Carefront Residential Living

Allegation investigated: Facility did not provide bedding for resident. Facility mismanaged resident's medication Facility did not meet resident's nutrition needs Staff did not change resident's bandages.

On 02/10/2026 at 1:15 PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit and met with Caregiver, Sinelita Rivera, to deliver the findings of the above allegations. LPA explained the purpose of the visit. Sinelita Rivera phoned the Licensee/Administrator, Ding "Angela" Wang, to inform. Sinelita Rivera stated that they also phoned, Co-Administrator, Laly Bascao, to inform that LPA was present. LPA spoke with Angela on the phone and Angela gave authorization for Sinelita Rivera to sign report. During the investigation, LPA obtained and reviewed the following documents: Resident (R1)’s Physician’s Report (dated 12/22/24), Kaiser After Visit Summary (dated 12/22/24), Hospital Discharge Instructions (dated 12/22/24), Resident Appraisal (dated 12/22/24), Resident Registry, LIC 500 (dated 12/23/24 and 10/27/25), RCFE Care Plan Agreement (dated 12/22/24), Hospice IDG Comprehensive Assessment and Plan of Care Update Report (received 12/10/25), Client Medication Report (received 12/10/25), and a letter from Anchor Health (received 12/12/25). LPA interviewed Staff (S) and Witnesses (W). Unsubstantiated LIC9099-C (Page 2) Allegation: Facility did not provide bedding for resident Finding: Unsubstantiated On 01/16/2025, LPA interviewed S1, who stated that R1 was admitted to the facility on 12/22/2024 and left the facility with family on 12/26/2024. S1 stated that R1’s responsible party was informed that linens are shared among residents and that families may bring personal linens if desired. S1 further stated that R1’s responsible party said that they were going to buy their own bed linens. On 12/06/2025 and 01/21/2026 respectively, LPA interviewed W1 and W2, who stated that the family purchased and provided bedding for R1 because the facility did not have bed linens available. However, W2 stated that bedding was brought due to concerns related to R1’s COVID-positive status and the staff did not want to launder R1’s bed sheets. , Although witnesses stated that family provided bedding, there is insufficient evidence to establish that the facility failed to provide bedding as required. Therefore, the allegation is unsubstantiated. Allegation: Facility mismanaged resident’s medication Finding: Unsubstantiated On 01/21/2026, LPA interviewed W2, who stated that the hospice agency responsible for R1 was Anchor Hospice and reported that medications were not present at the facility during the first 24-48 hours. W2 further stated that during a visit, a pill was observed in R1’s mouth, which W2 identified as the last medication administered by caregivers. LIC9099-C Continued... LIC9099-C (Page 3) LPA reviewed an electronically signed letter (dated 12/11/2025) from Medical Director at Anchor Health stating, “R1 was a hospice patient of Anchor Health from the dates of 12/22/2024 thru 12/27/2024. …The patient transferred home on 12/26/2024, and we continued to provide care at home until the patient passed.” LPA attempted to obtain additional records and confirmation from the hospice agency. However, documentation was not received despite multiple attempts. Due to the lack of corroborating documentation and insufficient evidence demonstrating improper medication administration by facility staff, the allegation is unsubstantiated. Allegation: Facility did not meet resident’s nutrition needs Finding: Unsubstantiated On 12/06/2025 and 01/21/2026 respectively, W1 and W2 stated that food and fluids were not offered to R1 and that the family provided broth, soft foods, and Ensure nutritional shakes. S1 stated that R1 was actively transitioning, non-verbal, non-responsive, and on continuous oxygen. S1 further stated that hospice instructed staff not to offer food or fluids unless the resident was oriented and able to swallow due to the risk of choking. LPA reviewed RCFE Care Plan Agreement which noted, “dysphagia pre-caution.” LPA reviewed Anchor Health agency letter that stated, “R1 was ordered a mechanical soft diet by our admission nurse on 12/22/2024. R1 was not taking solid foods and only noted to be taking sips. Our records note that on 12/23/2024 and 12/24/2024 our nurse provided education to facility staff regarding dysphagia and hydration. Education for dysphagia at end of life includes instruction to only feed a patient if they are awake and alert and able to swallow.” LIC9099-C Continued... LIC9099-C (Page 4) Based on the information obtained, LPA did not find sufficient evidence to establish that the facility failed to meet R1’s nutritional needs in violation of applicable regulations. LPA attempted to obtain nutrition documentation and clarification from the hospice agency on 01/27/26 and 02/02/26; however, the requested information was not received. Therefore, the allegation is unsubstantiated. Allegation: Staff did not change resident’s bandages Finding: Unsubstantiated On 12/06/2025, LPA interviewed W1, who stated that wound dressings were not changed by staff and appeared soaked. On 01/21/2026, LPA interviewed W2, who stated that the family performed dressing changes after the second day. On 12/10/2025 and 01/27/2026 S1 stated that the wound was not a pressure injury, was located in the left armpit/breast area, and that wound care was managed by hospice. S1 further stated that staff changed wound dressings in the mornings. LPA reviewed Anchor Health agency letter that stated “Our hospice nurse is responsible for wound care for all our patients. Our instruction to our facilities is to contact hospice when wound is soiled is dislodged.” LPA attempted to obtain wound care documentation and clarification from the hospice agency on 01/27/26 and 02/02/26; however, the requested information was not received. Although information obtained during the investigation suggests that the alleged incidents may have occurred, LPA was unable to establish a preponderance of evidence to determine that the facility violated applicable regulations. Conflicting witness and staff statements, combined with the lack of supporting documentation from the hospice agency responsible for R1’s medical care, prevent a determination that the alleged violations occurred. Therefore, the allegations are determined to be UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Feb 10, 2026 · control 15-AS-20250106161139

Type of visit: Case Management - Other

On 01/28/2026 at 12:00 PM, Licensing Program Analysts (LPAs) L. Alexander and A. Christy arrived unannounced to conduct a Case Management visit. LPAs met with Laly Bascao, Co-Administrator, and explained the purpose of the visit. Laly phoned the Licensee/Administrator, Ding Wang, to inform. While LPAs was conducting a complaint investigation, 15-AS-20250106161139, during file review and touring the facility LPAs observed the following deficiencies: 1/2 bed rails on Resident's (R) R2, R3, R5 and R6 without doctors orders for mobility/postural support. Prescription medication powder unlocked and sitting on night stand in R4's bedroom. LPAs interviewed S2 that stated caregivers apply powder medication to R4. During file review there were no doctor's order for medication Screened door, 3 (three) window frames, paint can, 2 (two) bags of compound cement mix, garbage bag on side of shed, strollers, infant car seat and other garbage located behind shed in backyard LPA's observed missing home health care plan for R1's foley catheter in file. LIC809-C Continued... LIC809-C (Page 2) Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Jan 28, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Feb 4, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. Based on observation the licensee did not comply with the section cited above by having unlocked medication, including but not limited to MiconazorbAF 2% which was unlocked in R2's bedroom, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: Administrator agreed to obtain a dr's order for the medication and will conduct an In-Service training with caregivers. Administrator will submit documents and sign-in sheet to CCLD by POC due date. Administrator removed the medication from resident's room during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(e) · Plan of correction due date: Feb 4, 2026

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, maintained in the residents file, Both the physician's order and the label shall contain at least all of the following information. Based on file review the licensee did not comply with the section cited above by not having on a file a doctor's order for R2's MiconazorbAF 2% which poses an health, safety risk and personal rights to persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: Administrator agreed to obtain a doctor's order for the medication for R2 and will submit a copy to CCLD by POC due date. During visit Administrator obtained doctor's order for R2's Miconazole Powder prescription. Deficiency cleared during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(3) · Plan of correction due date: Mar 4, 2026

87608 Postural Supports (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. Based on file review and observation the licensee did not comply with the section cited above by not having on a file a doctor's order for R3, R4, R5 and R6 1/2 bed rails which poses an health, safety risk and personal rights to persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: Administrator agreed to remove 1/2 bed rails. During visit caregiver removed 1/2 rails from R3, R4, R5 and R6's beds. Deficiency cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(d)(6) · Plan of correction due date: Feb 11, 2026

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. Based on observation the licensee did not comply with the section cited above by not having backyard cean and cleared of window frames, paint cans, bags of cement mix, stroller, infant car seat, wood, reindeer Christmas decorations located outside which poses an health, safety risk and personal rights to persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: Administrator agreed to clear, remove and clean the backyard and will submit photos to CCLD by POC due date. Repeat Violation. Civil penalty $250.00 assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87609(b)(4) · Plan of correction due date: Feb 4, 2026

87609 Allowable Health Conditions and the Use of Home Health Agencies (b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s). Based on observation and record review, the licensee did not comply with the section cited above in not having a home health care plan for R1's foley catheter which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 28, 2026

Plan of correction: Administrator agreed to obtain a copy of home health care plan for R1 and submit copy to CCLD by POC due date.

Type of visit: Required - 1 Year

On 11/04/2025 at 8:30AM, Licensing Program Analyst (LPA) Andrew Christy conducted an unannounced 1-Year required inspection. LPA met with caregivers Sinelita Rivera and Teojenes Rivera and explained the purpose of the visit. Administrator Assistant Laly Bascao arrived 9:30AM. The facility is currently at max capacity with six (6) residents. LPA toured the facility including, but not limited to, bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of eight (8) bedrooms and two (2) bathrooms. One (1) bedroom in the house and one (1) in the garage is occupied by staff. LPA did not observe any bodies of water. A comfortable temperature is maintained at 71.0 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 112.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide detectors are operational. Fire extinguisher was last purchased 10/01/2025. First aid kit was observed to be complete. LPA reviewed the files for five (5) residents and five (5) staff members, all found to be complete. Emergency Disaster Plan was last reviewed 11/01/2025. Quarterly emergency drills were last conducted 10/09/2025. Review of residents' medications and Medication Administration Record (MAR) showed no outstanding errors. Continued on LIC809C..... Continued from LIC809C..... The following deficiencies were cited during the inspection: Both emergency exits from the backyard have doors that are tied to the fence and difficult to open in an emergency. The cabinet under the sink was unlocked and filled with cleaning chemicals. As well, an unlocked drawer in the kitchen had an easily accessible pair of scissors. In the kitchen fridge, there was a couple of pieces of fruit and vegetables that were expired. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report, along with appeal rights, was given to the Administrator Assistant.the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: Case Management - Other

On 10/16/2025 at 11:05am, Licensing Program Analyst (LPA), L. Hall conducted an unannounced case management visit to obtain facility information for residents. LPA met with Ma Sanelita Rivera, Caregiver, and explained the reason for the visit. During the visit LPA toured facility and reviewed the six (6) residents files. LPA obtained a copy of the resident roster and LIC500 (personnel report). No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 16, 2025

Type of visit: Required - 1 Year

On 10/15/2024 at 9:45am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year required inspection. LPA met with Ma Sinelita Rivera, Caregiver, and explained the purpose of the visit. LPA spoke with Ding Wang, Administrator via telephone and received approval for caregiver to sign documents. The facility’s fire clearance was approved for five (5) non-ambulatory, and one (1) bedridden resident. Facility has a hospice waiver for two (2). LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of eight (8) bedrooms and two (2) bathrooms. One (1) bedroom in the house and one (1) in the garage is occupied by staff. LPA did not observe any bodies of water. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 99.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide had beeping low battery sound. First aid kit was observed to be complete. Continued on LIC809. Continued from LIC809. LPA reviewed three (3) staff files and none had first aid or CPR. All six (6) residents' files were reviewed and missing documents. LPA observed the following deficiencies: At 10:15am, LPA observed during record review R1, R2, and R3 does not have an exception for prohibited health condition. At 10:30am, LPA observed during record review that none of the residents have an appraisal needs and services plan. At 10:30am, LPA observed during record review R4 and R5 did not have a hospice care plan. At 10:30am, R1, R2, and R3 does not have a doctor's order for hospital bed with full rails. At 10:45am, LPA observed during record review Administrator's file was not available for review. At 10:45am, LPA observed the three (3) staff files reviewed did not have first aid or CPR. At 11:00am, LPA observed unlocked kitchen cabinet over dishwasher containing knives. At 11:05am, LPA observed R5's bed blocking patio exit in room #3, but on facility sketch it shows (#4). At 11:15am, LPA observed alterations completed at facility. Garage has a bedroom, bedroom added on side of living room (1), small staff room added behind laundry room and room #1 on facility sketch. At 11:20am, LPA observed facility did not complete a fire drill. At 11:25am, LPA observed fire extinguisher has not be repurchased or serviced. Continued on LIC809C. Continued from LIC809C. At 11:30am, LPA observed 6 hoyer lifts, a rolling tray, a hospital bed, and a wheelchair in the back yard. At 11:30am, LPA observed shed located in the back yard unlocked. LPA requested the following documents to be submitted to CCLD by 10/22/2024. LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan (9 pages) Liability insurance Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. *An immediate civil penalty of $250.00 for a repeat violation will be assessed on today's date* Exit interview conducted. A copy of appeal rights, LIC421FC, and this report provided.the state’s words, verbatim · CDSS document, Oct 15, 2024

Allegation investigated: Facility has a lock on the front door to prevent the residents from leaving the facility

On 03/08/24 at 1:34PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with administrator (ADM), gathered information and delivered investigation finding of above allegation. LPA explained the purpose of the visit with ADM. During investigation, LPA interviewed staff (S1, S2) and observed additional inside front door lock. LPA obtained the following documents from administrator: Personnel record and Resident roster. LPA observed an additional inside lock located on the upper right hand corner of the front door during visit. Continued on next page, LIC 9099-C Substantiated Allegation: Facility has a lock on the front door to prevent the residents from leaving the facility Investigation Finding: Substantiated During investigation, LPA interviewed staff (S1, S2) who stated that the front door lock was necessary to prevent residents with dementia from leaving the facility without the knowledge of staff. Witness (W1) also observed the front door lock at the facility during a site visit on 03/04/24 and confirmed with staff (S1, S2) that the front door lock was placed to keep exit seeking residents from leaving the facility. ADM instructed staff (S1) to remove the additional front door inside lock. LPA witnessed staff remove the additional front door lock during visit. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the allegation(s) that facility has a lock on the front door to prevent the residents from leaving the facility was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, Mar 8, 2024 · control 15-AS-20240306134630

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Mar 8, 2024

Residents in all residential care facilities for the elderly shall have all of the following personal rights: 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 was not met as evidenced by the facility having an additional inside front door lock to prevent residents from leaving the facility which is in violation of Title 22 Section 87468.1 1 Personal Rights of Residents in all Facilities.the state’s words, verbatim · CDSS document, Mar 8, 2024

Plan of correction: On 03/07/24 at 1:45PM, LPA observed staff (S2) remove the additional inside front door lock during visit. Deficiency cleared during visit.

Type of visit: Case Management - Other

On 1/31/2024 at 3:00 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to meet in person with Licensee Angela Wang concerning the requests for exceptions for residents R1, R2, and R3 Percutaneous Endoscopic Gastrostomy (PEG) tube. Upon arrival, the LPA stated the purpose of the visit to caregivers Teo Rivera and Maria Rivera. The Licensee arrived at approximately 3:20 PM. During the visit, the LPA and Licensee discussed the requests for exceptions and what updates were required in the Care Plans for R1, R2, and R3 for those exceptions to be granted. The LPA met residents R2 and R3 and observed their Percutaneous Endoscopic Gastrostomy (PEG) tube care. No citations issued during visit. Exit interview conducted with Maria Rivera. A copy of this report sent to Licensee via email.the state’s words, verbatim · CDSS document, Jan 31, 2024

Type of visit: Required - 1 Year

On 11/06/2023 at 12:30 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Ding Wong and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory which 1 may be Bedridden. LPA toured facility with Ding including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which all 6 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathrooms were measured within range of 105-120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguishers were observed. First aid kit was observed to be complete. At 12:55 PM, LPA reviewed 5 of 5 residents records. At 2:30 PM, LPA reviewed 4 of 7 staff records and 4 of 4 have first aid training and associated to the facility. At PM, LPA reviewed a sample of 5 of 5 resident’s medications. Report continues on 809 C Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/27/2023: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate The following deficiency was observed during inspection: -At approximately 1:00 PM LPA observed that the facility admitted resident (R1) with a prohibited health condition. Based on record review R1 has a Gastrostomy "g-tube" (feeding tube). -At approximately 1:28 PM LPA observed that R2 was also admitted with a prohibited health condition. Based on record review R2 has a Gastrostomy "g-tube" (feeding tube). -At approximately 1:35 PM LPA observed that R3 was also admitted with a prohibited heath condition. Based on record review R3 has a Gastrostomy "g-tube" (feeding tube). -At Approximately 1:54 PM Administrator informed LPA that R4 was also admitted with a prohibited health condition. Based on record review R4 has a Gastrostomy "g-tube" (feeding tube). -At approximately 2:32 PM LPA observed that staff personnel records were missing forms. S1 and S2 staff files are missing LIC 501, LIC 503 and LIC 508. S3 staff file is missing LIC 503 and LIC 508 The following deficiencies were observed (see LIC 809 D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted and a copy of this report provided along with Appeal rightsthe state’s words, verbatim · CDSS document, Nov 6, 2023