Care Connection

Allegation investigated: The facility is not assisting resident with medication

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. The Department received the complaint on July 7, 2026 and the initial 10 day visit on July 15, 2026. LPA Mendivil interviewed staff and resident as well as collected documents such as Medication Administrator Records for March - July 2026, medication list, and physician's orders for Resident 1 (R1). Regarding the allegation that facility is not assisting resident with medication the investigation revealed the following : Resident 1 (R1) was admitted to the facility on September 30th, 2025 after a hospital stay. R1 has a diagnosis of dementia , afib, and chronic diastolic congestive heart failure based on Physician’s Report dated September 25, 2025. When R1 arrived at the facility in September 2025 their medication list included Amiodarone 200mg 1tab once daily. Amiodarone was also on a medication list dated October 10, 2025 for 200 mg 1tab once daily Unsubstantiated R1 was enrolled with hospice in October 2025 with Grand Hospice which was discontinued shortly after enrollment. It was then reported R1 was enrolled Cinta Hospice in November, per medication list in November 2025 it listed amiodarone 200 mg 1 tab per day. On May 26, 2026 Cinta Hospice’s Dr advised R1's family and facility that R1 would be discharged from hospice effective on June 25, 2026. Per review of documents R1’s hospice was terminated on May 26, 2026 by R1’s responsible party which left R1 without a prescribing physician. On June 1, 2026 R1 was assigned to Mobile Care Medical Group and a physician assistant conducted an evaluation. During the evaluation R1’s medication list was reconciled by Mobile Care Medical Group on June 1, 2026, which lists Amiodarone 200mg 1 tab once daily. On June 18th, 2026, a prescription is dropped off with the label for Amiodarone 200mg ½ tab once daily. Facility nurse attempted to reconcile the medication as it did not match the prescription of 200mg 1 tab once daily. During this time the facility was then informed via email that the prescription for Amiodarone had been updated by R1’s cardiologist in November 2025 to Amiodarone 100mg once daily . It was reported by the facility that they did not receive the discharge paperwork or new prescription from R1 or R1’s responsible party in November 2025. The facility nurse was able to obtain the correct prescription from R1’s cardiologist on June 26, 2026 and R1 was given medications as prescribed. LPA also reviewed Medication Administration records for the months of May, June and July and medications appeared to be given as prescribed. Facility Administrator Eric Gilbert and facility nurse both deny the allegation that the facility was not assisting R1 with their medications as they attempted to provide R1 with the correct dosage. Therefore based on the preponderance of evidence through records reviewed and interviews the allegation that the facility is not assisting a resident with medication is determined to be UNSUBSTANTIATED, meaning although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred. An exit interview was conducted and a copy of this report was provided along with LIC 811 - Confidential Names List.the state’s words, verbatim · CDSS document, Aug 21, 2026 · control 22-AS-20260706165624

Allegation investigated: Staff does not ensure resident has privacy during medical visits Staff prevents medical professionals from visiting resident

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on May 13, 2026. LPA was greeted and granted entry into the facility and met with Administrator (AD) Eric Gilbert. LPA explained the reason for the visit. This Department has investigated the complaint alleging that staff does not ensure resident has privacy during medical visits. Regarding the allegation the following was revealed: During the interviews with residents, Resident 1 (R1) reported that they have privacy during their visits. Per R3, they have privacy during their medical visits. During the initial visit on May 20, 2026, LPA observed that R1 had privacy during their visit from Hospice. During the interviews with staff, Staff 1 (S1) and S2 reported that R1 has privacy during their medical visits. During the interviews with witnesses, Witness 1 (W1) and W2 reported that there is always privacy when visiting R1 and/or stated that R1 has privacy during their medical visits. CONTINUED ON LIC9099-C... Unfounded Regarding the allegation that staff prevents medical professionals from visiting resident, the following was revealed: During the initial visit LPA observed that Hospice was allowed to visit R1. During the interviews with residents R1 reported that they are allowed to have visitors. Per R3, their Doctor and Nurse have never been denied entrance. During the interviews with staff, S1 and S2 reported that staff have not prevented medical professionals from visiting R1. During the interviews with witnesses, W1 and W2 stated that they have never been denied entry to visit R1. Therefore, these allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or are without a reasonable basis. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA Ramirez conducted an exit interview with AD Gilbert, and a copy of this report was provided to the facility. Regarding the allegation that staff released personal information to an unauthorized individual, the following was revealed: During the interviews with witnesses, W3 reported that staff released R1's personal information to an unknown Health company without R1's authorization. During the interviews with residents, R1 reported that they are not aware if staff released their personal information to an unauthorized individual. During the interviews with staff, S1 and S2 reported that staff have not released R1's personal information to an unauthorized individual. W2 reported that she is not aware about staff releasing the resident's personal information to an unauthorized individual. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with facility representative, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 5, 2026 · control 22-AS-20260513104158

Allegation investigated: Staff do not respond to authorized representatives request for residents records

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit regarding the complaint allegation above. LPA was greeted by staff and explained the reason for the visit upon entry. Regarding the allegation above, 4 of 4 individuals could not provide any evidence or supporting information to corroborate the complaint allegation. During the pre-investigation, it was discovered there’s no information regarding what was requested from the facility or when information was requested from the facility. Based on the information gathered during through interviews, the allegation is deemed Unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Jul 22, 2026 · control 22-AS-20260714081727

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by Eric Gilbert, Administrator and LPA explained the nature of the visit. There are six residents at the facility and there are three residents receiving hospice services currently. LPA accompanied with Administrator began the tour of the inside and outside of the facility. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in the garage in a pantry. The facility is maintained at a comfortable temperature. LPA inspected that medication is centrally stored in a safe locked storage cabinet located in the kitchen. LPA reviewed medication and observed medication was labeled and stored inaccessible to residents in care. Medication cross checked for accuracy of date and dosage. LPA inspected the bathrooms, and LPA measured the hot water temperature which measured 117.3 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked underneath kitchen sink and locked in the garage. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage Continued on LIC809-C space is provided for residents in their bedroom. Carbon monoxide and smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed a shaded area, patio furniture, and the grounds were free of any hazards. There are two gates in the backyard, which both are self-closing and self-latching. No bodies of water were observed. LPA observed a fire extinguisher with service date of September 15, 2025, mounted in the kitchen wall and throughout the facility. LPA reviewed and verified fire drill are conducted. Facility has a second floor which is inaccessible to residents in care, door that leads to the second floor is by the kitchen or through the main entry of the facility. There are no residents residing on the second floor of the facility. LPA verified resident in care do not have access to the second floor. LPA began review of records. LPA reviewed three resident records. All the required documentation was present and current in the residents’ files reviewed. LPA reviewed three employee records. All employees present have a criminal record clearance and are associated with the facility. LPA observed records reviewed have a current First Aid certificate. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Administrator and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 29, 2025

Type of visit: Office

An Informal meeting was conducted on this date in Orange County Adult and Senior Regional Office. Present in this meeting were Licensing Program Manager Lourdes Montoya, Licensing Program Analyst Jenifer Tirre, and Licensee Eric Gilbert. During meeting LPM Montoya discussed Appeal response and Amended Complaint Investigation Report for complaint findings issued on July 24, 2025 on complaint # 22-AS-20250716111635. Report was amended from Unsubstantiated to Unfounded. Licensee was provided clarification on appeal rights. During meeting Licensee’s signature was obtained for amended report on complaint #22-AS-2025071611635. An exit interview was conducted. Copies of Appeal Response, Amended Complaint Investigation Report and Facility Evaluation Report was provided to Licensee Eric Gilbert.the state’s words, verbatim · CDSS document, Oct 21, 2025

Type of visit: Office

An informal office meeting was held today September 23, 2025 in Orange County Adult and Senior Care Regional Office, in Orange, California. Present at meeting was Licensing Program Manager Lourdes Montoya, Licensing Program Analyst Jenifer Tirre and Licensee Eric Gilbert. Purpose of the meeting was to hear concerns of Licensee Eric Gilbert in regards to a recent lawsuit Licensee received. Licensee also discussed concerns regarding appeal made to complaint #22-AS-20250716111635. Licensee stated that lawsuit is not related to complaint. Licensing Program Manager Montoya explained to Licensee Gilbert that the Department has no jurisdiction over Lawsuit and Licensee's relationships in regards to Staff. Department explained to Licensee that current appeal is being looked into and Department will respond in timely manner. An exit interview conducted with Licensee Eric Gilbert and copy of report was provided.the state’s words, verbatim · CDSS document, Sep 23, 2025

Allegation investigated: Facility staff is not following physicians orders Facility staff are forcing residents to sleep in the living room Facility staff are violating residents personal rights

***THIS IS AN AMENDED REPORT*** Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced inspection visit to deliver findings for complaint investigation into the above allegations. LPA Tirre explained the reason for the visit with Licensee Eric Gilbert. During the course of the investigation LPA toured facility, reviewed records, conducted interviews, made visual observations and requested pertinent documentation such as Resident Roster, Physician’s reports, Resident Needs And Appraisal, Staff training and Family testimonials. During investigation LPA reviewed facility records such as Physician's reports, needs & service Appraisal for Residents in care. LPA Tirre also reviewed staff training. Record review revealed that facility currently has six residents in care all of which have a form of Dementia or Mild Cognitive Impairment. Six of six residents physicians reports state that each resident is able to communicate their needs. Five of six residents are Non Ambulatory and one is Ambulatory with Assist based off Residents Physicians Reports. CONTINUED ON 9099C Unfounded During visit LPA Tirre conducted interviews with staff members. Three of three staff members interviewed stated that they follow Physician orders and provide care accordingly. Staff members stated that as part of their facility activities they encourage residents to do daily exercises such as chair exercises where residents are rotating their arms in circular motions and lifting light 1 pound weights for those residents who choose to lift weights. Staff Members stated that they do not force residents to use weights if they choose not to. Staff stated that residents who don’t use weights still do same arm movements and gestures like those with weights. Three of three staff members interviewed stated that residents sleep inside their bedrooms. Staff stated that sometimes when residents are sitting in their recliner chairs inside living room, residents may dose off for naps. All staff interviews stated that no residents are being forced to sleep in living room. Three of three staff members stated that they respect the personal rights of residents in care. During Visit, LPA Tirre conducted interviews with residents. Two of Two residents interviewed stated that facility staff give them medications accordingly and provide meals. Residents interviewed stated that staff have never forced them to do something against their will. Residents interviewed stated they sleep inside their bedrooms and have never been forced to sleep in the living room or witnessed other residents sleeping in living room. Residents interviewed stated that their personal rights have not been violated. Residents interviewed confirmed they have no concerns regarding care being provided to them at facility. During visit LPA Tirre interviewed family witnesses, and two of two witnesses confirmed they have no issues with facility or the level of care being provided to residents. Witnesses confirmed they sent over testimonials to Licensee earlier today in regards to facility complaint and stated they are pleased with quality of care that is being provided to residents. Witness testimonials state that five of six families have no complaints regarding facility care. Based on records reviewed and interviews conducted, this agency has investigated the complaint alleging facility staff is not following physician’s orders, facility staff are forcing residents to sleep in the living room and facility staff are violating resident’s personal rights. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and / or is without reasonable basis. An exit interview was conducted with Licensee Eric Gilbert and a copy of this report was reviewed and provided at the time of this visit.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 22-AS-20250716111635

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Administrator (AD) Eric Gilbert. For today’s visit, LPA observed a total of five residents in care and two staff members on duty. During today's visit LPA observed the AD certificate for AD Suzanne Anderson which expires on February 17, 2026. LPA toured the interior and exterior portions of the facility with AD Gilbert. The facility is a two-story structure and is licensed for one ambulatory and five non-ambulatory residents, of which six may be on hospice and one bedridden. There are a total of nine bedrooms, of which six are resident bedrooms, and three are bedrooms for staff. LPA toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of four restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 108.3-110.7 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguishers were charged and one was located by the kitchen and one by the Residents' bedroom hallway. During today's visit LPA observed as residents were watching television and having lunch. LPA observed the emergency disaster and evacuation plan which is located by dining room. Facility had back-up emergency food and water supply. CONTINUED ON LIC809-C... LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care. For the exterior portion, LPA observed a shaded area, patio furniture, and the grounds were free of any hazards. There are two gates in the backyard, which both are self-closing and self-latching. No bodies of water were observed. LPA reviewed five resident and two staff files. LPA interviewed residents and staff present. During today's visit LPA consulted with AD regarding the updated Health Screening Report-Facility Personnel (LIC503). LPA informed AD to use the updated LIC503. For today's visit one deficiency was issued per Title 22 Division 6 of the California Code of Regulations. LPA advised AD Gilbert to use the general email address: CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA. An exit interview was conducted with AD Gilbert. A copy of this report and Appeal Rights were provided at the time of exit.the state’s words, verbatim · CDSS document, Oct 23, 2024