Carmel Village Retirement Community

Allegation investigated: Resident is not provided with a comfortable living accommodation

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director Mandy Taylor and explained the reason for the visit. The investigation into the allegation, Resident is not provided with a comfortable living accommodation, revealed the following. It was reported that Resident 1 (R1) did not have a comfortable living environment because of neighbors making loud noises which made it difficult for R1 to sleep. LPA interviewed the Executive Director who reported no complaints have been made regarding any resident not having a comfortable living accommodation or any unauthorized visitors harassing residents. LPA interviewed 3 neighbors of R1 who denied making any loud noises. LPA interviewed 3 staff members who reported no one has complained to them about loud noises or visitors. R1 declined to be interviewed. There is no evidence to support the allegation. Based on the evidence gathered the allegation is unsubstantiated, meaning that although the alleged violation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation occurred. An exit interview was conducted and a copy of the report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 18, 2026 · control 22-AS-20260813155504

Allegation investigated: Faciltiy is charging for services not provided Faciltiy does not ensure resident is changed timely resulting in multiple UTIs

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. The Deparmtent received the complaint on March 30th, 2026 and the initial 10 day visit was conducted on April 09th, 2026. LPA Mendivil obtained copies of : admission agreement, physician's report, and needs and services, and staff schedules. LPA Mendivil interviewed staff and residents. Regarding the allegations facility is charging for services not provided and facility does not ensure resident is changed timely resulting in multiple UTIs, the investigation revealed the following: It is alleged that the facility is charging for services not provided.Per interviews with 4 out of 4 staff, staff stated that everyday assistance with Activities of Daily Living (ADLs) are not documented , this would include repositioning or checking on resident. Per Resident Care Coordinator Ruby Molina only exceptions are documented for care, meaning only out of the norm items are documented. Unsubstantiated Staff stated that a resident that needs repositioning is repositioned every 2-3 hours. Interviews with 6 residents with varying levels of care needed all stated that the staff is providing the care they need and pay for. 6 out of 6 residents stated the staff is wonderful and helpful. It was alleged that facility does not ensure resident is changed timely resulting in multiple UTIs. Per interviews with 4 out of 4 staff, staff denies leaving any resident in soiled diapers for an extended period of time. Interviews with 6 residents, residents stated that staff is responsive and have not left them for extended periods of time. Therefore based on the preponderance of evidence through records reviewed and interviews the allegations facility is charging for services not provided and facility does not ensure resident is changed timely resulting in multiple UTIs is determined to be UNSUBSTANTIATED, meaning that although the alleged violation may have happened or is valid there is not a preponderance of evidence to prove the alleged violation occurred. An exit was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 22-AS-20260330161235

Type of visit: Case Management - Health Checks

On July 10, 2026, Licensing Program Analyst (LPA) Eboni Bentley made an unannounced case management visit for the purpose of following up on an Incident Report submitted to the Orange County Regional Office on April 24, 2026. LPA met with Regional Health & Wellness Director Terrie Sherrell as Executive Director Mandy Taylor was on vacation. The facility self-reported an incident where Resident #1 (R1) sustained a fall, was transported to the hospital, and returned to facility with diagnosis of brain bleed. During today's visit, LPA obtained copies of the following: Resident Roster, Staff Roster, Health & Services Evaluation dated June 15, 2026, Service Plan dated June 10, 2026, Facility Progress Notes, and Hospice Visit Notes. LPA observed R1 in the main building common area with other residents, during a live music entertainment activity. The resident was siting in a standard wheelchair with facility staff present. During an interview, Staff #1 (S1) stated the facility would be providing 1:1 caregiver to R1 from and outside agency beginning on the evening of July 10, 2026, to ensure resident safety. No deficiencies are being cited during today's visit. LPA informed staff that subsequent visits and document requests could be required and staff stated they understood. An exit interview was conducted with Regional Health & Wellness Director Terrie Sherrell, and a copy of this report provided at the end of the visit.the state’s words, verbatim · CDSS document, Jul 10, 2026

Allegation investigated: Facility staff is withholding care and supervision from resident Unlawful eviction

This report is being amended to reflect signatures. On 05/23/2026, Licensing Program Analyst (LPA) Arielle Pascua conducted a complaint visit via telephone call regarding the complaint allegations above. Current census was 187. It was alleged that the facility staff is withholding care and supervision from resident and have issued an unlawful eviction. LPA Pascua attempted to contact former staff from this facility to obtain additional information, however, LPA Pascua was unable to reach staff as they were no longer employed by this facility. In addition, contact with current staff deny or have not been employed by the facility during the time of the complaint. A review of the facility records were also conducted. Based on interviews conducted and observation, the allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided via email for signature. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 23, 2026 · control 22-AS-20230320090137

Allegation investigated: Facility failed to ensure that resident is kept clean and dry from incontinence. Facility failed to ensure that resident's belongings were provided to current facility.

On 05/23/2026, Licensing Program Analyst (LPA) Arielle Pascua conducted a complaint visit via telephone call regarding the complaint allegations above. Current census was 187. A brief interview with FDA Taylor was conducted. It was alleged that the facility failed to ensure that the resident was kept clean and dry from incontinence and did not ensure that resident's belongings were provided to the current facility. LPA Pascua attempted to contact former staff from this facility to obtain additional information, however, LPA Pascua was unable to reach staff as they were no longer employed by this facility. In addition, contact with current staff deny or have not been employed by the facility during the time of the complaint. A review of the facility records were also conducted. Based on interviews conducted and observation, the allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided via email for signature. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 23, 2026 · control 22-AS-20221129102336

Allegation investigated: Failure to meet the resident's needs. Failure to provide supervision resulting in inappropriate behaviors. Residents are wandering into other residents' rooms. Failure to follow COVID-19 protocols. Staff ignores resident's request for help. Facility is billing for an additional month. Facility staff is insufficient to meet the resident's needs.

On 05/23/2026, Licensing Program Analyst (LPA) Arielle Pascua conducted a complaint visit via telephone call regarding the complaint allegations above. Current census was 187. A brief interview with FDA Taylor was conducted. It was alleged that the facility failed to meet the residents needs, provide supervision resulting in inappropriate behaviors, residents wander into other resident's rooms, fail to follow COVID protocols, facility staff ignore resident's request for help, facility is billing for an additional month, and is unsufficient to meet the resident's needs. LPA Pascua attempted to contact former staff from this facility to obtain additional information, however, LPA Pascua was unable to reach staff as they were no longer employed by this facility. In addition, contact with current staff deny or have not been employed by the facility during the time of the complaint. A review of the facility records were also conducted. Based on interviews conducted and observation, the allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided via email for signature. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 23, 2026 · control 22-AS-20221128152508

Type of visit: Case Management - Health Checks

On April 29, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for the purposes of conducting a case management health and safety check. The visit is a follow up to an SOC341 and Incident Report received by Orange County Regional Office on April 24, 2026. LPA introduced self to Executive Director (ED) Mandy Taylor, explained the reason for the visit, and was granted entry into the facility. LPA reviewed facility documents including: Resident Roster, Staff Roster, Progress Notes, Medication Administration Record, and Hospice Records. Interviews were conducted with residents and staff. During the inspection, LPA toured the facility with ED and observed no imminent health and safety issues. A volunteer with Silverado Hospice was observed visiting with the resident in their room. Interviews were conducted and records were reviewed. An exit interview was conducted with Executive Director Mandy Taylor, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Apr 29, 2026

Type of visit: Case Management - Deficiencies

On April 29, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced, for the purpose of conducting a Plan of Correction - Deficiencies inspection. This is a follow up to a deficiency issued during the annual inspection conducted on April 23, 2026. During today’s visit, LPA was greeted and granted entry after explaining the purpose of the visit to Executive Director (ED) Mandy Taylor. LPA conducted a tour of the facility with ED, and observed all delayed egress devices on exterior doors and perimeter fence gates were operational with all alarms working properly. The kitchen was observed with a sufficient amount of perishable and non-perishable food items. There was no sign of gnats in the main kitchen, dining room, and common areas observed during the tour. Based on observations, deficiencies are being cleared. An exit interview was conducted with Executive Director Mandy Taylor, and a copy of this report including the Letters of Deficiency Citations Cleared were provided at the end of the visit.the state’s words, verbatim · CDSS document, Apr 29, 2026

Allegation investigated: Licensee did not properly address a pest infestation in the facility. Staff did not communicate with resident’s representative in a timely manner. Staff did not safeguard residents’ personal belongings.

On April 23, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for a subsequent complaint investigation visit into the above allegations. LPA was greeted and granted entry after stating the purpose of the visit to staff. Executive Director Mandy Taylor was present and assisted with the visit. During the course of the investigation, LPA reviewed facility documents including: Resident Roster, Staff Roster, Staff Contacts, Staff Schedule, Maintenance and Pest Control logs, Resident Emergency Info & Contact Sheet, Physician's Report, Service Plan, and Resident Property & Valuables form. Interviews were conducted with residents, staff, and witnesses. CONTINUE TO LIC9099-C...... Unsubstantiated The investigation revealed the following: Regarding the allegation, Licensee did not properly address the infestation in the facility, it was alleged that Resident #1 (R1) was experiencing bites on his back and arms from an unidentified type of bug in his room. LPA toured the facility during the initial inspection visit conducted on October 31, 2025, and no immediate health and safety threats were identified. LPA did not observe any bugs in R1’s room and R1 confirmed no bites were visible at the time. A record review revealed R1 reported bugs in their room on September 29, 2025 and staff responded to the room on the same date. Staff #1 (S1) stated the room was inspected but no bugs were found. S1 stated R1 showed them zip lock bags of what R1 indicated were bugs, however S1 stated they were actually earwax and lint. Pictures were taken and provided. LPA interviewed R1 who reported the facility fumigated the room and the bugs were gone but returned shortly after. Resident stated they collected a bug in a zip lock bag and then stated it was later disposed of, therefore LPA was unable to observe the reported evidence. On September 30, 2025, R1 submitted a second request for service and a record review of a Pest Flex vendor invoice revealed the room was fumigated on October 4, 2025. Regarding the allegation, Staff did not communicate with resident’s representative in a timely manner, it is alleged that the facility did not respond to calls made to the resident’s representative regarding bugs and bites until two weeks after initial contact attempts. During an interview with Witness #1 (W1), it was reported that calls were made to staff and not immediately returned, however no evidence was provided during the investigation. Four out of four staff denied the allegation, stating call requests are returned in a timely manner and a record of all maintenance service requests are documented via LifeLoop software. Regarding the allegation, Staff did not safeguard residents’ personal belongings, it is alleged that resident’s shirts went missing during the first year of their residency and have not been returned. Four out of four staff interviewed and one witness denied the allegation, stating the resident’s laundry is done off site by family and returned weekly. This was corroborated during an interview with R1 and Witness #2 (W2). A record review of R1's Resident Property & Valuables form revealed the document was blank with no items listed and no evidence of missing items was provided during the investigation. Based on the observations made, interviews which were conducted, and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are deemed UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 22-AS-20251028084748

Type of visit: Case Management - Annual Continuation

On April 23, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for the purposes of conducting a required 1-Year Annual Continuation. LPA was greeted and granted entry after explaining the purpose of the visit to staff. Executive Director (ED) Mandy Taylor was present to assist with the annual inspection. During the visit, LPA conducted a tour of the facility with ED Taylor and observed all required regulatory postings in the main entry way. Facility was operating within the approved capacity. Three resident apartment buildings with three floors were inspected, along with common areas, and outdoor patios with shaded seating for residents. There were no bodies of water or obstructions. The memory care unit is located in Building 3 where LPA observed one exterior egress gate requiring a key to exit and two interior egress doors with non-operational alarms. LPA observed gnats in 8 out of 20 residents apartments, the main kitchen, dining room, and additional common areas. There were 6 small trash bags with soiled contents in hallways throughout Building 1, Building 2 and Building 3 requiring proper disposal. Deficiencies are being cited. An audit was conducted of 20 resident files and 10 staff files. The medications and the Medication Administration Records (MARs) were reviewed. Additional interviews were conducted with residents and staff. The Emergency and Disaster Plan (610E) was reviewed with administrator and amendments were recommended. The facility conducts quarterly disaster drills with the last one conducted on January 27, 2026, with minimal attendance. CONTINUE TO LIC809-C.... Additional linens for residents were not available during the visit and ED stated an order had been placed. Technical Assistance were issued. Based on observations, deficiencies are being cited on the attached LIC9099-Ds, and Technical Assistance (TAs) are being issued. An exit interview was conducted with Executive Director Mandy Taylor, and a copy of this report including the LIC9099C, LIC9099-Ds, TAs, and the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Apr 23, 2026

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On April 22, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for the purposes of conducting a required 1-Year annual inspection. LPA was greeted and granted entry after explaining the purpose of the visit to staff. Executive Director (ED) Mandy Taylor arrived at approximately 9am to assist with the annual inspection. The facility is licensed to provide services to residents age range 60 and over, (220) non-ambulatory, of which 20 may be bedridden. Non-ambulatory is on the first and second floor and 50% of third floor. Approved for delayed egress, with a hospice waiver for 40 residents. During the inspection, LPA conducted a tour of the facility with ED Taylor and the following was observed: All common areas were inspected along with 20 resident apartment, which had all the required elements. The residents’ personal bathrooms were observed operational, grab bars were secure and the hot water temperatures in 16 out of 20 resident bathrooms measured between 116.2 and 119.5 degrees Fahrenheit. LPA advised staff to monitor water temperatures on a weekly basis to ensure temperatures do not exceed 120 degrees Fahrenheit. LPA inspected the kitchen and the dining areas, and toured the outside grounds of the facility. All walkways were clear of hazards and there was ample seating with outdoor shade available for the residents. The smoke alarms and carbon monoxide detectors were last tested on November 25, 2025 per the fire alarm inspection report conducted by Tricom Fire & Electric Co. Evacuation chairs were observed at the top of each stairwell. There were several fire extinguishers mounted throughout the facility, fully charged, and serviced on September 22, 2025. Interviews were conducted with 20 residents and 4 staff during today's visit. Due to time constraints, an annual continuation visit is needed and ED was advised that deficiencies may be cited. An exit interview was conducted and a copy of this report provided to Executive Director Mandy Taylor.the state’s words, verbatim · CDSS document, Apr 22, 2026

Allegation investigated: Staff are not keeping record of resident's medical information Staff are not safeguarding resident's personal items Staff are not keeping resident's restroom clean and sanitary Staff are using the resident's restroom Unauthorized staff have access to resident's locked room

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on 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, the department toured the facility and interviewed staff as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegations that staff are not keeping record of resident's medical information, staff are not safeguarding resident's personal items, staff are not keeping resident's restroom clean and sanitary and unauthorized staff have access to resident's locked room, the investigation revealed the following: LPA reviewed the available record for R1 including physician report, care plan and pre-placement appraisal. Due to the age of the complaint, LPA is unable to review electronic records. Per interview conducted with former Executive Director, there is not a recollection of a missing item and LPA observed no record of item. LPA is unable to review housekeeping records from time of complaint however, LPA observed the facility to be clean and sanitary on three different occasions. CONTINUED ON LIC 9099C DATED 03/28/2026. Unsubstantiated Interview with staff indicated staff use public restrooms and not resident rooms. The resident moved out on 01/07/2023. Responsible party came back to resident's room on 01/11/2023 and at that time witnessed evidence that someone had used the restroom. There is no evidence to prove who may have used the restroom once the resident was moved out. All staff have access to resident rooms in the facility in order to provide care and supervision thus would be authorized. Staff interviewed confirm knocking on resident rooms prior to entering. Staff interviewed were unable to recall the resident or circumstances regarding the allegations. Based on interviews conducted and record review, the allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 28, 2026 · control 22-AS-20230112082829

Allegation investigated: Facility released private information without authorization Facility failed to dispense medication Facility changed hospice company without authorization

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on 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, the department toured the facility and interviewed witnesses as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegations that facility released private information without authorization, facility failed to dispense medication and facility changed hospice company without authorization, the investigation revealed the following: R1 was enrolled in hospice care with Advantage Hospice. Witness 1 (W1) stated that the facility would be unable to change a hospice company without authorization from the family and indicates conversations were had with the responsible party. Due to the age of the complaint, W1 is unable to remember if the resident ever changed hospice companies before passing. LPA reviewed R1's records and did not find evidence of any other hospice company besides Advantage. W1 denies providing protected health information about R1 to any outside agency. CONTINUED ON LIC 9099C DATED 03/28/2026. Unsubstantiated LPA reviewed medication orders for R1. LPA observed orders for four different eye drops but was unable to review medication administration records. Due to the age of the complaint, facility was unable to access the resident's records in the electronic administration record. LPA attempted to interview staff employed during time of complaint but no staff were able to remember R1. Based on interviews conducted and record review, the allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 28, 2026 · control 22-AS-20230106135453

Allegation investigated: Staff are not keeping indoor passageways and stairways free of obstruction Staff are not providing services to resident as agreed upon in resident's Admissions Agreement Staff are not according resident(s) privacy while in care Staff do not prominently post information in areas accessible to resident(s) in care Staff are prohibiting residents from holding Resident Council meetings Facility does not provide reasonable accommodations(s) for resident in care

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. Regarding the allegation that staff are not keeping indoor passageways and stairways free of obstruction, the investigation revealed the following: Two out of two staff and four out of four residents deny seeing any areas of the facility with obstructions. LPA toured the facility on two different occasions and did not observe any obstructions. Regarding the allegation that staff are not providing services to resident as agreed upon in resident's Admissions Agreement: Admission agreement dated 11/15/2021 for Resident 1 (R1) does not specify how often staff will check in on the resident. However, two out of two staff confirm that staff check residents every 2 hours when on care. CONTINUED ON LIC 9099C DATED 03/21/2026. Unsubstantiated Regarding the allegation that staff are not according resident(s) privacy while in care: Four out of four residents and two out of two staff confirm staff are respectful and announce themselves before entering a resident's apartment. Two out of two staff indicate staff wear earpieces connected to their pagers and resident names are not mentioned over the system. Care staff communicate room numbers only and LPA observed this during the investigation. Regarding the allegation that staff do not prominently post information in areas accessible to resident(s) in care: LPA observed all required postings in common area of the facility. All postings were accessible to residents and in an appropriate font. Regarding the allegation that staff are prohibiting residents from holding Resident Council meetings: Five out of five residents and two out of two staff confirm resident council meetings have been conducted. Regarding the allegation that facility does not provide reasonable accommodations(s) for resident in care: LPA observed postings and resident notices in elevators and common areas to be at appropriate heights and accessible to residents in care throughout the facility. Based on interviews conducted and observation, the allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 21, 2026 · control 22-AS-20221025101527

Allegation investigated: Facility failed to report resident's hospitalization to family Facility failed to comply with resident's discharge orders Facility failed to provide supervision to resident resulting in resident pulling catheter out Facility failed to properly store resident's medication Facility staff failed to report resident's true condition to responsible party

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on 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, the department toured the facility and interviewed staff and witness. Regarding the allegation that Facility failed to report resident's hospitalization to family, the investigation revealed the following: Resident 1 (R1) had several hospitalizations as the resident was declining. Witness 1 (W1) states the resident's responsible party was always notified when the resident was sent out to the hospital. W1 indicates resident had instances of being transferred to a different hospital once admitted and sometimes the faciliy had to track down the resident. W1 confirms speaking with family regarding hospitalizations. Regarding the allegation that facility failed to comply with resident's discharge orders, the investigation revealed the following: W1 states that all prescribed medications were administered to the resident. W1 does not recall specific medications due to the age. CONTINED ON LIC 9099C DATED 03/21/2026 Unsubstantiated W1 states that all prescribed medications were administered to the resident. W1 does not recall specific medications due to the age of the complaint but denies facility wouldn't administer non-prescribed medication. Facility staff confirm physician orders are followed. LPA did not observe an order for Vitamin B on the resident's medication orders. Regarding the allegation that facility failed to provide supervision to resident resulting in resident pulling catheter out, the investigation revealed the following: Responsible Party and W1 confirm resident had a sitter at the facility as well as staff checking in every 2 hours. Once it was observed that the resident had pulled out the catheter, medical attention was sought immediately. The resident did not return to the facility after being sent out on this occasion due to declining health. Two out of two staff confirm residents on care are checked every 2 hours. Regarding the allegation that facility failed to properly store resident's medication, the investigation revealed the following: W1 states medications are delivered to the medication room and not to a resident's room. W1 does not recall an incident where insulin was observed to be in the resident's room especially since the resident was on med management. Two out of two staff confirm medications are not delivered to resident rooms. Regarding the allegation that facility staff failed to report resident's true condition to responsible party, the investigation revealed the following: W1 confirms sending condolences to the resident's family being inadvertently informed that the resident had passed. The hospital had mistakenly notified about the passing of the resident as the resident had not passed. The family was understandably upset but the notification came from the hospital and not the facility. W1 stated following what had been told to the witness. Due to the age of the complaint, LPA is unable to review parts of the resident's electronic medical record and staff interviewed do not remember the resident. Based on interviews conducted, the allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 21, 2026 · control 22-AS-20221018074030

Allegation investigated: Facility did not ensure the health and safety of resident in Memory Care

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on January 14, 2025. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Mandy Taylor. LPA explained the reason for the visit. This Department has investigated the complaint alleging that facility did not ensure the health and safety of resident in Memory Care. Regarding the allegation the following was revealed: During the investigation LPA reviewed the Carmel Village Retirement Community Memory Care staff schedule dated January 23, 2025, and March 18, 2026. Per Memory Care staff schedule, on average there are five caregivers and one Medication Technician (MT) for the morning and evening shifts and three caregivers for the night shift. LPA reviewed the Unusual Incident/Injury Report (UIIR) dated January 16, 2025, for Resident 1 (R1). Per UIIR, on January 10, 2025, R1 was found on the floor with her head under the bed. Per UIIR, 911 was called and R1 was transported to the Hospital and admitted for a Urinary Tract Infection (UTI). CONTINUED ON LIC9099-C... Unsubstantiated Documents reviewed include the Carmel Village Retirement Community Service Plan dated January 8, 2025, for R1. Per Service Plan, it states R1 requires one person total assistance by staff members for all mobility/ambulation needs. During the interviews with residents, R2 reported that staff are helpful and attentive and stated that staff will respond quickly when he uses his call button. Per R2, staff work around the clock and reported that staff are meeting his needs. During the interviews with staff, Staff 1 (S1) reported that staff ensure the health and safety of the residents in Memory Care. S2 stated that staff are attentive and reported that the fall was not due to neglect. Per S3, staff do their best to ensure the health and safety of the residents in Memory Care. During the interviews, Witness 1 (W1) reported that she could not say if the fall was due to lack of care and supervision. Based on the information gathered during the investigation and review of documents obtained, 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, this allegation is 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 ED Taylor, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 22-AS-20250114102443

Allegation investigated: Resident's personal items are being moved around in his room Resident had several personal items stolen from his room Visitors are not screened or temperature checked before entering the facility

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. Regarding the allegations that Visitors are not screened or temperature checked before entering the facility, resident had several personal items stolen from his room and resident's personal items are being moved around in his room, the investigation revealed the following: Two out of two staff state that the Resident 1 (R1) was blind and did not want items moved around. Staff state resident would move things around and then forget about it. Staff interviewed was not aware of item being stolen and due to the age of the complaint there is no documentation present regarding stolen items. Four out of four residents deny missing items in their rooms and verbalize satisfaction with the facility. Three out of three staff state that visitors were screened for illness and/ or covid prior to entering the facility in 2022.CONTINUED ON LIC 9099C DATED 03/14/2026. Unsubstantiated Based on interviews conducted, the allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 14, 2026 · control 22-AS-20220810143732

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visits 22-AS-20220810143732, 22-AS-20221018074030, 22-AS-20221025101527, 22-AS-20230106135453, and 22-AS-20230112082829. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPA requested documents from staff. Documents were unavailable during the visit. Please forward the following requested documents by close of business Wednesday March 18, 2026: Any documents pertaining to missing/ stolen items for Resident 1 and physician report. Physician report, pre-appraisal, care plan and any progress notes for 2022 for Resident 2. Physician report, pre-appraisal, care plan/ hospice notes and any progress notes for 2022 for Resident 3 Physician report, pre-appraisal, care plan and any progress notes for 2022 for Resident 4 Admission agreement for Resident 5. Exit interview conducted and a coy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 14, 2026

Allegation investigated: Staff handles residents in a rough manner

On February 25, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to initiate 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. Executive Director (ED) Mandy Taylor was present and assisted on today's visit. During the course of the investigation, LPA conducted resident interviews, staff interviews, reviewed and collected pertinent documents to this complaint. Regarding the allegation, staff handles residents in a rough manner, the following has been concluded: It was alleged that staff handled Resident #1 (R1) in a rough manner. LPA conducted an interview with R1 who corroborated the allegation and stated that Staff #1 (S1) has treated her in a rough manner on previous occasions. LPA conducted an interview with S1. S1 denied the allegation and stated that he has never treated R1 in a rough manner, or any other resident. LPA conducted interviews with eleven other residents. One out of the eleven residents interviewed corroborated the allegation and stated that they have also been treated roughly by S1. CONTINUED ON LIC9099-C Unsubstantiated However, ten out of the eleven residents interviewed denied the allegation and stated that they have not been treated roughly by any staff at the facility. LPA conducted six staff interviews. Three out of the six staff interviewed corroborated the allegation and stated that residents have complained to them about being treated roughly by S1. However, three out of the six staff interviewed denied the allegation and stated that they have not observed, or heard of any resident being treated roughly by staff. Due to conflicting information received during the investigation, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed UNSUBSTANTIATED. An exit interview was conducted with Journey Care Director Rosa Avila and Resident Care Coordinator Ruby Molina. A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 22-AS-20260220164850

Allegation investigated: Facility is in disrepair.

On January 26, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for a initial complaint investigation visit into the above allegation. LPA was greeted and granted entry after stating the purpose of the visit to staff. Executive Director Mandy Taylor arrived shortly and assisted with the visit. LPA reviewed facility documents including: Resident Roster, Staff Roster, Staff Contacts, Staff Schedule, Resident Emergency Info & Contact Sheet, Physician's Report, Service Plans, and admission agreements. Interviews were conducted with residents, staff, and witnesses. Regarding the allegation: Facility is in disrepair It is alleged that the facility ceilings leak when it rains, staff uses buckets to catch the water, and repairs to leaks have not been made. CONTINUE TO LICE9099-C... Substantiated During the visit, LPA Bentley toured the interior and exterior of the facility with staff. Observations were made and photos were taken of water damage to ceiling panels in the hallways and in resident bedrooms. LPA observed a ceiling panel in the hallway where a leak was reported. Four out of five staff interviewed confirmed the allegation, stating the area leaked during a recent rain in December 2025 and a bucket was used to catch the water. One staff stated leaks were first discovered in December 2024, recurred in December 2025, and have not been repaired. A record review confirmed repairs had not been done to repairs the leak. Based on the evidence gathered through interviews and observations, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. A deficiency is being cited per California Code of Regulations Title 22. An exit interview was conducted Executive Director Mandy Taylor, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 26, 2026 · control 22-AS-20260116091806

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 6, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provisions of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation and interviews conducted, the licensee did not comply with the section cited above, which poses a potential health and safety or risk to persons in care. LPA observed water stains on ceiling panels of Building 2, third floor where leaks were resported. Interviews confirmed water damage occurred due to rain between Dec 2024 and Dec 2025 with no record that repairs had not been made.the state’s words, verbatim · CDSS document, Jan 26, 2026

Plan of correction: Executive Director stated the entitre third floor roof will be inspected by a professional vendor and repaired by POC due date with proof submitted to CCLD by POC due date via email.

Type of visit: Case Management - Incident

On January 26, 2026, Licensing Program Analyst (LPA) Eboni Bentley made an unannounced case management visit for the purpose of following up on an SOC341 and Incident Report submitted to the Orange County Regional Office on December 18, 2025. The facility self-reported an incident where Staff #1 (S1) was accused of hitting and choking Resident #1 (R1) in their bedroom. Staff #2 (S2) reported hearing screaming while walking down the hallway, and responded to R1’s room, where they found R1 crying and both R1 and S1 accusing the other of being physically aggressive. A body check was conducted and two bumps were found on the R1’s head that were not previously reported. During the investigation, interviews were conducted with residents and staff. According to S1, the resident refused to go to the bathroom by screaming they did not want to up out of bed, and verbalized refusal repeatedly. S1 stated they ignored R1’s refusal when they pulled R1 up by the arms to a seated position in the bed, S1 placed their hand behind R1’s back to stand on the floor, and then proceeded to walk R1 to the bathroom, all while R1 was refusing to get up, and shouting at S1 to “leave me alone” and “get out.” Although there was not enough evidence to prove that S1 is the cause of R1 sustaining two bumps on the head, S1 admitted they should have stopped insisting R1 get out of bed and go to the bathroom for a shower, and should have called for assistance instead. S1 admitted they did not report the two bumps on head R1’s head. Three out of five individuals confirmed witnessing S1 being aggressive while caring for residents. No additional details were provided. Based on the interviews conducted during the investigation, a deficiency is being cited. An exit interview was conducted Executive Director Mandy Taylor, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jan 27, 2026

All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews conducted, S1 admitted to ingoring R1's refusal to get out of bed and physically forcing resident to get out of bed, stand, and walk to the bathroom for a shower, which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2026

Plan of correction: Executive Director stated S1 will be given a written notice with the possibility of termination and proof will be submitted to CCLD by POC due date.

Type of visit: Case Management - Health Checks

On December 18, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purpose of conducting a case management health and safety check. The visit is a follow up to an Incident Report received by Orange County Regional Office on November 19, 2025. LPA introduced self to Executive Director (ED) Mandy Taylor, explained the reason for the visit, and was granted entry into the facility. LPA obtained copies of Resident/Staff Roster, Staff Schedules, and the following records for R1: Emergency Contact Info Sheet, Physician’s Report and Orders, Service Plans, Progress Notes, and Hospice records. During the inspection, LPA toured the facility with staff and observed no imminent health and safety issues. An exit interview was conducted with Executive Director Mandy Taylor, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Dec 18, 2025

Type of visit: Case Management - Health Checks

On December 18, 2025, Licensing Program Analyst (LPA) Eboni Bentley arrived unannounced for the purpose of conducting a case management health and safety check. The visit is a follow up to an SOC341 and Incident Report received by Orange County Regional Office on December 15, 2025. LPA introduced self to Executive Director (ED) Mandy Taylor, explained the reason for the visit, and was granted entry into the facility. LPA obtained copies of Resident/Staff Roster, Staff Schedules, and the following records for R1: Emergency Contact Info Sheet, Physician’s Report, Service Plans, Progress notes, and Hospital After Care Summary dated December 7, 2025. LPA also received written statements of four staff provided to the facility. During the inspection, LPA toured the facility with staff and observed no imminent health and safety issues. Interviews were conducted and records reviewed. An exit interview was conducted with Executive Director Mandy Taylor, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Dec 18, 2025

Type of visit: Case Management - Other

On November 25, 2025, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced case management visit to follow up on incident reports received by Orange County Regional Office on October 31, 2025 and November 6, 2025. LPA introduced self to Executive Director (ED) Mandy Taylor, explained the reason for the visit, and was granted entry into the facility. During the visit, LPA toured the facility and obtained copies of Resident/Staff Roster, Staff Schedules, and the following records for R1 and R2: Emergency Contact Sheet, Physician’s Report, Admissions Agreement, Service Plans, and Resident Personal Property and Valuables. LPA conducted interviews with residents and staff. The incident report submitted to the Department on October 31, 2025, stated that Resident #1 (R1) reported missing one hundred and seventeen dollars and R1's money clip on October 27, 2025. R1 reported last seeing the missing items on October 27, 2025. Facility staff reported incident to Fountain Valley Police Department, submitted a police report, and questioned staff who were scheduled to work on that date. Staff searched R1's apartment to attempt to locate the missing money and money clip and was unsuccessful. Facility reviewed camera footage and found internal investigation was inconclusive. LPA interviewed R1 who stated they are missing additional items and unhappy with the outcome of the investigation. Continue to LIC809-C.... The incident report submitted to the Department on November 6, 2025, stated that Resident 2 (R2) reported missing thirty three dollars and R2's wallet on October 28, 2025. R2’s family reported last seeing the missing items on October 29, 2025, as indicated in emails dated November 6-14, 2025. Family reported incident to Fountain Valley Police Department (FVPD) and submitted a police report. Facility questioned staff who were scheduled to work on that date, reviewed camera footage, and found internal investigation was inconclusive. LPA interviewed R2 who stated they are dissatisfied with the status of the investigation. ED stated they will provide in-service training for all personnel regarding Mandated Reporting and the facility policy for Theft and Loss. ED stated they will follow up with FVPD and will provide an update to LPA on December 2, 2025, regarding any new developments. No deficiencies were cited during this visit. An exit interview was conducted with Executive Director Mandy Taylor, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Nov 25, 2025

Allegation investigated: - Resident sustained an unexplained injury while in care

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. Executive Director (ED) Mandy Taylor arrived later to assist with the visit. On November 23, 2021, the Department received a complaint alleging that a resident sustained an unexplained injury while in care. During the investigation, LPA Tea conducted interviews with facility staff and residents and reviewed relevant facility records and documentation. The investigation revealed the following: A review of facility records showed no unusual incident reports indicating that any memory care resident sustained an unexplained injury during the period in which the complaint was received. LPA Tea interviewed three long-term memory care residents who were present at (Complaint Investigation continued on LIC9099C) Unfounded the facility at the time of the alleged incident. All three residents stated they did not recall any residents sustaining an injury or experiencing a fall during that time. LPA Tea also interviewed two memory care staff members who were working during the period in question. Both staff members reported no knowledge or recollection of any resident sustaining an unexplained injury. Staff acknowledged that while falls are common among the residents’ population, they did not recall any specific incident matching the allegation. A previous LPA assigned to the complaint interviewed a former hospice staff member who provided care at the facility during the time of the alleged incident. The hospice staff reported they did not witness any injuries, falls, or inappropriate staff conduct. They stated they had never observed staff being rough or unkind to residents and described the allegation as a “he-said, she-said” situation without substantiating evidence. Based on LPA Tea’s observations, interviews conducted, and records reviewed, the allegation is determined to be UNFOUNDED. An unfounded finding indicates the allegation is false, could not have happened, and/or lacks a reasonable factual basis. No deficiencies cited at this time and an exit interview was conducted with the facility. A copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 22-AS-20211123115313

Allegation investigated: - Faclity staff cannot meet the resident's needs - Facility staff are forcing resident to receive unnecessary services

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. Executive Director (ED) Mandy Taylor arrived later to assist with the visit. The Department received a complaint on March 9, 2023. During the investigation, Licensing Program Analyst (LPA) Tea interviewed facility staff and witnesses, and reviewed facility records, resident documentation, and other pertinent information. It was alleged that facility staff cannot meet the resident’s needs. Per Interviews with six out of six staff revealed that Resident 1 (R1) was identified as one of the most aggressive residents in the memory care unit. Staff consistently reported that R1 frequently exhibited combative behaviors during incontinence care (Complaint investigation report continued on LIC9099C) Unsubstantiated and bathing. Staff stated it was common for R1 to hit them during attempts to provide care. Review of facility progress notes for R1 corroborated these accounts, documenting multiple incidents of staff being hit and noting additional episodes of aggressive behavior toward other residents. Staff further reported that R1’s family expressed concerns about neglect due to R1 often being observed in bed. However, caregivers’ notes confirmed that R1 routinely did not sleep through the night and was awake for extended periods. Staff stated that R1 would become upset, irritable, or resistant in the mornings when care was provided and would often prefer to remain in bed. All staff interviewed reported that memory care staff provided the best care possible to meet R1’s needs, noting that R1 was a physically large, heavy, and tall individual who required extensive assistance. Staff reported that R1’s health was declining and that the family requested one-to-one care at all times, which facility staff could not provide due to responsibilities for other residents in the memory care unit. Review of R1’s evaluation and needs assessment indicated that R1 required the highest level of assistance with mobility and ambulation, including the assistance of two staff members. R1 also required total assistance with bathing, dressing, and toileting. One staff member reported that at times a third staff member was needed due to R1’s size and behaviors, but staff stated they continued to provide care to the best of their ability. It was alleged that facility staff are forcing resident to receive unnecessary services. Per a witness alleged that the facility threatened to require approval of medications for R1 or require the family to hire a private caregiver to meet R1’s care needs. Interviews with four out of six staff confirmed that R1 was a high fall risk and that their overall health was declining during their stay. Staff reported R1 would attempt to stand up from their wheelchair or bed without assistance, necessitating close supervision. Due to these safety risks, staff stated they recommended that the family consider a private caregiver to ensure continuous supervision. LPA reviewed R1’s medication records and Outside Agency Documentation, which showed that medication changes were initiated by R1’s family in consultation with R1’s Physician Assistant. Four out of six staff confirmed that the facility followed medical orders as prescribed. No evidence was found indicating the facility forced or manipulated medication decisions. LPA also reviewed R1’s billing records and resident ledger. Records did not show additional charges, or rate increases throughout the year, aside from a standard rent increase at the beginning of the new year. No unexplained or forced charges for private caregiving or additional services were noted. (Complaint investigation report continued on LIC9099C) Therefore, based on LPA Tea's observations, interviews conducted, and records reviewed the allegations mentioned above have been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited at this time and an exit interview was conducted with the facility. A copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 18, 2025 · control 22-AS-20230309095855

Allegation investigated: Staff left resident in soiled clothing for extended periods of time Staff did not safeguard residents personal belongings Residents room was malodorous

On July, 21, 2025 Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint visit to investigate allegations that a "resident's room was malodorous," that "staff did not safeguard residents’ personal belongings," and that "staff left a resident in soiled clothing for extended periods." Upon arrival, LPA Haddadin was greeted, granted entry into the facility by Memory Care Director Laura Forman, and explained the purpose of the visit. The investigation included a tour of the facility, a review of relevant documentation, and interviews with staff and residents. Specifically, this involved interviews with three staff members and three residents, as well as a review of resident and facility files. Regarding the allegation that a "resident's room was malodorous," none of the three residents and none of the three staff members interviewed supported the claim. During the investigation, LPA Haddadin conducted interviews in two resident rooms and the resident breakroom and did not notice or smell any unpleasant odors. Unsubstantiated Concerning the allegation that "staff did not safeguard residents’ personal belongings," the investigation found that none of the three residents or three staff members interviewed supported this allegation. A review of Resident 1's (R1) file showed that the inventory intake sheet, signed and dated on May 10, 2019, listed no personal items. The file also contained email communication from April 5, 2021, between the resident's responsible party and the facility administrator. In this email, the responsible party provided a price list for items for which a refund was requested. Records show a check was issued to R1's responsible party on April 5, 2021, and cleared on May 11, 2021. As to the allegation that "staff left a resident in soiled clothing for extended periods," none of the three residents or three staff members interviewed corroborated this claim. Furthermore, staff interviews revealed that facility employees conduct routine checks on all incontinent residents at intervals ranging from every 20 minutes to two hours, and also assist residents whenever they request to be changed or refreshed. During the facility tour, LPA Haddadin did not observe any residents in soiled clothing or detect any related odors. Therefore, based on the preponderance of evidence gathered through interviews, documentation review, and observations conducted by LPA Haddadin, the allegations are deemed UNSUBSTANTIATED. This means that although the alleged events may have happened or are valid, there is not a preponderance of evidence to prove that the violations occurred. No deficiencies were cited during the visit. An exit interview was conducted, and a copy of this report was provided to the facilitythe state’s words, verbatim · CDSS document, Jul 21, 2025 · control 22-AS-20210324151302

Allegation investigated: Resident sustained unexplained fracture while in care. Resident sustained multiple falls due to lack of supervision.

On 05/16/25, Donna Gurriere, Licensing Program Analyst (LPA) contacted the licensee via telephone to deliver final findings regarding a complaint that was received on 09/20/2024. LPA Gurriere spoke with Kianny Soto, Health and Wellness Director and explained the purpose of the call. Resident sustained unexplained fracture while in care. During the interview process, the Resident Care Coordinator, the resident (Resident 1), and several staff persons were interviewed. In addition, documents were reviewed and obtained to include Personnel Report, Physicians Report, Emergency Information, Admission Agreement, Appraisal and Needs, Medication Administrative Record (MARs), Incident Reports and Medical Records. continued Unsubstantiated During the investigation of a complaint received on 09/20/24, it was reported that the resident (Resident 1) pressed their pendant for assistance and when staff arrived the resident was observed on the floor lying on her back. It was stated that the resident independently tried to get out of her wheelchair and fell to the floor. The resident complained of back and hip pain and was sent by emergency services to the hospital. It was reported that the resident suffered a Lumbar Compression Fracture; however, it was not due to a lack of care and supervision. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated. Resident sustained multiple falls due to lack of supervision. During the interview process, the Resident Care Coordinator, the resident (Resident 1), and several staff persons were interviewed. In addition, documents were reviewed and obtained to include Personnel Report, Physicians Report, Emergency Information, Admission Agreement, Appraisal and Needs, Medication Administrative Record (MARs), Incident Reports and Medical Records. During the investigation of a complaint received on 09/20/24, it was reported that the resident (Resident 1) would independently page for assistance at times; however, other times, they would try and stand on their own and then fall. Documents reviewed, indicated that staff were available to assist the resident when they needed assistance or paged them. Falls were not due to a lack of supervision. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated. Licensee/health and wellness director was advised a copy of this report will be sent via certified mail. Two copies of the report will be sent. The licensee/health and wellness director is to sign and return a copy to the Orange County Regional Office.the state’s words, verbatim · CDSS document, May 16, 2025 · control 22-AS-20240920115247

Type of visit: POC

On May 13, 2025, at 8:30am, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced, for the purpose of conducting a Plan of Correction - Deficiencies inspection. This is a follow up to a deficiency issued during the annual inspection conducted on April 22, 2025 by LPA Jessica Cho. During today’s visit, LPA Bentley was greeted and granted entry after explaining the purpose of the visit to Administrator/Executive Director Mandy Taylor. LPA inspected all common areas and inspected 16 resident apartment units which had all the required elements. The residents’ personal bathrooms were checked. Toilets and water faucets worked properly, and the grab bars were secure. Showers were free of mold/mildew, and the slip resistant mats were in place. Regarding, 87303(e)(2), Maintenance and Operation, regulation indicates that "the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F." Water temperature was measured today between 109.2 and 119.3 degrees Fahrenheit. Facility has complied with the terms of the Plan of Corrections (POC). An exit interview was conducted with Administrator Mandy Taylor, and a copy of this report including the Letter of Deficiency Citations Cleared were provided at the end of the visit.the state’s words, verbatim · CDSS document, May 13, 2025

Allegation investigated: Facility staff mismanaged resident's medications. Facility staff are not adequately trained. Facility laundry room is not maintained clean Resident's sleep is disturbed by staff slamming doors, conversations and other activitities. Facility does not have adequate lighting. Facility does not have adequate staff to meet the needs of the residents. Resident was not given their test results upon request. Facility is in disrepair. Facility does not provide a safe environment for residents.

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint visit to present findings regarding the allegations. Upon arrival, LPA Haddadin was greeted, granted entry to the facility, and explained the purpose of the visit. During the investigation, LPA Haddadin toured the facility, interviewed staff members and residents, and reviewed both staff and resident files. The following allegations were investigated: "Resident's sleep is disturbed by staff slamming doors, conversations, and other activities"; "Facility staff mismanaged resident's medications"; "Facility does not have adequate staff to meet the needs of the residents"; "Facility staff are not adequately trained"; "Facility laundry room is not maintained clean"; "Facility does not have adequate lighting"; "Resident was not given their test results upon request"; "Facility is in disrepair"; and "Facility does not provide a safe environment for residents." The findings of the investigation are as follows: Unsubstantiated Regarding the allegation of "Facility staff mismanaged resident's medications," it was reported that Resident 1 (R1)'s medication was not being administered promptly or in the correct dosages. LPA Haddadin conducted six staff interviews, three of whom were Medical Technicians. These interviews did not corroborate the allegation, and all staff members denied any mishandling of residents' medications. Six resident interviews also yielded denials of the allegations. Furthermore, LPA Haddadin interviewed R1, who stated they had previously experienced issues with the timely and correct administration of medications. However, R1 reported that the facility no longer manages their medications as R1 now self-administers. Additionally, LPA Haddadin observed a Medical Technician distributing medications to four randomly selected residents. The Medical Technician utilized electronic software that logs the time and date, and the software displays the medication name, resident's name, room number, and resident's picture, all of which staff verified before administering the medication. For the allegations: "Facility laundry room is not maintained clean," "Facility does not have adequate lighting," and "Facility is in disrepair," the investigation, through six staff interviews and six resident interviews, found no support for these claims. LPA Haddadin also conducted a walkthrough of the two laundry rooms and observed both to be clean, free of odors and debris. Both the washer and dryer were maintained and in working condition, and the trash bins were empty. Regarding the allegation of "Facility does not have adequate lighting," LPA Haddadin interviewed R1 in their room and observed an additional light stand, not present in other residents' rooms, which provided extra illumination. R1 indicated that the previous Executive Director had provided the light stand to address a lighting concern. For the allegations: "Facility does not provide a safe environment for residents," "Resident was not given their test results upon request," and "Resident's sleep is disturbed by staff slamming doors, conversations, and other activities," LPA Haddadin conducted six staff interviews and six resident interviews, all of whom denied the allegation that the "Facility does not provide a safe environment for residents." LPA Haddadin also reviewed the facility's required Annual Inspection report, conducted on April 19, 2022, by Community Care Licensing, and found no deficiencies to support this allegation. However, regarding the allegation that "Resident was not given their test results upon request," LPA Haddadin interviewed R1, who stated that the facility did provide the test results in January but could not recall the exact date. A review of records also showed that the test results were in R1's file and accessible to the resident. For the allegation that "Resident's sleep is disturbed by staff slamming doors, conversations, and other activities," LPA Haddadin conducted six resident interviews and six staff interviews, all of whom denied the allegations. For the allegations: "Facility does not have adequate staff to meet the needs of the residents" and "Facility staff are not adequately trained," LPA Haddadin interviewed six residents and three staff members. Six out of six residents stated that staff respond to their calls for assistance within twelve to twenty-five minutes. All three staff members stated that they respond to residents' calls within fifteen to twenty minutes. All interviewees indicated that staff respond to residents' calls in a timely manner. Regarding the allegation that "Facility staff are not adequately trained," a review of records showed that all Medical Technicians are mandated to complete an eight-hour refresher course every six months. Furthermore, a review of staff files for the three interviewed Medical Technicians showed that they had all been employed for at least two years and had completed the required training. Therefore, based on the preponderance of evidence gathered through interviews conducted by LPA Haddadin, the allegations: "Facility staff mismanaged resident's medications," "Facility staff are not adequately trained," "Facility laundry room is not maintained clean," "Resident's sleep is disturbed by staff slamming doors, conversations, and other activities," "Facility does not have adequate lighting," "Facility does not have adequate staff to meet the needs of the residents," "Resident was not given their test results upon request," "Facility is in disrepair," and "Facility does not provide a safe environment for residents" were found to be UNSUBSTANTIATED. This determination means that while the alleged incidents may have occurred or the concerns may be valid, there is not a preponderance of evidence to prove that the alleged violation took place. No deficiencies were cited during today's visit. An exit interview was conducted with the Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 30, 2025 · control 22-AS-20220318131858

Type of visit: Case Management - Incident

On April 22, 2025, Licensing Program Analysts (LPAs) Edward Kim and Jessica Cho conducted an unannounced Case Management Visit to follow-up on an incident report received from the facility. LPAs Kim and Cho met with Executive Director (ED) Mandy Taylor and explained the purpose of the visit. During today’s visit, LPAs obtained information pertaining to the incident which occurred on January 29, 2025, involving Resident #1 (R1) and Staff (#1). LPAs obtained the Staff Roster, Resident Roster, S1’s records, and R1’s records which includes the Physician’s Report, Admissions Agreement, Emergency Information, and other pertinent documents. During the visit, LPA Kim interviewed two staff members and one witness. A deficiency was observed during this visit as facility did not maintain R1’s Physician’s Report that was signed and dated. An exit interview was conducted, and a copy of this report along with the LIC809-D, LIC811, and the appeal rights were provided to Executive Director Mandy Taylor.the state’s words, verbatim · CDSS document, Apr 22, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: May 6, 2025

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional ... This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above by not maintaining a Physician’s Report that was signed and dated which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 22, 2025

Plan of correction: Licensee states they will provide a signed medical assessment of R1 via email to Edward.kim@dss.ca.gov by POC due date May 6, 2025.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Jessica Cho and Edward Kim arrived at the facility unannounced for the purpose of conducting the Required 1 Year Annual Inspection. LPAs were greeted and granted entry after explaining the purpose of the visit to Executive Chef Teri McLeod. Executive Director Mandy Taylor arrived approximately 9am to assist with the annual inspection. The facility is licensed to provide services to residents age range 60 and over, (220) non-ambulatory, of which 20 may be bedridden. Non-ambulatory is on the first and second floor and 50% of third floor. Approved for delayed egress, and has a hospice waiver for 40 residents. There are currently 13 residents receiving hospice care services. During the tour with ED Taylor. LPAs inspected all common areas and inspected 16 resident apartment units which had all the required elements. The residents’ personal bathrooms were checked. Toilets and water faucets worked properly, and the grab bars were secure. Showers were free of mold/mildew, and the slip resistant mats were in place. The hot water temperatures in four out of the 16 private bathrooms in the apartments exceeded 120 degrees Fahrenheit measuring at 123.0, 122.0, 126.1, and 121.2. LPAs observed one apartment unit having a strong odor from the litter box. LPAs inspected the kitchen and the dining areas. Facility maintains ample supply of two-day perishables and seven-day non-perishables. LPA observed the emergency food and water in the kitchen and supply storage. The fire extinguishers were mounted, fully charged, and serviced on July 1, 2024. The smoke/carbon monoxide detectors were last tested on November 19, 2024 per the fire alarm inspection report conducted by Tricom Fire & Electric Co. LPAs toured the outside grounds. There were ample seating and shading for the residents, and the walkways were clear of hazards. Facility conducts quarterly disaster drills with the last one conducted on January 30, 2025. LPAs reviewed 15 residents' and 4 staff files. No discrepancies noted. Interviews were conducted with 16 residents and 4 staff. The medications and the Medication Administration Records (MARs) were reviewed. No discrepancies noted. The following were advised: to maintain the hot water temperature between 105-120 degrees Fahrenheit and to remove the source of the odor in the apartment unit of Resident #9 (R9). Based on the observations, a deficiency is being cited on the attached LIC9099-D, and a Technical Violation (TV) is being issued. An exit interview was conducted with Executive Director Mandy Taylor, and a copy of this report including the LIC9099C, LIC9099-D, TV, and the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Apr 22, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff mismanaged resident's medication

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint received in our office on April 20, 2022. LPA was greeted and granted entry at 12:30pm and met with Mandy Taylor, LVN, Executive Director and explained the purpose of the visit. On February 28, 2025 LPA Ruppert obtained the resident file and reviewed: Identification Form, Physician's Report, Appraisal Needs and Services Plan and Medication list; as well as Unusual Incident Reports. LPA Samer Haddadin conducted six of six resident interviews and three of three staff interviews regarding the above allegation. LPA Rosie Quiroz made an initial visit on May 28, 2022 and spoke with the Health Services Director (HSD) regarding if staff mismanaged resident's medication. The HSD stated to LPA Quiroz that the resident received the same exact dosage of medication but was taken out of another medication box. (Continued on LIC 9099-C) Substantiated (continued from LIC 9099) LPA reviewed records and it is noted that the medication was not taken from the resident's medication supply but it was the same dosage. LPA spoke to the resident's family member who stated she was contacted by the facility and that the resident was accidentally given someone else's medication. When family member inquired if resident was given the wrong dose, the response was that the medication given was the exact dose. Based on LPA record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. A deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Pam Munday, Regional Vice President of Operations, who did not wish to sign the reports, and a copy of this report was given to the facility along with a copy of the LIC 9099-D and Appeal Rights.the state’s words, verbatim · CDSS document, Apr 21, 2025 · control 22-AS-20220420165307

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(5) · Plan of correction due date: May 5, 2025

87465 Incidental Medical and Dental Care. (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement has not been met as evidenced by: Based on LPA file review and interview, this was not followed in one of one residents, which poses a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Apr 21, 2025

Plan of correction: Facility to provide a staff in-service on medication administration and documentation. The date, desciription of the topic covered and participant signatures are to be documented and emailed to the LPA by May 5, 2025.

Allegation investigated: Staff neglect resulting in resident sustaining a pressure ulcer Staff do not respond to resident's call for assistance in a timely manner Staff dropped resident while assisting resident in the shower

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint received in our office on April 20, 2022. LPA was greeted and granted entry at 12:30pm and met with Mandy Taylor, LVN, Executive Director and explained the purpose of the visit. On February 28, 2025 LPA Ruppert obtained the resident file and reviewed: Identification Form, Physician's Report, Appraisal Needs and Services Plan and Medication list; as well as Unusual Incident Reports. LPA Samer Haddadin conducted six of six resident interviews and three of three staff interviews regarding the above allegations on February 28, 2025. Staff and residents interviewed by LPA Haddadin were asked If they knew of staff neglect that resulted in a resident sustaining a pressure ulcer. Six of six residents and three of three staff denied this allegation. (Continued on LIC 9099-C) Unsubstantiated (Continued from LIC 9099) Staff and residents interviewed by LPA Haddadin were asked if staff respond to residents calls for assistance in a timely manner. Six of six residents stated calls are answered between twelve and twenty five minutes. Three of three staff stated calls are answered within fifteen to twenty minutes. All interviewed stated staff respond to residents calls in a timely manner. Staff and residents interviewed by LPA Haddadin were asked if staff dropped a resident while assisting resident in the shower. All of the staff and residents interviewed were unaware of this and denied this allegation. Based on LPA Ruppert's record review and LPA Haddadin's interviews with residents and staff; although the allegations above may have happened or were valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Mandy Taylor, LVN, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 21, 2025 · control 22-AS-20220420165307

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced to follow-up on the death report and incident report. LPA met with Executive Director (ED) Justine Ortiz and explained the purpose of the visit. During the course of the visit, LPA interviewed two staff and reviewed pertinent documentation such as the Death & Incident Reports dated February 19, 2025 and Progress Notes dated February 19 - February 27, 2025. The incident is as follows: On February 25, 2025 at 3:11pm, the Department received the Incident Report (LIC624) and Death Report (LIC624A) for Resident #1 (R1). It was reported that R1 was discovered unresponsive in their room with food in their mouth by staff on February 25, 2025 at 9:37am. Per review of the Physician's Report dated January 1, 2025, R1 does have a special diet but is able to feed self. Staff performed CPR while on the 911 call. Fountain Valley Police Department and paramedics arrived to assist and transported resident to the hospital for further evaluation after detecting a pulse. R1 passed away at the hospital. There were no health and safety violations noted during today's visit. An exit interview was conducted with Executive Director Justine Ortiz, and a copy of this report was emailed during the visit.the state’s words, verbatim · CDSS document, Mar 5, 2025

Allegation investigated: Staff is yelling at resident

Findings: allegation: Staff is yelling at resident. Licensing Program Analysts (LPAs) Samer Haddadin, and Rose Ruppert conducted an unannounced complaint visit to deliver findings on the above allegation. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the investigation, LPA toured the facility, interviewed staff members and residents as well as reviewed staff files and resident files. It was alleged: Staff is yelling at resident. The investigation determined as follows: LPA conducted interviews with three staff members and three residents. The investigation revealed three of three residents’ interviews could not support the allegation due to their cognitive ability and mental awareness. Meaning, residents did not completely understand what the LPA was asking them. However, one of three staff interviews collaborated the allegation, while two of three staff interviews denied seeing or witnessing any staff yelling at residents. Substantiated LPA reviewed staff records for S1 and observed that on April 3, 2023, S1 was reprimanded and put on 90-day probation for unprofessional conduct and yelling at residents. Also, staff record shows that on September 20th, S1 was given a final reprimand which led to termination of staff on October 9th, 2023. S1 is no longer employed due to past similar incidents. Therefore, based on the preponderance of evidence through interviews, documentation allegation that staff is yelling at resident is deemed SUBSTANTIATED. A deficiency is being cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations. See LIC9099D. An exit interview was conducted, and a copy of this report was provided to facility administrator along with appeal rights.the state’s words, verbatim · CDSS document, Feb 28, 2025 · control 22-AS-20211202124852

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Feb 28, 2025

87468.1(a)(1) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by facility employee yelled at resident which posed a protentional personal rights risk to residents in care. ***THIS IS AN AMENDED DEFICIENCY PAGE.***the state’s words, verbatim · CDSS document, Feb 28, 2025

Plan of correction: Licensee did terminate employee as evident by paperwork provided and e mailed to LPA. POC was corrected by facility

Allegation investigated: Staff intimidated a resident

Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility Health and Wellness Director and explained the reason for the visit. During the investigation, LPA toured the facility, interviewed staff members and residents as well as reviewed staff files and resident files. It was alleged: Staff intimidated a resident. The investigation determined as follows: LPA conducted interviews with three staff members and three residents. Three of three staff interviews did not support the allegation. However, one of three staff interviews did confirm observing S1 yelling at residents on multiple occasions. Per interview, S1’s yelling was not done in any way threatening or intimidating as they believed S1 was doing so due to residents being hard of hearing and not a form of intimidation. Unsubstantiated LPA reviewed S1 record and observed that training on subject of Personal Rights was completed by S1 on March 28, 2021. Also training for Abuse and Neglect was completed by S1 on March 1, 2021. During residents’ interviews, LPA observed that three of three residents did not comprehend the questions asked due to their cognitive ability and mental awareness. Meaning, residents did not completely understand what the LPA was asking them. Therefore, based on the preponderance of evidence through interviews and documentation reviewed by LPA Haddadin, the allegation that the "staff intimated resident," is UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies cited during today's visit. An exit interview was conducted a copy of report was provided.the state’s words, verbatim · CDSS document, Feb 4, 2025 · control 22-AS-20211202124852

Allegation investigated: Facility is malodorous

This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to initiate and conclude this agency’s investigation in the complaint allegation(s) mentioned bove. LPA met with Executive Director Justine Ortiz and explained the nature of the inspection.The department received a complaint on 12/4/2024 alleging the facility is malodorous. On 12/4/2024 LPA conducted a visit to the facility. LPA obtained copies of the resident roster and staff roster. LPA toured the facility and did not observe any malodorous smells. LPA conducted interviews with 7 residents. 6 out of 7 residents stated the hallways do not smell like urine or have a malodorous smell. Based on observations and interviews conducted there is insufficient evidence to support the allegation(s). Although the allegation(s) may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099 was provided to the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 11, 2024 · control 22-AS-20241204091230

Type of visit: Case Management - Incident

On 11/5/2024, LPAs Dwayne Mason Jr. and William Vanegas arrived at the facility for the purpose of conducting a Case Management visit for the purpose of following up on incident reports received by the Department. LPAs were greeted and granted entry by Front Desk/Receptionist Silvia Villalobos. LPAs met with Laura Foreman, Memory Care Director. LPAs obtained copies of the resident roster, staff roster, staff schedules and staff training logs. LPAs requested an electronic copy of the call button report from 10/21/2024 through 11/4/2024. LPAs conducted interviews with Memory Care Director, staff and residents. Based on staff interviews conducted, the majority of staff indicated that the facility is understaffed. However, based on interview with MCD, it was revealed that the facility utilizes a staffing agency called Pioneer Home Care to fill any call-outs from staff. MCD also showed LPA the job postings currently on the facility's website indicating the facility is currently hiring. Based on today's visit no deficiencies are being issued. This report was reviewed with facility staff and a copy was provided.the state’s words, verbatim · CDSS document, Nov 5, 2024

Allegation investigated: Facility staff did not ensure resident's food was protected against vermin.

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to conduct the initial visit to begin the investigation into the allegation listed above. LPA met with Justin Ortiz, Executive Director and explained the nature of the visit. Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegation. Findings are based upon this investigation which included interviews conducted, tour of the physical plant of the facility, resident file review, and copies of pertinent documents obtained (Pest Flex pest control contract and service invoices). It is alleged that facility staff did not ensure resident’s food was protected against vermin. Interview conducted with resident (R1) stated that R1 had an issue with vermin in their sandwich 3 years ago. R1 stated Continued on LIC9099-C Unfounded that they had not had an issue since then with vermin. File review of resident records revealed that R1 admission to the facility was March 25, 2023, about a year and 4 months ago. Interview with 13 of 13 residents revealed that residents have not ever had an issue with vermin in their food or have seen any vermin in the facility. Residents stated that they were very happy with the food quality of the facility. LPA obtained statements from the staff who stated that facility has had continuous pest control service from an outside vendor, which comes twice a month to do pest control maintenance. Records review reflect that facility has a contract with Pest Flex to services the facility. Copies of records obtained reflect that facility has a service agreement for pest control indicating facility had a previous pest company prior to contracting with them. Services instructions indicate to treat exterior and interior, focusing in kitchen areas, semi-monthly services, 2x month and service existing equipment. We have found the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. A copy of this report is being reviewed with the Executive Director and a copy furnished to the facility.the state’s words, verbatim · CDSS document, Aug 21, 2024 · control 22-AS-20240816143222

Allegation investigated: Staff are not properly addressing pest infestation in facility

An unannounced complaint investatigation was conducted on this day by Licensing Program Analysts (LPAs) Michael Tea and Rose Ruppert and Licensing Program Manager (LPM) Alisa Ortiz regarding the allegation mentioned above. LPAs and LPM met with Executive Director (ED) Justine Ortiz. It was alleged that staff are not properly addressing pest infestation in facility. During the investigation LPAs interviewed residents and staff, checked resident files and reviewed facility maintanence invoices. The investigation determine the following: In October 2023 Resident 1 (R1) had reported to facility about flea and mite infestation in their bedroom. Facility provided pest fumagation to R1's room. Per interview with maintanence director the facility has a contracted pest control company and contacted them to inspect for pests in R1's room. Per pest control records obtained no flea or mite activity was noted in the invoices and reports. (continued ... ) Unsubstantiated (... continued) Interviews with three of three residents confirm that they have never encountered pest within the facility. Two of three residents reported they had heard of R1 reported infestation but had never observed any pest themselves. Interviews with two of two med-techs reported that R1 complained about pest bites however med-techs denied observing bites on R1. R1 was assessed by their physician and prescribed cream to assist with itching. Prescription forms provided by physician do not list any diagnoses or report of pest bites. Interviews with staff and residents indicated R1 had a dog, however the dog normally appeared well groomed and maintained and did not itch or scratch. LPA toured the room and observed no evidence of fleas or mites. Therefore based on LPA Tea's observation and interviews conducted and records review the allegation the staff are not properly addressing pest infestation has been determined to be unsubstantiated meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies cited and an exit interview was conducted with Executive Director Justine Ortiz and a copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Jun 14, 2024 · control 22-AS-20240311095131

Allegation investigated: Staff do not prevent a resident from sustaining multiple falls while in care

LIcensing Program Manager (LPM) Alisa Ortiz, Licensing Program Analysts (LPA) Michael Tea and Rose Ruppert made an unannounced visit to the facility today to conduct a complaint follow-up visit. LPM and LPAs were greeted and granted entry by Jennifer Cerda, Concierge. During today’s visit, LPM and LPAs met with Justine Ortiz, Administrator. LPM and LPA Ruppert reviewed resident's (R1) Service Plan, Physician's Report (LIC 602A), Progress Notes and medical file. LPA Ruppert conducted interviews with facility staff. The investigation determined the following: It was alleged staff did not prevent a resident from sustaining multiple falls while in care due to R1 sustaining five falls within a thirty day period. R1 moved into the facility on March 1, 2024. R1 is ambulatory with the assistance of a walker, is able to communicate needs and had a secondary diagnosis of Mild Cognitive Impairment (MCI) based on the LIC 602A dated on March 8, 2024. (Continuation...) Unsubstantiated (Continued...) Per Needs and Service Plan dated May 6, 2024, R1 was assessed by the facility to be a high risk for falls. R1 sustained unwitnessed falls on April 2 and April 28, 2024. Facility spoke with R1's responsible party (RP) on April 28, 2024 regarding R1's change of condition. As a result facility spoke to RP about memory care placement and removed items from the apartment that could be potentially harmful. Following discussion with RP, R1 sustained falls on April 29th, 30th and May 1, 2024. Facility sought medical attention on April 30th and May 1st. RP was notified by facility of incidents after each fall. Upon return facility retained a private caregiver to provide additional supervision for R1 on May 2, 2024. Per email from Agape Home Care to facility on May 16, 2024, Agape Home Care was notified by RP on May 6, 2024 to stop service. RP advised facility that they would make arrangements for their own private caregiver for R1. On May 7, 2024 R1 sustained an unwitnessed fall. 911 was called and R1 was transported to the hospital. Health and Wellness Director notified RP of fall and the absence of a private caregiver. RP advised they were aware and was planning to provide supervision themselves and had been en route to the facility when the fall occurred. Following the fall, RP notified facility of intent to move R1 to a higher level of care. Shortly after moving on May 8, 2024 it was reported R1 passed away. Interviews with three of three staff members confirmed they were aware of R1's fall risk and that measures had been put in place to prevent falls from occurring. Two of the three staff members stated falls could have been prevented if a private caregiver was provided. Facility progress notes show staff were monitoring R1 continuously. Based on the preponderance of evidence, the allegation that staff do not prevent a resident from sustaining multiple falls while in care is unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. No deficiencies cited during today's visit. An exit interview was conducted with Administrator Justine Ortiz and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 14, 2024 · control 22-AS-20240507144901

Type of visit: Required - 1 Year

On today’s date, Licensing Program Analysts (LPA) Rosie Quiroz and Rose Ruppert conducted an unannounced visit for the purpose of conducting an annual required evaluation. LPAs were greeted upon entry to the facility by front desk concierge. LPAs met with Health and Wellness Director (HWD) Laura Sanchez and explained the purpose of the visit. Administrator (AD) Justine Ortiz arrrived shortly after. AD Justine Ortiz has an Administrator certificate with expiration date of 11/4/2023. AD Ortiz indicated submitting payment and CEU's and pending renewal. AD Ortiz agreed to submit copy of Administrator certificate to CCLD upon receiving it. The facility is licensed to provide services to residents age range 60 and over, (220) Non-ambulatory, of which 20 may be bedridden. Non Ambulatory on first and second floor and 50 percent of third floor. Approved for delayed egress, and has a hospice waiver for (40) forty residents. There are currently thirty four (34) residents receiving hospice care services. Between 9:55am-11:20am, LPAs reviewed ten (10) resident files and ten (10) personnel files. Six of ten personnel files were missing health screening and Tuberculosis test screenings. (SEE LIC 809-D) LPAs along with AD Justine Ortiz and Maintenance Director Alfonso Cerda toured the interior and exterior of facility premises. The required two (2) day perishable and seven (7) day non-perishable food supply was observed. Toxic substances were locked and inaccessible to residents. LPAs observed cooking areas to be maintained with cleanliness. LPAs observed facility refrigerator and freezer to be operational and met regulatory requirements. Resident bathrooms were observed to have working sinks, faucets and flushing toilets. LPAs tested hot water temperatures in seven (7) resident bathrooms which ranged between 113.0 degrees- 120.2 degrees Fahrenheit. Grab bars and non-skid mats were also observed in resident bathrooms. Personal hygiene items for resident use were observed in each bathroom. LPAs observed all resident rooms to have required linens, furnishings, and adequate lighting. (CONTINUED ON LIC 809 C) CONTINUED...All linens and furnishings were clean and in good repair. Smoke alarms and carbon monoxide detectors were last serviced on 2/15/2023 by Tricom Fire and Electric Company. The medications were inaccessible to residents, centrally stored and maintained in compliance. All pathways, doorways, and emergency exits were observed to be free of obstruction. There were no bodies of water observed anywhere on the property. Emergency lights for use in the event of a power outage are stored in medication room area. PPE stored in Building #2, second floor area. LPAs observed staff answer facility telephone which verified a working telephone was maintained at the facility. Regulatory required postings were observed in the resident mail box area of the facility. Facility was operating within the allowed capacity. Fire extinguishers were charged, mounted throughout the facility and last serviced 7/11/2023. Facility indicated Pest Control services facility two times per month, last serviced on 3/29/2024. LPAs verified that fire/disaster drills are conducted at least quarterly and on each shift. Last fire drill was conducted on 2/8/2024. The Emergency exit plans were posted and available for reference throughout the facility. Residents were accorded clean and comfortable accommodations. Based on the observations made during today’s visit, the facility cited per Title 22, Division 6, of the California Code or Regulations. An exit interview was conducted with ED Justine Ortiz. A copy of today's report, LIC 809-D, Appeal rights and LIC 858 and LIC 859 pages were provided at exit.the state’s words, verbatim · CDSS document, Apr 11, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Ruth Martinez made visit to this facility to conduct a case management visit. LPA arrived at facility was greeted and granted entry by receptionist. LPA met with Laura Sanchez, Resident Care Coordinator and Terrie Sherrell, Regional Director of Health and Wellness and explained the nature of the visit. LPA is conducting this visit as a follow up on an incident that was self reported an on October 24, 2023 regarding resident R1’s incident on October 20, 2023. During today’s visit, LPA interviewed staff and obtained copies pertinent documents. LPA toured the facility and observed R1 during activities with other residents. On October 20, 2023 at approximately 5:30pm staff received a call from R1's son notifying staff that R1 had called son from near by store. Staff immediately went to pick up resident and bring them back to the community. Upon return R1 was immediately evaluated by resident care coordinator, no injuries were noted. Primary care physician was notified and Health and Wellness Director. When R1 was interviews R1 was able to recall the whole process of the incident. Due to the nature of R1's recall the following was done out of protocol procedures: resident was assessed, 24 hour caregiver was put in place, all door codes were changed and place on a rotation for change of code, and an in-service training was conducted for all staff/all shift regarding elopement and code safety. Code safety measure are in place and continuous training is provided. This report was reviewed with facility representatives and a copy of the report was provided and left at the facility.the state’s words, verbatim · CDSS document, Nov 2, 2023