R1 to the hospital. LPA interviewed AD who admitted that when the hospital cleared R1 to return, the facility refused to accept R1 back to the facility without having issued any eviction notice. 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. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. 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, Feb 18, 2026 · control 22-AS-20260209140124

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a) · Plan of correction due date: Feb 19, 2026

87224 Eviction Procedures (a) The licensee may evict a resident ... Thirty (30) days written notice to the resident is required... This requirement was not met as evidenced by: Based on admission, the licensee did not follow the 30-day eviction procedure when they refused to accept R1 back from the hospital, which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 18, 2026

Plan of correction: Licensee stated they will review Section 87224, submit a statement of understanding, and create and submit a protocol for ensuring eviction procedures are followed with residents in the future to LPA by POC due date.

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-20260209140124. LPA met with Administrator (AD) Lauren Chon and Staff #1 (S1) Lupe Jaime and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed AD, and obtained and reviewed copies of the resident roster, staff roster, and a facility incident report dated January 5, 2026. Per a facility incident report dated January 5, 2026, on January 3, 2026, Resident #1 (R1) was intoxicated, threatened staff and themselves with a knife, and police were called and took R1 to the hospital. However, based on incident reports received at the Orange County Regional Office (OCRO), this incident report was never received at the OCRO and the incident 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, Feb 18, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Mar 4, 2026

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, the licensee did not ensure R1’s hospitalization on January 3, 2026, was reported to the OCRO, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 18, 2026

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

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Kerry Hiratsuka arrived unannounced at the facility to conduct a required 1-year annual inspection. LPAs met with Executive Director (ED),Lauren Chon and explained the purpose of the visit. LPA and Staff conducted a tour of the facility. Areas toured included but not limited to: five (5) rooms on the ground floor and four (4) rooms on the second floor, laundry rooms, kitchen, dining room, medication room and common areas. LPA observed residents in the dining room having lunch. The residence was found to be clean, safe, sanitary and in good condition. LPAs observed the facility to have the mandated posters posted. Fire extinguishers are maintained and ready for emergency use. Facility has required food supplies. LPAs conducted a record review of ten (10) resident records. Resident records contain signed admission agreements, physician's reports, appraisals, identification sheets, and resident's rights. LPAs reviewed eight (8) staff records. A review of staff records indicates that facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current training completed. LPAs completed the full care tool and no deficiencies was observed. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2025

Allegation investigated: Residents are distributing and using illicit drugs while in the facility. Staff are not ensuring that resident's diapering needs are being met while in care. Staff do not respond to resident's requests for assistance in a timely manner.

Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced and met with Executive Director (ED) Lauren Chon to deliver findings for the above complaint allegations. During the investigation, the department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: ***Report continued on 9099-C*** Unsubstantiated Allegation: Residents are distributing and using illicit drugs while in the facility.- Unsubstantiated CCLD interviewed staff and residents. Records indicate there are a few residents who are capable of leaving the facility unassisted. The residents are capable of making their own purchases. The facility staff policy for residents is they cannot physically search the person without consent and cannot search resident rooms without consent of the resident. Administrator stated as soon as they found out they contacted the police, CCLD, and local ombudsman for assistance. CCLD is unable to determine when and where the residents obtained drugs and alcohol and how long it was going on without the facility staff knowing. Allegation: Staff are not ensuring that resident's diapering needs are being met while in care.- Unsubstantiated LPA conducted interviews with facility staff and residents Staff interviews revealed that residents are assisted with incontinence care every two hours or as needed. Residents will also utilize their pull cord if they need assistance between that time. Resident interviews revealed that staff meet their incontinence needs. Residents indicated they feel comfortable with staff and will use their pull cords or staff will just check on them. Allegation: Staff do not respond to resident's requests for assistance in a timely manner.- Unsubstantiated Interviews with residents revealed that staff generally respond in five (5) to ten (10) minutes. Around meal times it can take a little longer. Staff interviews indicated as soon as they see the call light they will respond unless they are working with another resident. Based on interviews conducted by the Department and records review, the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means 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. At this time no citations were issued. Exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 22-AS-20240712140617

Allegation investigated: Facility is not following the admission agreement

Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced and met with Executive Director (ED) Lauren Chon to deliver findings for the above complaint allegations. During the investigation, the department conducted interviews. Resident #1 (R1) went from being independent to needing additional care. Facility did discuss with R1 about increase in rent due to additional services. LPA attempted to obtain facility records but was not able to due to the records being more than (3) years old and the facility was not required to maintain them. Based on interviews conducted by the Department and records review, the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means 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. At this time no citations were issued. Exit interview was conducted and a copy of this report was provided to the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 10, 2025 · control 22-AS-20210412104141

Allegation investigated: Staff did not groom resident Licensee did not seek timely medical attention for resident in care Staff did not bathe resident Staff stole resident's personal property Staff spoke to resident inappropriately Staff mismanaged resident's medication

Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced and met with Executive Director (ED) Lauren Chon to deliver findings for the above complaint allegations. During the investigation, the department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: ***Report continued on 9099-C*** Unfounded Allegation: Staff did not groom resident-Unfounded The Department conducted interviews with staff and residents. Interviews with residents indicated that their grooming needs are being met by facility staff. Residents were able to get their fingernails cut at the facility salon. Residents interviewed revealed that they are seen by a podiatrist who comes into the facility. Staff interviews further revealed they have a podiatrist that comes to the facility every one to two months. Residents would have to agree to this service and would be charged if they did not have the right insurance. Allegation: Licensee did not seek timely medical attention for resident in care-Unfounded The Department conducted interviews with staff and residents. Resident interviews revealed they have not needed medical attention but feel confident that staff would seek it timely manner. Interview with staff revealed that in some cases they will try to get medical professionals to come to the facility to make it easier for the residents. Allegation: Staff did not bathe resident-Unfounded The Department conducted interviews with staff and residents. Some residents are assisted by staff with their showers which are two (2) to three (3) times a week. Resident interviews indicated that they receive their showers as scheduled. Allegation: Staff stole resident's personal property- Unfounded The Department conducted interviews with staff and residents. Resident interviews revealed that have not had any stolen property. Staff interviews revealed residents had not reported any stolen property. Allegation: Staff spoke to resident inappropriately- Unfounded The Department conducted interviews with staff and residents. LPA interviewed residents in which they stated staff do not yell at them or speak inappropriately to them and that staff treat them very well. LPA interviewed staff in which they stated they have not observed staff talking inappropriately to residents. Allegation: Staff mismanaged resident's medication- Unfounded The Department conducted interviews with staff and residents. Interviews with residents revealed they have not had any issues with medications or they manage their own medication. LPA did a walk-through of the facility and did not observe any medications on the floor. Based on this information, the Department did not find any evidence to prove the allegation that staff do not provide adequate care and supervision, therefore this allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. At this time no citations were issued. Exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 22-AS-20210330154030

Allegation investigated: Staff did not ensure resident uses designated smoking area to smoke Staff did not prevent resident from making inappropriate comments towards other resident's Staff did not clean up after resident's pet.

Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced and met with Executive Director (ED) Lauren Chon to deliver findings for the above complaint allegations. During the investigation, the department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: ***Report continued on 9099-C*** Unsubstantiated Allegation: Staff did not ensure resident uses designated smoking area to smoke - Unsubstantiated ED stated that facility does have a designated smoking area outside. Residents are good about smoking in that area. Resident interviews revealed they do not have issues with residents who utilize the smoking area. Allegation: Staff did not prevent resident from making inappropriate comments towards other resident's - Unsubstantiated Staff interviews revealed that have not heard of residents doing this. Staff did say that residents will make inappropriate comments to staff but not other residents. Staff interview further revealed that if they notice a resident becoming agitated they will intervene and redirect. Resident interviews revealed they could not recall anything like this happening. Allegation: Staff did not clean up after resident's pet.- Unsubstantiated Interview with ED revealed they only have two (2) pets in the facility now. Going forward the facility is no longer allowing pets in the facility due to issues in the past. Resident interviews revealed they have not had any issues with other residents pets. Staff interviews revealed that if they have seen poop on the floor they will clean it up immediately. Based on interviews conducted by the Department and records review, the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means 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. At this time no citations were issued. Exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 22-AS-20220228122954

Allegation investigated: Facility is not providing resident with availability to engage in facility activities. Resident is not being assisted with getting in and out of bed.

Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced and met with Executive Director (ED) Lauren Chon to deliver findings for the above complaint allegations. During the investigation, the department conducted interviews. LPA conducted interviews with residents which revealed that the facility provides engaging activities such as bingo, water color painting, movie nights, sometimes outings outside of the facility. For residents who are more bed bound someone will come into their room to provide an activity. Interviews further revealed that hoyer lift is used for residents who need additional assistance with getting in and out of bed. Based on interviews conducted by the Department and records review, the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means 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. At this time no citations were issued. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 10, 2025 · control 22-AS-20230316110406

Allegation investigated: Staff does not ensure facility has hot water

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility, tested water temperature and interviewed staff and residents. Regarding the allegation that staff does not ensure facility has hot water, the investigation revealed the following: Resident 1 (R1) stated not having hot water in the shower for a very long time. Administrator indicates bringing a plumber in to address the issue as soon as it was reported and the plumber was at the facility working on it last week. Administrator offered the resident the opportunity to move while the water temperature was being addressed but the resident declined. Water temperature in the shower and sink measured at 98.2 degrees F during today's visit. Based on interviews conducted and observation, the preponderance of evidence standard has been met. Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights. Substantiatedthe state’s words, verbatim · CDSS document, Feb 24, 2025 · control 22-AS-20250219151509

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Mar 10, 2025

Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained.. to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) This req is not met as evidenced by: Based on observation, Licensee failed to ensure hot water is maintained between 105 and 120 degrees F. Water temperature measured 98.2 degrees F in resident restroom. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 24, 2025

Plan of correction: Licensee to adjust water temperature and forward proof to LPA by POC due date.

Allegation investigated: - Staff did not ensure resident's wound care needs were met

Licensing Program Analyst (LPA) Michael Tea made an unannounced complaint visit on this day to conclude the investigation and to deliver findings for the allegation mentioned above. LPA met with Purchasing House Keeper Supervisor (PHKS) Lupe Jaime and spoke to Executive Director (ED) Lauren Chon over the phone. It was alleged that staff did not ensure resident’s wound care needs were meet. During the investigation LPA interviewed Resident 1 (R1) and facility staff, checked, and reviewed resident files. The investigation determined the following: Resident 1 (R1) is an independent resident. They are able to care for their personal needs, can administer and store their own medication and does not need constant medical supervision as indicated on their physician’s report. R1’s Individualized Service Plan indicates that staff monitors R1 for fall risk and any change of behavior. The Appraisal Needs and Services Plan shows R1 does not need any services. R1’s Resident Assessment form indicates they are independent and requires no assistance in all the ADLs assessed. Two out of two staff interviewed and Executive Director, Lauren Chon indicated that Report continued on LIC9099-C Unsubstantiated R1 was independent and refused assistance. All staff interviewed said they would help R1 when called or needed assistance. Per interview with R1, they indicated they were independent and did not need assistance only when asked. R1 said the facility staff helped them as best as they could. Per records obtain, it was not until R1 went to the hospital in October for weakness and a urinary tract infection, that they discovered R1’s wound. The hospital provided outpatient care and home health services to care for the wound. All staff interviewed, and ED Chon indicated that after R1 came back from the hospital and said that home health services was responsible for taking care of R1’s wound. Two out of two staff interviewed indicated that they helped occasionally with cleaning and bandaging the wound when R1 asked for assistance when home health was not present. All staff interviewed said they check on her everyday and said that R1 never complained or said anything. Based on records obtain, an internal incident report for December 23, 2024, a home health nurse asked Staff 1 (S1) to call 911 to send R1 out because their wound got infected. S1 also said that the home health nurse who asked them to call 911, explained a previous home health nurse did not properly care and bandaged the wound for R1 which resulted in the wound getting infected. When interviewed about home health care, R1 said that they were taking good care of them and had no problems with the services provided. Facility staff and the ED thought home health service was taking proper care of R1’s wound until 911 had to be called and the home health service did not indicated or communicated anything to the facility. Therefore, based on LPA Tea's observations and interviews conducted and records review the allegation that staff did not ensure resident’s wound care needs were met has been determined 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. No deficiencies cited at this time and an exit interview was conducted with Executive Director Chon over the phone and a copy of the report and confidential names list was provided to the facility.the state’s words, verbatim · CDSS document, Feb 21, 2025 · control 22-AS-20241224142052

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a required annual inspection on 12/07/2024. LPA met with Lupe Jaime (House Keeping/Purchasing Supervisor) and discussed the purpose of today’s visit. The facility is licensed for ninety-nine (99) non-ambulatory residents, age 60 and over. The facility has an approved hospice waiver for nine (9) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants and cleaning solutions that could pose a danger if readily available to residents, were observed to be accessible in resident room#118. Staff removed disinfectant and cleaning solutions after LPA Ramirez made observation. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected seven (7) resident rooms. All resident bedrooms contained required furniture, linens, and lighting. Water temperatures in grooming and bathing areas were measured to be above 120 degrees F. 1st floor communal bathroom sink water temperature was measured to be 129.4 degrees F, during inspection. Resident room# 112, bathroom sink water temperature was measured to be 122.7 degrees F during inspection. Resident room# 213, bathroom sink water temperature was measured to be 124.0 degrees F during inspection. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed emergency call cords to be operational. LPA Ramirez observed video surveillance in common areas of the facility. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). LPA Ramirez observed facility weekly and daily menu, which is approved by the facility certified dietary manager. LPA Ramirez observed kitchen staff preparing for lunch while wearing hair nets and gloves. LPA Ramirez observed several dining room servers disinfecting tables and counters while wearing gloves and hair nets. See 809-C for continuation. Planned Activities: LPA Ramirez observed an activities calendar for December of 2024 with various activities and outings for residents. LPA Ramirez observed sufficient outdoor space. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed evacuation chair in stairway. Last documented emergency drill was conducted on 11/06/24 and 10/03/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. Operational Requirements: The facility is licensed for ninety-nine (99) non-ambulatory residents, age 60 and over. The facility has an approved hospice waiver for nine (9) residents. LPA Ramirez reviewed facility liability insurance and auto registration for one (1) facility vehicle. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez did not observe documented required initial training for S1 and S2. LPA did not observe completed 20 required annual training hours for S1, S2, and S3. S1 completed 9 out of 20 required annual training hours. S2 completed 10 out of 20 required annual training hours. S3 completed 9 out of 20 required annual training hours. Staffing: Administrator Certificate for Lauren Chon and it expires 10/09/2025. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. Four (4) deficiencies were observed and cited during inspection. Exit interview was conducted and a copy of this report, 9099-D, and appeals rights was provided.the state’s words, verbatim · CDSS document, Dec 7, 2024

Allegation investigated: Staff are not providing adequate food service Staff are not providing activities for residents

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and residents. LPA reviewed and obtained pertinent documentation such as food menu and activity schedule. Regarding the allegations that staff are not providing activities for residents and staff are not providing adequate food service, the investigation revealed the following: Four out of four residents admitted at the facility in 2020 confirm appropriate food delivery to rooms during the covid lockdown. All four state no issues with the food being warm. LPA toured the kitchen during the investigation and observed insulated food delivery boxes utilized for delivery. Three out of three staff state food deliveries occurred right after plating the containers and were delivered in the insulated boxes. All three state no complaints received from residents regarding the temperature of food. Four out of four residents state the facility provided Bingo in the facility hallways as well as games and puzzles in the resident rooms during the lockdown. CONT ON LIC 9099C DATED 4/23/24 Unsubstantiated LPA observed current activity schedule which includes activities throughout the day including music therapy, Bingo, and exercise. Facility supervisor indicates rate increases are given annually and no rate increase occurred due to covid. Based on interviews conducted, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed 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. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 23, 2024 · control 22-AS-20201102151301

Type of visit: POC

On this day Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced Plan of Correction (POC) visit in conjunction with complaint control #22-AS-20201008113606 and citation issued on 12/28/23. LPA was greeted and granted entry into the facility by Purchasing Supervisor (PS) Maria Jaime and explained the reason for the visit. On 01/04/2024, AD failed to correct the following: Deficiency cited under Title 22 Regulation 87507(f) pertaining to Admission Agreements. Deficiency cited under Title 22 Regulation 87507(f) pertaining to Admission Agreements has NOT been cleared. Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with PS Jaime and a copy of this report along with the LIC809D and Appeal Rights were provided at the time of this visit.the state’s words, verbatim · CDSS document, Apr 5, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Apr 8, 2024

Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement... This regulation was not met as evidenced by: Based on interviews conducted and file reviews the facility failed to follow their non-smoking policy as documented per facility's Admission Agreement. This poses a potential risk to resident’s health and safety while in care.the state’s words, verbatim · CDSS document, Apr 5, 2024

Plan of correction: Licensee/Administrator agrees to read regulation and sign a statement of understanding and forward proof 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-20210106170715. LPA met with Staff #1 (S1) Edgar Palacios and explained the reason for today’s inspection. Administrator (AD) Lauren Chon appeared via telephone. 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, Feb 13, 2024

Allegation investigated: Medications are not stored.

This is an amended 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 allegation(s). LPA met with Staff #1 (S1) Edgar Palacios and explained the reason for today’s inspection. Administrator (AD) Lauren Chon appeared via telephone. The investigation into the allegation that medications are not stored revealed the following: During the course of the investigation, LPA inspected the facility, interviewed the administrator and residents, and obtained and reviewed copies of the resident roster, staff roster, and resident files. Substantiated Regarding the allegation that medications are not stored: It was alleged that some residents are storing their own medications. LPA inspected the medication room and observed that the centrally stored medications were properly stored. LPA interviewed AD who stated that some residents handle their own medications if they are able to per their Physician’s Reports. LPA interviewed eight residents, three of whom stated they handle their own medications. LPA reviewed the Physician’s Reports for these three residents and the Physician’s Reports for two of the residents stated they are able to handle their own medications. However, the most recent Physician’s Report for one of the residents stated they are not able to handle their own medications and the facility still allowed them to store and handle their own medications. No information was obtained that this resulted in harm to the resident. 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. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. This is an amended report LPA attempted to interview a staff member who the resident claimed could confirm that the $160.00 and package were not present in the resident’s room, but LPA was unsuccessful. The resident did not claim that they, or anyone else, witnessed a staff member actually take the items. LPA interviewed AD who stated that the facility does receive complaints about missing money or items, but that the facility is unsure if they were lost or stolen and there have been incidents of these items later being found after it was originally thought that they were stolen. AD stated that when residents are in the hospital, their rooms are double-locked and only a few staff have the key to the second lock as a measure to protect resident property. AD also stated that after hearing of these incidents they had a meeting with staff about the issue. While one resident believes $160.00 and a package were stolen by staff, there is insufficient evidence to support this allegation as these items could have been misplaced, taken by a family member or another resident, or the resident may have otherwise disposed of them and forgotten. Regarding the allegation of staff not serving an adequate amount of food to residents: It was alleged that the food is substandard and residents are not able to eat much of the food served. LPA inspected the kitchen and observed no spoiled or expired foods, proper temperatures in the refrigerator and freezer, the kitchen, refrigerator, and freezer were clean and organized, and the perishable food appeared fresh and included fresh fruit and vegetables. LPA interviewed eight residents, five of whom provided positive reviews of the food. Three residents expressed concerns over the food, but one of these concerns was related to COVID-19 dining restrictions in the past that are no longer in effect and another concern had never been reported to the staff which did not allow the facility opportunity to address the issue. None of the residents reported an issue with the amount of food provided. AD stated that the facility is proud of the food it serves, emphasizes quality food even if it costs more, and uses a dietician to approve the menu and inspect the kitchen regularly. LPA reviewed the facility’s menus and noted a proper variety of foods including mostly hot dishes with a balance of meat and vegetables. LPA also reviewed documents provided by the facility’s dietician corroborating AD’s statement that a dietician is reviewing the facility’s menu and food practices. AD also stated that if there is an issue with the food, residents can communicate that to staff and the facility will address the issue. A resident interviewed corroborated that they are offered choices in their meals and that the facility is responsive to their preferences. The information received regarding this allegation is conflicting. 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. This is an amended report LPA interviewed eight residents, none of whom corroborated that staff are accessing residents’ personal belongings without permission. No information was obtained corroborating this allegation. 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, Jan 30, 2024 · control 22-AS-20210106170715

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 27, 2024

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 provide required assistance with medications to one out of eight residents, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2024

Plan of correction: Licensee stated they create a list of all residents storing and handling their own medications, review the residents’ Physician’s Reports to ensure they are able to handle their own medications, and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 00000 · Plan of correction due date: Feb 27, 2024

This page was amended due to this second citation being created in error.the state’s words, verbatim · CDSS document, Jan 30, 2024

Allegation investigated: Facility is not following the admission agreement in regards to smoking at the facility

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings of the investigation. LPA was greeted and granted entry into the facility by Receptionist Daniela Lopez. LPA explained the reason for the visit. This agency has investigated the complaint alleging that facility is not following the admission agreement in regards to smoking at the facility. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: One of six individuals interviewed confirmed the allegation. During interviews conducted with the residents, Resident 1 (R1) reported that this was supposed to be a non-smoking facility and that their Admission Agreement states that. Per R2 residents who smoke always smoke at the table in the central courtyard. During the course of the investigation LPA reviewed documents including the Admission Agreement dated 02/07/15 for R1. Per Admission Agreement on page 7 under House Rules/Facility Policies it states that the following behaviors are not consider CONTINUED ON LIC9099-C... Substantiated appropriate for residents residing at our facility: smoking in the facility. During the course of the interviews ED stated that smoking is allowed in the designated smoking area. Per ED as of 08/10/21 there were new additional smoking rules that were suggested by the resident council. Records reviewed by LPA included the Cambridge Court Smoking Rules dated 08/10/21. Per Smoking Rules all smoking should be done in the designated smoking area and only in the designated smoking area. Based on the interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: facility is not following the admission agreement in regards to smoking at the facility is 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 Medication Technician Reyes, and a copy of this report, 9099-D Page, and Appeal Rights was left at the facility.the state’s words, verbatim · CDSS document, Dec 28, 2023 · control 22-AS-20201008113606

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(f) · Plan of correction due date: Jan 4, 2024

Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement... This regulation was not met as evidenced by: Based on interviews conducted and file reviews the facility failed to follow their non-smoking policy as documented per facility's Admission Agreement. This poses a potential risk to resident’s health and safety while in care.the state’s words, verbatim · CDSS document, Dec 28, 2023

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

Allegation investigated: Staff violated resident's personal rights Staff isolated resident while in care Facility is in disrepair Facility is unsanitary

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 allegations listed above. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit. An initial complaint investigation was conducted on October 13, 2023. LPA requested and obtained the facility's employee roster and resident census. Resident records for 4 residents were requested and obtained. LPA accompanied by facility staff toured the physical plant of the facility. Two staff interviews were conducted along with two resident interviews. Additional video evidence was provided and reviewed over the course of the investigation. During the present follow-up, additional resident and staff interviews were conducted by LPA prior to findings being delivered. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM FORM LIC9099 Regarding the allegation that Staff violated resident's personal rights, the following has been concluded: Based on records and evidence reviewed, observation conducted at the facility and interviews conducted, it is determined that on multiple occasions, facility staff passively or actively disregarded the resident's expressed wishes and either continued providing care without taking the request into account or acknowledging it. Resident R1's physician report on file along with multiple appraisals indicate that R1 does not have dementia and is able to express their needs and wishes, which were then ignored by facility staff. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A Type A deficiency is cited on the attached form LIC9099-D. Regarding the allegation that Staff isolated resident while in care, the following has been concluded: Based on interviews conducted and evidence reviewed, it was confirmed that on multiple instances, facility staff locked the door to R1's unit in the evening despite requests made verbally to leave the door unlocked. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A Type A deficiency is cited on the attached form LIC9099-D. Regarding the allegation that Facility is in disrepair, the following has been concluded: Based on facility visit and interviews conducted, it was determined that following a technical incident, the facility's call system was left non-operational during an entire week-end, with no alternative means of contacting staff to request assistance or care being provided. At the time of the initial visit, visual alerts were observed to be operating, but sound alerts and doorbell rings were still not working. Therefore the allegation is Substantiated, meaning that the preponderance of evidence standard has been met. A Type B deficiency is cited on the attached form LIC9099-D. Regarding the allegation that Facility is unsanitary, the following has been concluded: Based on evidence submitted and interviews conducted, facility staff was noted to not be observing basic infection prevention measures and were confirmed to be handling food or drinks with the same gloves that they had conducted toileting and handling of incontinence items with, thus not meeting the standards of sanitation required by Title 22 regulations. The allegation is thus found to be Substantiated, meaning that the preponderance of evidence standard has been met. A Type B deficiency is cited on the attached form LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative. CONTINUED FROM FORM LIC9099-A Regarding the allegation that Resident doesn't feel safe at facility, the following has been concluded: Based on interviews conducted, records reviews and tour of the facility's physical plant, no items of non-compliance putting the resident's safety into jeopardy could be identified. After a suspicion of electrical issues was expressed by R1's family, facility maintenance staff along with Fire Marshall staff inspected the facility without finding any dysfunction needing to be addressed. As a result, the allegation is found to be Unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Regarding the allegation that Staff left resident unattended in feces for an extended period, the following has been concluded: According to video evidence obtained during the investigation, there was at least one instance of having diarrhea during which R1 expressed difficulty in obtaining assistance. The evidence provided did not sufficiently establish the exact time frame during which the resident was left unattended that night beyond the four minutes captured by video. As a result, the allegation is found to be Unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Regarding the allegation that Staff did not treat resident with dignity and respect, the following has been concluded: Based on the review of records and interviews conducted, a consistent pattern of not allowing the resident with the dignity and respect required by facility staff could not be evidenced. As a result, the allegation is found to be Unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Regarding the allegation that Staff did not meet resident's needs, the following has been concluded: Facility staff states that they notified R1's conservator and relatives that the resident had reached a level of care incompatible with their remaining at the facility, however due to the duration of the resident's admission at the facility, facility staff eventually agreed to let the resident remain admitted there and to provide the required care and supervision there. Despite indications that care for R1 was complex, there is insufficient evidence to demonstrate that the facility did not meet the resident's needs before their relocation to a different board and care. Thus, the allegation is found to be Unsubstantiated, meaning although the allegation may have happened or is valid, there is not a preponderance of 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, Dec 11, 2023 · control 22-AS-20231010130615

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Dec 12, 2023

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (...) (3) To be free from (...) other actions of a punitive nature, such as (...) interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on evidence reviewed and interviews conducted, there were two documented instances of staff disregarding verbal requests to go back to bed. This constitutes an immediate risk to the health, safety or personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 11, 2023

Plan of correction: Licensee to provide a statement indicating its plan to retrain all staff members on the applicable rights of residents in care by the plan of corrections due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Dec 12, 2023

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (...) (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met as evidenced by: Based on interviews conducted, it was determined that facility staff was locking R1's room at night regardless of the resident's agreement or not. This constitutes an immediate risk to the health, safety or personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 11, 2023

Plan of correction: Licensee to provide a statement indicating its plan to retrain all staff members on the applicable rights of residents in care and measures to ensure no resident is locked without their consent by the plan of corrections due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1) · Plan of correction due date: Dec 12, 2023

(1) All facilities licensed for 16 or more (...) shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff (...) (C) Identify the specific resident living unit. This requirement is not met as evidenced by: Based on interviews conducted, the facility spend several days with a completely inoperant call system in October 2023. This constitutes a potential risk to the health, safety and personal rights of residents in carethe state’s words, verbatim · CDSS document, Dec 11, 2023

Plan of correction: The call system was verified to be fully operational during the follow-up investigation visit and the deficiency was cleared at that time.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87470(a)(1) · Plan of correction due date: Jan 10, 2024

87470 Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained as follows: (1) All staff and volunteers shall perform hand hygiene.This requirement is not met as evidenced by: Based on evidence reviewed, it was determined that adequate hand hygiene measures had not been followed after staff handled bodily fluids and/or provided incontinence care to a resident with a urostomy. This constitutes a potential risk to the health, safety and personal rights of residents in care,the state’s words, verbatim · CDSS document, Dec 11, 2023

Plan of correction: Licensee to provide a statement indicating its plan to retrain all staff members on adequate hand hygiene by the plan of corrections due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to conduct a health and safety visit of residents in care for the purpose of following up on incident which occurred late evening on 11/22/23. Orange Adult and Senior Care Regional Office received a phone message that facility had to shut down water and power due to a pipe bursting. Upon contacting Administrator Lauren Chon it was discovered that a accident occurred where a car ran up on street curb hitting facility sign and sides of facility building. During visit LPA Tirre toured facility with Administrator Lauren Chon. LPA observed first and second floor hallways resident rooms, kitchen dining rooms, common area activity rooms and resident common areas. LPA observed facility to have working power, water and food supply. LPA observed residents in common areas playing bingo, watching TV and relaxing inside bedrooms. Residents observed were neatly groomed in appearance, and appeared alert as evidenced by greeting LPA. During visit LPA conducted interview with Resident 1, who was one of the residents impacted by incident. R1 confirmed they were healthy, safe and not harmed during incident. LPA also talked to resident 2 whose room was also impacted by incident. Resident 2 confirmed they were not harmed, was evacuated and relocated to another room. Resident 2 confirmed they feel safe in facility. LPA was unable to speak to other two residents impacted by incident due to one being out of facility and other resident was preoccupied with activities. Rooms impacted were taped with notices of Limited Entry Signs stating off limits to unauthorized Personnel. LPA did not observe any additional health and safety risks. Based on today's inspection, no deficiencies were observed at this time in the areas evaluated. This report was reviewed with Administrator and copy of report was left at facility.the state’s words, verbatim · CDSS document, Nov 27, 2023

Allegation investigated: Resident fell due to staff neglect

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced complaint visit to deliver findings on the above allegation received on 10/24/23. LPA was greeted and granted entry into the facility and initially met with Receptionist Daniela Lopez. LPA explained the reason for the visit. Executive Director (ED) Lauren Chon arrived shortly after. This agency has investigated the complaint alleging that resident fell due to staff neglect. LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegation, the following was revealed: Twelve of thirteen individuals denied the allegation. During interviews conducted with residents it was reported that they have not had a fall due to staff neglect. Per Resident 1 (R1) if she sustains a fall it is because of her Vertigo not because of staff neglect. Per R2 he does not remember a resident laying on the floor for over two hours. During the interviews conducted with staff, Staff 1 (S1) reported that residents have not sustained a fall due to staff neglect and that if residents CONTINUED ON 9099-C... Unsubstantiated sustain a fall that residents are not on the floor for long. During the investigation LPA reviewed documents including the Unusual Incident/Injury Reports (UIIRs) dated 10/24/23 for R2 and R3. Per UIIR R2 and R3 had an unwitnessed fall and were taken to the Emergency Room for evaluation. During the course of the interviews ED stated that she is not aware of an alleged fall where the resident was laying on the floor for over two hours. Per ED R2 and R3 did not wait on the floor for long and reported that the highest staff response time could be 30 minutes. Based on LPA's observation and information gathered during the investigation, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. LPA Ramirez conducted an exit interview with ED Chon, and a copy of this report was provided to the facility. Per R2 staff respond to the call button within two minutes. During the course of the interviews ED stated that staff respond to the residents' call button in a timely manner and that the goal is to answer the call button within three minutes. Therefore, the allegation is deemed UNFOUNDED, meaning the allegation is false, could not have happened and/or is without a reasonable basis. LPA Ramirez conducted an exit interview with ED Chon, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 16, 2023 · control 22-AS-20231024084217