Chateau Long Beach

Type of visit: Annual/Random

On 8/28/26 Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced annual required visit. LPA met with Olivia Alvarado as the purpose of the visit was explained. The facility is licensed to serve residents 60 and above. The facility is licensed for 178 non-ambulatory residents, and (6) bedridden residents in bedrooms #102, 104, 105,106, 107, and 108. The facility is approved for (12) hospice residents. Physical Plant/Structure The facility is a two-story structure located in a commercial neighborhood that consists of the following: reception area, (80) resident bedrooms with a bathroom in each unit, (4) public bathrooms, an activity room, kitchen, a large dining room, laundry room, medication room, a PT room, administrative offices, (3) outside patios, and storage areas Bedroom: LPA inspected 6 resident rooms (104, 117, 119, 219, 229, 248) the mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Page 1 of 2 Bathrooms: Toilets and water faucets worked properly, grab bars were secure, and a non-skid material was in place. Adequate lighting and toiletries are accessible to clients. LPA tested hot water temperature, and each room measured between 105 and 120 degrees Fahrenheit. Kitchen/Dining: LPA inspected the kitchen and observed all appliances to be in good working repair. LPA observed an ample supply of cutlery, pots, pans, and bowls to be in good repair. Kitchen safety posting, menu observed. LPA observed knives and additional sharps to be secured area and are inaccessible to residents. LPA observed a 2-day supply of perishable foods, and a 7-day supply of non-perishable foods properly stored, packaged, and labeled. Dinning area was clean and sanitary. Safety: LPA observed 9 fully charged fire extinguishers last serviced on 8/2026. Call buttons were operable. LBFD conducted fire testing service on 7/14/26. Disaster drill on 7/17/26 File Review: LPA reviewed (6 ) client files and found that (6) out of (6) had the required documents. LPA Lee reviewed (5) staff files and found that (5 ) out ( 5 ) had the required documents, training, and certifications. Medications: LPA observed all centrally stored medications secured in med cart located in med room. LPA reviewed a copy of the facility’s Liability Insurance with expiration date of 01/01/27 During today’s visit there were no deficiencies cited. An exit interview was conducted with Administrator Olivia Alvarado. A copy of this report was provided. Page 2 of 2the state’s words, verbatim · CDSS document, Aug 28, 2026

Allegation investigated: Staff do not ensure resident has access to telephone to make and receive calls.

On 05/20/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to address the above mentioned allegation. LPA me with Administrator, Olivia Alvarado, and explained the purpose of the visit. LPA was granted access to the facility. The investigation consisted of the following: On 05/20/26, the department received the following documents: staff roster, and resident roster. The department conducted a review of service records for residents #1-#3(R1-R3) and obtained copies of the following documents: Identification and Emergency Information, Admission Agreement, Telecommunications Device Notification, Personal Rights, and House Rules. Additionally, the department conducted interviews with staff #1- #5 (S1-S5), resident #1- #8 (R1-R8), and attempted to interview witness #1-#3 (W1-W3). Additionally, the department conducted a tour of the facility. Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation #2: Staff do not ensure resident has access to telephone to make and receive calls. It is alleged that staff refused to connect a caller with the resident via telephone. On 05/20/26, the department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. An interview with S1 revealed that residents are permitted to make and receive telephone calls at any time. S1 stated that residents have access to a wireless phone, the front desk phone, and the office phones for additional privacy. S1 further stated that after-hours calls are directed to a wireless phone located in the medication room, and the med-techs assist in connecting calls to residents. On 05/20/26, the department conducted interviews with R1-R8. Of those interviewed, 8 out of 8 residents could not corroborate the allegation. 8 out of 8 residents said they are satisfied with the services provided. During the visit, the department observed front desk staff assisting residents with telephone calls. The department observed one resident independently walking to the front area of the facility to speak on the phone. Based on observation, interviews conducted, and a review of records, the department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted and copy of the report was provided to Olivia Alvarado.the state’s words, verbatim · CDSS document, May 20, 2026 · control 11-AS-20260511100019

Allegation investigated: Staff do not ensure resident has access to telephone to make and receive calls.

On 05/20/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to address the above mentioned allegation. LPA me with Administrator, Olivia Alvarado, and explained the purpose of the visit. LPA was granted access to the facility. The investigation consisted of the following: On 05/20/26, the department received the following documents: staff roster, and resident roster. The department conducted a review of service records for residents #1-#3(R1-R3) and obtained copies of the following documents: Identification and Emergency Information, Admission Agreement, Telecommunications Device Notification, Personal Rights, and House Rules. Additionally, the department conducted interviews with staff #1- #5 (S1-S5), resident #1- #8 (R1-R8), and attempted to interview witness #1-#3 (W1-W3). Additionally, the department conducted a tour of the facility. Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation #2: Staff do not ensure resident has access to telephone to make and receive calls. It is alleged that staff refused to connect a caller with the resident via telephone. On 05/20/26, the department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. An interview with S1 revealed that residents are permitted to make and receive telephone calls at any time. S1 stated that residents have access to a wireless phone, the front desk phone, and the office phones for additional privacy. S1 further stated that after-hours calls are directed to a wireless phone located in the medication room, and the med-techs assist in connecting calls to residents. On 05/20/26, the department conducted interviews with R1-R8. Of those interviewed, 8 out of 8 residents could not corroborate the allegation. 8 out of 8 residents said they are satisfied with the services provided. During the visit, the department observed front desk staff assisting residents with telephone calls. The department observed one resident independently walking to the front area of the facility to speak on the phone. Based on observation, interviews conducted, and a review of records, the department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted and copy of the report was provided to Olivia Alvarado.the state’s words, verbatim · CDSS document, May 20, 2026 · control 11-AS-20260511100019

Type of visit: Case Management - Health Checks

On 3/27/2026 at approximately 8:30 pm, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a Case Management visit to conduct a Health & Safety check-up. LPA met with Olivia Alvarado/Assistant Administrator and discussed the purpose of the visit. LPA Iniguez is following up on a resident (R#1) who was transferred from an unlicensed facility regarding complaint #11-AS-20260302091713. LPA Iniguez interviewed (R#1) and asked whether they now have all the basic needs. (R#1) stated that they do, that the facility staff is “very” supportive and “went all the way” to accommodate their needs. In addition, LPA Iniguez conducted a health and safety check of (R#1)’s room at the facility. (R#1)’s room looked sanitary and had the appropriate Bedroom furniture, which included: a chair, a nightstand, a lamp, or lights sufficient for reading, and a chest of drawers. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Olivia Alvarado/Assistant Administrator.the state’s words, verbatim · CDSS document, Mar 27, 2026

Allegation investigated: Staff unlawfully evicted a resident.

*This report does not supersede the previous report dated 09/17/25 but is used to clarify findings* On 03/13/2026 at approximately 04:30 PM, LPA Troy Watson conducted a subsequent complaint visit. LPA Watson met with Business Office Manager Anahi Rivera and explained the purpose of the visit. LPA Watson was granted entry into the facility. The investigation consisted of the following: On 08/01/2025, at approximately 10:18 AM, LPA Watson requested and obtained the following documents: Resident Roster, Staff Roster, and Special Incident Reports dated 08/27/25 – 09/01/25. On 09/17/2025, between 03:14 PM – 04:58 PM, the Department conducted interviews with Staff #1–#3 (S1–S3) and Residents #1–#8 (R1–R8). CONTINUNED ON LIC9099 Unsubstantiated The investigation revealed the following: Allegation: Staff unlawfully evicted a resident. This complaint alleges that Resident #1 (R1) was unlawfully evicted from the facility. On 08/01/2025, LPA Troy Watson conducted interviews with Administrator Esperanza Naaktgeboren and Staff #1 (S1). The Administrator confirmed that no eviction notice was ever served or had occurred. On 08/01/2025, between 10:18 AM and 12:15 PM, the Department interviewed Staff #1–#3 (S1–S3). Out of those interviewed, 3 out of 3 staff denied the allegation that a resident was unlawfully evicted from the facility. On 09/17/2025, between 03:14 PM and 04:00 PM, the Department interviewed Residents #1–#8 (R1–R8). Out of those interviewed, 8 out of 8 residents denied the allegation that a resident was unlawfully evicted from the facility. LPA Watson requested from the facility a copy of any eviction notice pertaining to R1, but no documentation was available because an eviction notice was never served. Based on interviews, record reviews, observations, and the information gathered, there is insufficient evidence to support the allegation that staff unlawfully evicted a resident. Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated. No deficiencies were cited, and no citation was issued. An exit interview was conducted with Business Office Manager Anahi Rivera and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 13, 2026 · control 11-AS-20250724125527

Allegation investigated: Staff unlawfully evicted a resident.

*This report does not supersede the previous report dated 09/17/25 but is used to clarify findings* On 02/11/2026 at approximately 03:07PM LPA Troy Watson conducted a subsequent complaint visit. LPA Watson met with the Administrator Esperanza Naaktgeboren and explained the purpose of the visit. LPA Watson was granted entry into the facility. The investigation consisted of the following: On 08/01/2025, at approximately 10:18 AM, LPA Watson requested and obtained the following documents: Resident Roster, Staff Roster, and Special Incident Reports (08/27/25 - 09/01/25). On 09/17/2025, between 03:14 PM – 04:58 PM, the department conducted interviews with Staff #1–#3 (S1–S3) and Residents #2–#8 (R2–R8). CONTINUED ON LIC9099-C Unsubstantiated An attempt to interview Resident #1 was made but (R1) was no longer residing at the facility during the interviews. The investigation revealed the following: Allegation: Staff unlawfully evicted a resident. This complaint alleges that Resident #1 (R1) was unlawfully evicted from the facility. On 08/01/2025 LPA Troy Watson conducted an interview with Administrator Esperanza Naaktgeboren, Staff#1 (S1). The department interviewed Administrator S1 and the administrator confirmed that no eviction notice was ever served or had occurred. On 08/01/2025, between 10:18 AM and 12:15 PM, the department interviewed Staff #1–#3 (S1-S3). Out of those interviewed, 3 out of 3 denied the allegation that a resident was unlawfully evicted from the facility. On 09/17/2025, between 3:14 PM and 4:00 PM, the department interviewed Residents #2–#8 (R2–R8). Out of those interviewed, 7 out of 7 residents denied the allegation that a resident was unlawfully evicted from the facility. LPA Watson requested from the facility a copy of an eviction notice pertaining to R1, but no documentation was available because an eviction notice was never served. Based on interviews, record reviews, observations, and the information gathered, there is insufficient evidence to support the allegation that staff unlawfully evicted a resident. Although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed unsubstantiated. No deficiencies were cited, and no citation was issued. An exit interview was conducted with Administrator Esperanza Naaktgeboren and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 11-AS-20250724125527

Allegation investigated: Staff did not properly report incidents.

On February 05, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Esperanza Naaktgeboren admnistrator greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, record reviews, and a tour of the facility. Interviews with Staff member #1- Staff #5 (S1-S5) and Resident #1- #2 (R1-R2) . The Department reviewed several documents, including the Facility Resident Roster (dated 02/04/26), the Personnel Report LIC 500 (dated 01/12/26), (R1's) Physician’s Report LIC 602A (dated 04/17/25), Resident Assessment and Indivual Service Plan (dated 04/16/25 & 01/08/26) , Unusual Incident Report LIC 624 (dated 11/08/25, 11/26/25, 12/02/25, 12/05/25, 12/10/25, 12/30/25, 1/22/26 and 01/27/26) and other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099--C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #2: Staff did not properly report incidents. It is alleged that the facility staff did not properly report Resident #1 (R1’s) incident. It is indicated the last fall incident on January 22, 2026, was not reported to Welbe Health until January 26, 2026. It is reported that (R1) fell on January 22, 2026, on voicemail, and no fall notification was provided. No additional details regarding this allegation have been provided. On February 4, 2026, between 10:00 AM and 01:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of five (5) staff members could not validate this allegation. All incidents involving (R1) are reported to Community Care Licensing, the primary physician, and the family representative, as indicated by (S1-S2). (S1-S3) confirmed that all fall incidents involving (R1) that occurred in November and December 2025, as well as January 2026, have been reported in accordance with Title 22 regulations. (S1) noted that (R1) was admitted to Chateau Long Beach on April 17, 2025. (R1) is a client of Welbe Health, which provides the Program of All-Inclusive Care. However, Welbe Health has not partnered with Chateau Long Beach and has not provided protocol guidelines for reporting requirements to the facility. (S1) stated that the facility is licensed under the California Department of Social Services Community Care Licensing (CDSS/CCL) and follows the protocol guidelines outlined in Title 22 regulations. Every incident is documented with a written report using licensing form LIC 624, along with notifications to the primary physician at Welbe Health and the family representative. (S1-S2) asserted that the fall incident on January 22, 2026, was reported to CCL, the primary physician, and the family representative. On February 04, 2026, between 11:00 AM and 11:50 AM, the Department interviewed resident members identified as Resident #1 and Resident #2 (R1-R2). Two (2) out of two (2) cannot support this claim. Both residents emphasized that the facility communicates with their primary physicians and family representatives about any incidents involving them. This approach ensures that all relevant parties are fully informed and aligned with the necessary reporting requirements. (Evaluation Report continues LIC 9099-C) On February 04, 2026, between 12:03 PM and 12:20 PM, the Department interviewed witness identified as Witness #1 (W1). (W1) verified to have received notifications of (R1) incidents dating back from November, December 2025 and January 2026 fall occurrences. The Department review of Resident #1 (R1’s) Unusual Incident Report LIC 624 (dated 11/08/25, 11/26/25, 12/02/25, 12/05/25, 12/10/25, 12/30/25, 1/22/26, and 01/27/26) confirmed that the facility meets Title 22 reporting requirements, including notifying the primary physician and family representative. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information gathered from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. An exit interview was conducted with Esperanza Naaktgeboren, and copies of report was provided.the state’s words, verbatim · CDSS document, Feb 5, 2026 · control 11-AS-20260130090223

Allegation investigated: Staff neglect resulting in resident sustaining multiple falls.

On February 04, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Esperanza Naaktgeboren admnistrator greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, record reviews, and a tour of the facility. Interviews with Staff member #1- Staff #5 (S1-S5) and Resident #1- #2 (R1-R2) . The Department reviewed several documents, including the Facility Resident Roster (dated 02/04/26), the Personnel Report LIC 500 (dated 01/12/26), (R1's) Physician’s Report LIC 602A (dated 04/17/25), Resident Assessment and Indivual Service Plan (dated 04/16/25 & 01/08/26) , Unusual Incident Report LIC 624 (dated 11/08/25, 11/26/25, 12/02/25, 12/05/25, 12/10/25, 12/30/25, 1/22/26 and 01/27/26) and other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099--C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff neglect resulting in resident sustaining multiple falls. It is alleged that Resident #1 (R1) sustained multiple falls due to staff negligence. Reports indicate that (R1) experienced several falls over three months: November 2025, December 2025, and January 2026. These incidents were attributed to delays in the emergency call system when responding to (R1's) basic needs, which were not met promptly. Although no injuries were reported, it was noted that (R1's) limited mobility, combined with the lack of assistance, contributed to these falls. No additional details regarding this allegation have been provided. On February 04, 2026, between 11:00 AM and 11:50 AM, the Department interviewed resident members identified as Resident #1 and Resident #2 (R1-R2). Two (2) out of two (2) cannot validate this claim that multiples falls were due to staff neglect in care. (R1) expressed a desire for independence and preferred not to rely solely on care staff. (R1) often took care of basic needs independently. Although (R1) stated that the treatment received from staff was satisfactory, (R1) exhibited impatience and was reluctant to wait for assistance, which sometimes led to falls. Additionally, (R1) reported experiencing gait issues, which caused (R1) to bend low to the ground and end up on the floor. Staff documented these instances as falls, even though (R1) did not perceive them as falls -"I just couldn't get back up." (R2) has frequently observed (R1) being assisted by care staff while in bed. After the care staff leaves, (R1) often becomes defiant and attempts to transfer to an assistive device independently. This behavior frequently results in slips and falls, leading (R1) to use the emergency call system for help instead of asking for assistance beforehand. (R2) stated that (R1) requires staff assistance and will receive it but prefers to work independently. Furthermore, (R2) mentioned that the care staff are responsive when dispatched via the emergency call system and perform routine checks throughout the day to ensure the residents' care and well-being. On February 04, 2026, between 10:00 AM and 01:00 PM, the Department interviewed staff members identified as Staff #1 through Staff # (S1-S5). Five (5) out of five (5) cannot corroborate this claim of (R1’s) falls were due neglect or lack of care. (Evaluation Report continues LIC 9099--C) (S1-S5) has verified that (R1) requires full assistance due to (R1's) health condition and non-ambulatory status and has had multiple falls. However, they do not agree that multiple falls have occurred with (R1) because of staff neglect. Rather, it is understood that, while care is available, (R1) often prefers to act independently and chooses not to follow the care directives provided. (S1-S3) reported that (R1) experienced several falls; however, in each incident, (R1) did not suffer any serious injuries and refused medical care at the hospital afterward. (S1-S3) reported that medical assessments are performed each time of a fall incident, but no reappraisal is performed. A fall prevention plan has been implemented to enhance (R1's) safety. Key measures have been implemented to ensure (R1's) safety and comfort. The room is kept clutter-free, and frequently used items are stored at waist height to prevent overreaching or bending. Additionally, half bed rails have been installed for extra support, and safety signs have been posted. An Individual Service Plan and a Resident Assessment for (R1) was conducted on January 8, 2026, with contributions from both the medical provider and family representatives which includes prevention of frequent falls. (S4-S5) verified completion of mandated staff training including fall prevention, proper positioning, back injury prevention, hoyer lift usability, and timely response to call lights. On February 04, 2026, between 12:03 PM and 12:20 PM, the Department interviewed witness identified as Witness #1 (W1). (W1), who has a close relationship with (R1), asserts that (W1) is unable to confirm the claim. (W1) stated that while it is true (R1) has experienced multiple falls, it is unclear whether these incidents are the result of staff negligence or a lack of care. (W1) believes that (R1) is receiving adequate care, but (R1) prefers to be independent and can become impatient when waiting for assistance. (W1) is uncertain whether the emergency call system is not being used effectively or if the staff are responding promptly. Additionally, (W1) confirmed that (R1) has an unsteady gait due to health conditions. Consequently, care staff may mistakenly think that (R1) has fallen when, in fact, (R1) may be positioning thyself on the ground for support without having sustained a fall. On February 4, 2026, an inspection was conducted in room #129, which is a shared space. The room was found to comply with all preventive measures, including the installation of half-bed rails, a clutter-free environment, and the positioning of frequently used items at waist height. Additionally, safety signs, a grabber tool, and an operational emergency call system were present. During the inspection, the Department also tested the emergency call systems in rooms #123, #124, #128, #129, and #130, confirming that all systems were in good working order. Care staff demonstrated timely responsiveness, addressing calls within one to two minutes. (Evaluation Report continues LIC 9099--C) A review of Resident #1 (R1’s) service record included Physicians Report LIC 602A (dated 04/02/25), Identification and Emergency Information LIC 601 (dated 04/17/25), Admissions Agreement (dated 04/17/25), Individual Service Plan (dated 04/16/25 & 01/08/26), Resident Assessment (dated 01/08/26) verified that (R1) due to health conditions requires complete assistance and is non-compliant using call light or asking for assistance. Medication Administration Record (dated 01/01/26 - 01/31/26) (R1) is taking (22) prescribed medications and (16) out of (22) causes a significant increase in the risk of falls (ref: National Institute of Health NIH). A further review of Unusual Incident Report LIC 624 (dated 11/08/25, 11/26/25, 12/02/25, 12/05/25, 12/10/25, 12/30/25, 1/22/26 and 01/27/26) verified multiple falls with no serious injuries with medical assessment performed. A further review of the Emergency Call System Log, (dated 01/01/26 - 01/31/26), revealed that only three calls were made from room #129. The response times for these calls ranged from 9 to 11 minutes. Additionally, staff training has been completed through Relias and In-Service sessions covering multiple safety and personal care services. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information gathered from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. An exit interview was conducted with Esperanza Naaktgeboren, and copies of report was provided.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 11-AS-20260130090223

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 did not provide resident with a pre-admission appraisal.

On 01/21/26 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Administrator as the purpose of today’s visit was explained. The investigation consisted of the following: On 01/21/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) Emergency ID form, resident assessment form dated: 01/15/26, admission agreement dated: 01/15/26, Physicians report dated:12/19/25, Individual service plan dated: 12/16/25, Advanced health care directive dated: 05/07/24, a copy of the Dual power of attorney for management of property and personal affairs dated: 05/7/24. On 01/21/26 from 10:00 am- 12pm LPA conducted Interviews residents # 1-10 (R1-R10) and from 1:15pm- 2pm LPA conducted interviews with staff #1-4 (S1-S4). On 01/21/25 LPA conducted a review of R1's file. The investigation revealed the following: Substantiated Allegation: Staff did not provide resident with a pre-admission appraisal. It is being alleged that staff did not perform a pre-appraisal to assess and confirm if the facility is able to meet R1's needs. On 01/21/26 from 10:00 am- 12pm LPA conducted Interviews with R1-R10 regarding the allegation above. 7 of 10 residents interviewed denied the allegation above and reported that someone from Chateau of Long Beach spoke to them about the facility and the services offered. 2 of 10 residents interviewed confirmed the allegation above, 1 of 10 residents reported they do not remember if a pre-admission appraisal was conducted. On 01/21/26 from 1:15pm- 2pm LPA conducted interviews with S1-S4 regarding the allegation above. S1 denied the allegation above and stated that a resident assessment was conducted, however it was never dated. During interviews with S2-S4 regarding the allegation above, 3 of 3 staff interviewed confirmed the allegation above and stated that a pre- admission appraisal was not conducted for R1 prior to admission. On 01/21/26 LPA conducted a review of R1's facility file, LPA did not observe any documentation indicating that a pre-admission appraisal was completed prior to when R1 moving in and started receiving services at Chateau of Long Beach. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided. It is being alleged that facility staff did not provide R1 with an admissions agreement per Title 22 regulations. On 01/21/26 from 10:00 am- 12pm LPA conducted Interviews with R1-R10 regarding the allegation above. 4 of 10 residents interviewed denied the allegation above and reported that a signed copy of their admission agreement was provided by facility staff, 1 of 10 residents interviewed confirmed the allegation above and stated they did not receive a signed copy of their admission agreement, and 5 of 10 residents interviewed stated that they cannot remember if they received a signed copy of their admission agreement. On 01/21/26 from 1:15pm- 2pm LPA conducted interviews with S1-S4 regarding the allegation above. During interview with S1, S1 denied the allegation above and reported that a copy of the signed admission agreement was offered to R1 and family, however R1 nor family wanted a copy. During interviews with S2-S4 regarding the allegation above, 2 of 3 staff reported that a copy of the signed admission agreement is always offered. 1 of 3 staff reported that a copy of a signed admission agreement is not provided unless requested by a resident. On 01/21/26 LPA conducted a review of R1's facility file, LPA observed that there was a completed admission agreement on file, LPA also observed that R1 signed the admission agreement dated 01/15/26. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 11-AS-20260115090806

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(a)(1) · Plan of correction due date: Feb 4, 2026

87457 Pre-Admission Appraisal. Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. Sufficient information about the facility and its services shall be provided...Based on involved in the placement to make an interviews and record review, facility staff failed to ensure a pre admission appraisal was done prior to R1 receiving services/ moving intoThe Chateau of Long Beach, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 21, 2026

Plan of correction: Licensee, Administrator, and all staff who assist with pre admission appraisals and admission to review regulation cited, and ensure all pre admission appraisals are conducted prior to resident officially moving into the facility and receiving services. LPA to receive by POC due date, astatement from Licensee/Administrator indicating that regulation has been reviewed and is understood

Allegation investigated: Staff neglect during transfer resulted in the resident being dropped

On 12/02/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Executive Director, Esperanza Naaktgeboren, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA inspected the facility, interviewed Staff S1-S8, interviewed Residents R1-R10, and received and reviewed the following documents Staff Roster, Resident Roster, Identification and Emergency Information, Physician’s Report, Individual Service Plan, Admission Agreement, Daily Logs, Hospice Orders, Outside Agency Documentation, Staff Training Logs, and Staff In-Service Training Logs. The investigation revealed the following: Unsubstantiated Allegation: Staff neglect during transfer resulted in a resident being dropped. The allegation alleges that while being transferred with a Hoyer Lift it broke, and the resident fell to the ground. During the facility inspection LPA observed a Hoyer Lift in R1’s room that was operating properly. During record review, LPA received and reviewed the Daily Logs, that indicates on 06/04/2025, R1 was observed sliding out of their wheelchair, an additional staff was called to assist with helping R1 to be lowered to the ground. Then the Hoyer Lift was used to transfer R1 to their bed. LPA observed during record review that the Hoyer Lift(s) were provided through R1’s former hospice agency and their medical program. Additionally, during record review, LPA received and reviewed Staff In-Service Logs, dated 05/22/2025, and material regarding Assisting with Proper Positioning, Commonly Used Mobility Devices, and Hoyer Lift usage with a two (2) person assist. During interviews with Staff S1-S8, were asked if they have been trained on how to use the Hoyer Lift, eight (8) out of eight (8) stated yes, they have had training regarding the Hoyer Lift on Relias, in an In-Service, and directors show you how to use it. Additionally, during interviews with Staff S1-S8, were asked if there have been any issues with a residents’ Hoyer Lift, three (3) out of eight (8) stated there was a reported issue with Resident R1’s Hoyer lift and it was replaced by the hospice agency right away. During interviews with Staff S2 and S3 stated that when they were transferring R1, the lift was not holding R1 and it slowly lowered R1 to the floor. Staff S2 and S3 stated they requested additional assistance and R1 was transferred manually. Staff S2 and S3 stated they reported the incident to the Wellness Director at the time who came and checked the lift and ensured a replacement was sent by the hospice agency. During interviews with Residents R1-R10, were asked if they have experienced a fall while being assisted with transferring either manually or with a Hoyer Lift, nine (9) out of ten (10) stated no they have not experienced a fall while being assisted with transferring. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director, Esperanza Naaktgeboren, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 11-AS-20251124120413

Allegation investigated: Staff do not ensure residents room is good repair. Staff do not ensure residents room is kept in clean sanitary conditions. Staff do not ensure facility is kept free of pests. Staff do not ensure continence care needs are being met for resident.

On 11/19/25 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Executive Director (S1) as the purpose of today’s visit was explained. The investigation consisted of the following: On 11/13/25 LPA Villegas obtained copies of the staff and resident roster, cleaning schedule, impressive extermination invoices for September 2025, October 2025, and November 2025, and copies of the following documents for Resident #1 (R1) Emergency ID form, pre-appraisal dated: 7/21/25, Admission agreement dated: , Physicians report dated: 06/17/25, service plan dated: 7/21/25, physicians orders, Besht progress note dated: 11/12/25, and unusual incident reports dated: 8/26/25 and 10/27/25. On 11/13/25 from 9:00 am- 11:50am LPA conducted Interviews with Residents #1-10 (R1-R10). On 11/13/25 LPA conducted interviews with staff #1-6 (S1-S6) from 1pm-2pm, and from 2:15pm-2:45 pm LPA toured 5 bedrooms, smoking patio, lobby, and outdoor patio/garden area. On 11/19/25 LPA condcuted an additional tour of the facility, and toured an additional 5 bedrooms. Unsubstantiated The investigation revealed the following: Allegation: Staff do not ensure residents room is good repair. It is being alleged that the bathroom in R1's bedroom has a leak and has a loose toilet seat. On 11/13/25 from 9:00 am- 11:50am LPA conducted Interviews with R1-R10 regarding the allegation above. 10 of 10 residents interviewed denied the allegation above, 7 of 10 residents interviewed reported that repairs happen right away, 2 of 10 residents interviewed reported repairs take a few days. On 11/13/25 LPA conducted interviews with S1-S6 regarding the allegation above. 6 of 6 staff interviewed denied the allegation above, 4 of 6 staff reported repairs happen same day, 2 of 6 staff reported repair time depends on what needs to be repaired. On 11/13/25 and 11/19/25 LPA conducted a tour of 10 bedrooms, LPA did not observe any disrepair's. Allegation: Staff do not ensure residents room is kept in clean sanitary conditions. It is being alleged that trash cans in resident bedrooms are not being emptied, and meal trays are not being removed from bedrooms which is causing mold. On 11/13/25 from 9:00 am- 11:50am LPA conducted Interviews with R1-R10 regarding the allegation above. 10 of 10 residents interviewed denied the allegation above and reported that trash cans are emptied out daily, and denied observing any mold in their bedrooms. On 11/13/25 LPA conducted interviews with S1-S6 regarding the allegation above. 6 of 6 staff interviewed denied the allegation above, 6 of 6 staff reported rooms are cleaned daily or as needed, 6 of 6 staff interviewed denied observing any mold in resident bedrooms. On 11/13/25 and 11/19/25 LPA conducted a tour of 10 bedrooms, LPA observed bedrooms actively being cleaned, LPA observed trash being removed, sweeping, mopping, and laundry service taking place. On 11/19/25 LPA conducted a review of the housekeeping schedule, LPA observed that each housekeeper cleans a 5-7 rooms each every day. Deep cleanings occur on Thursdays. LPA observed some bedrooms get cleaned more than once a week. Allegation: Staff do not ensure facility is kept free of pests. It is being alleged that the facility has a mosquito and cockroaches issue that is not being addressed. On 11/13/25 from 9:00 am- 11:50am LPA conducted Interviews with R1-R10 regarding the allegation above. 7 of 10 residents interviewed denied the allegation above, 3 of 10 residents interviewed reported seeing cockroaches in the past. On 11/13/25 LPA conducted interviews with S1-S6 regarding the allegation above. 6 of 6 staff denied the allegation above. 6 of 6 staff interviewed reported that if pest is observed or reported, pest control will be contacted and scheduled to treat the facility. On 11/19/25 LPA conducted a review of the Impressive extermination invoices for September 2025, October 2025 and November 2025. Per invoices, Impressive extermination treats the facility 2 times a month, the facility is treated more if any reports of pest have been submitted. On 11/13/25 and 11/19/25 LPA conducted a tour of 10 bedrooms, LPA did not observe any pest, LPA observed patio doors to be closed. Allegation: Staff do not ensure incontinence care needs are being met for resident. It is being alleged that facility staff are not assisting resident in care with changing soiled diaper resulting in resident being left in the same diaper for the entire day. On 11/13/25 from 9:00 am- 11:50am LPA conducted Interviews with R1-R10 regarding the allegation above. 4 of the 10 residents interviewed denied the allegation above, 6 of the 10 residents interviewed reported they do not require incontinence care. On 11/13/25 LPA conducted interviews with S1-S6 regarding the allegation above. 4 of 6 staff interviewed denied the allegation above, 2 of the 6 staff interviewed confirmed the allegation above and reported that sometimes residents are left in a soiled diaper due to shift exchange. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 11-AS-20251106083601

Allegation investigated: Staff did not seek medical attention for a resident in care. Staff placed a camera in a resident's room without permission.

On 11/13/25 Licensing Program Analyst (LPA) Villegas conducted a initial complaint visit regarding the allegation(s) above. LPA met with Executive Director (S1) as the purpose of today’s visit was explained. The investigation consisted of the following: On 11/13/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #2 (R1-R2) Emergency ID form, pre-appraisal, admission agreement, Physicians report, Service plan, Physicians orders, and incident reports, and tele-health progress notes. On 11/13/25 from 9:00 am- 11:48 am LPA conducted Interviews with Residents #2-11 (R2-R11), LPA unable to interview R1 as R1 is no longer receiving services at the facility. On 11/13/25 LPA conducted interviews with staff #1-6 (S1-S6) from 1pm-2pm, and from 2:15pm-2:45 pm LPA toured 5 bedrooms, smoking patio, lobby, and outdoor patio/garden area. The investigation revealed the following: Allegation: Staff did not seek medical attention for a resident in care. Unsubstantiated It is being alleged that facility staff is not making medical appointment for resident in care who is experiencing a cough. On 11/13/25 from 9:00 am- 11:48 am LPA conducted Interviews with R2-R11 regarding the allegation above. 9 of the 10 residents interviewed denied the allegation above and reported that staff assist with medical attention right away when they are feeling ill. On 11/13/25 LPA was unable to conduct interview with R1 as R1 is no longer receiving services at the facility. On 11/13/25 LPA conducted interview with R2 regarding the allegation above, R2 confirmed the allegation above and reported they have not been scheduled to see primary care physician (PCP) regarding a runny nose and a cough. On 11/13/25 LPA conducted a review of Tele-health progress note dated: 11/10/25 for R2, per progress note PCP provided order for nasal spray and cough medicine. On 11/13/25 from 1pm- 2pm LPA conducted interviews with S1-S6 regarding the allegation above. 6 of the 6 staff interviewed denied the allegations above and stated that if a resident reports feeling unwell the Wellness Coordinator will be notified. 6 of 6 staff interviewed denied assisting residents with medical assistance when requested. Allegation: Staff placed a camera in a resident's room without permission. It is being alleged that staff are recording residents while in their bedroom. On 11/13/25 from 9:00 am- 11:48 am LPA conducted Interviews with R2-R11 regarding the allegation above. 8 of the 10 residents interviewed denied the allegation above and reported that their privacy is not being invaded by staff. 2 of 10 residents in care confirmed the allegation above, and reported there is a camera hanging from their bedroom ceiling. On 11/13/25 from 1pm- 2pm LPA conducted interviews with S1-S6 regarding the allegation above. 6 of the 6 staff interviewed denied the allegation above. On 11/13/25 from 2:15pm-2:45 pm LPA toured 5 bedrooms, LPA did not observe any security cameras in resident bedrooms, LPA observed smoke detectors located on the bedroom ceiling. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 11-AS-20251104161215

Allegation investigated: Staff did not seek medical attention for a resident in care. Staff placed a camera in a resident's room without permission.

On 11/13/25 Licensing Program Analyst (LPA) Villegas conducted a initial complaint visit regarding the allegation(s) above. LPA met with Executive Director (S1) as the purpose of today’s visit was explained. The investigation consisted of the following: On 11/13/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #2 (R1-R2) Emergency ID form, pre-appraisal, admission agreement, Physicians report, Service plan, Physicians orders, and incident reports, and tele-health progress notes. On 11/13/25 from 9:00 am- 11:48 am LPA conducted Interviews with Residents #2-11 (R2-R11), LPA unable to interview R1 as R1 is no longer receiving services at the facility. On 11/13/25 LPA conducted interviews with staff #1-6 (S1-S6) from 1pm-2pm, and from 2:15pm-2:45 pm LPA toured 5 bedrooms, smoking patio, lobby, and outdoor patio/garden area. The investigation revealed the following: Allegation: Staff did not seek medical attention for a resident in care. Unsubstantiated It is being alleged that facility staff is not making medical appointment for resident in care who is experiencing a cough. On 11/13/25 from 9:00 am- 11:48 am LPA conducted Interviews with R2-R11 regarding the allegation above. 9 of the 10 residents interviewed denied the allegation above and reported that staff assist with medical attention right away when they are feeling ill. On 11/13/25 LPA was unable to conduct interview with R1 as R1 is no longer receiving services at the facility. On 11/13/25 LPA conducted interview with R2 regarding the allegation above, R2 confirmed the allegation above and reported they have not been scheduled to see primary care physician (PCP) regarding a runny nose and a cough. On 11/13/25 LPA conducted a review of Tele-health progress note dated: 11/10/25 for R2, per progress note PCP provided order for nasal spray and cough medicine. On 11/13/25 from 1pm- 2pm LPA conducted interviews with S1-S6 regarding the allegation above. 6 of the 6 staff interviewed denied the allegations above and stated that if a resident reports feeling unwell the Wellness Coordinator will be notified. 6 of 6 staff interviewed denied assisting residents with medical assistance when requested. Allegation: Staff placed a camera in a resident's room without permission. It is being alleged that staff are recording residents while in their bedroom. On 11/13/25 from 9:00 am- 11:48 am LPA conducted Interviews with R2-R11 regarding the allegation above. 8 of the 10 residents interviewed denied the allegation above and reported that their privacy is not being invaded by staff. 2 of 10 residents in care confirmed the allegation above, and reported there is a camera hanging from their bedroom ceiling. On 11/13/25 from 1pm- 2pm LPA conducted interviews with S1-S6 regarding the allegation above. 6 of the 6 staff interviewed denied the allegation above. On 11/13/25 from 2:15pm-2:45 pm LPA toured 5 bedrooms, LPA did not observe any security cameras in resident bedrooms, LPA observed smoke detectors located on the bedroom ceiling. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 11-AS-20251104161215

Allegation investigated: Staff did not ensure that the facility was kept free of pests. Staff did not provide proper bed accommodations to resident in care.

On 10/05/25 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted a initial complaint visit regarding the allegation(s) above. LPA met with Administrator ESPERANZA NAAKTGEBOREN as the purpose of today’s visit was explained. The investigation consisted of the following: On 11/05/25 LPA Villegas obtained copies of the staff and resident roster, housekeeping shedule, facility map, impressive extermination invoices for September and October 2025, and copies of the following documents for Resident #1 (R1) face sheet, admission agreement dated:06/27/25 , Pre-Appraisal dated:06/27/25 Physicians report dated: 06/24/25, Needs and service plan dated: 06/27/25, Physicians orders, order summary report dated 12/16/24, telephone order dated: 11/05/25, and incident reports dated June 2025, July 2025, and October 2025. On 11/05/25 from 10:00 am- 11:30 am LPA conducted Interviews with Residents #1-10 (R1-R10), from 11:30am -12 pm LPA and administrator conducted inspection of bedrooms #127, 28,129, 130. On 11/05/25 from 1pm-2pm interviews conducted with staff #1-5 (S1-S5). Unsubstantiated The investigation revealed the following: Allegation: Staff did not ensure that the facility was kept free of pests. It is being alleged that the facility has a roach infestation that is not being addressed. On 11/05/25 from 10:00 am- 11:30 am LPA conducted Interviews with R1-R10 regarding the allegation above. 7 of the 10 residents interviewed denied the allegation above, 2 of the 10 residents interviewed reported seeing roaches in the past. On 11/05/25 LPA conducted interview with R1 regarding the allegation above, R1 confirmed the allegation above and reported seeing a roach last night. On 11/05/25 from 11:30am -12 pm LPA and administrator conducted inspection of bedrooms #127, 28,129, and 130, LPA did not observe any pest, LPA observed housekeeping actively cleaning bedrooms, and hallways. On 11/05/25 from 1pm-2pm interviews conducted with S1-S5 regarding the allegation above, 3 of 5 staff denied the allegation above, 2 of 5 staff stated that residents have reported roaches in the their bedrooms, staff will notify management and pest control services will be scheduled. On 11/05/25 LPA conducted a review of the housekeeping schedule, LPA observed that each housekeeper cleans a 5-7 rooms each every day. Deep cleanings occur on Thursdays. On 11/05/25 LPA conducted a review of the Impressive extermination invoices for September 2025 and October 2025. Per invoices, Impressive extermination treats the facility 2 times a month, the facility is treated more if any pest is reported to staff. Allegation: Staff did not provide proper bed accommodations to resident in care. It is being alleged that facility provided a resident in care with a bed that is not operable. On 11/05/25 from 10:00 am- 11:30 am LPA conducted Interviews with R1-R10 regarding the allegation above. 9 of the 10 residents interviewed denied the allegation above and reported having no issues with their bed. 3 of the 10 residents interviewed reported having a hospital bed. On 11/05/25 LPA conducted interview with R1 regarding the allegation above, R1 confirmed the allegation above and reported having an issues with bed head rest. On 11/05/25 LPA conducted a review of telephone order dated 11/05/25 which indicates that Doctor gave order to remove hospital bed per R1's request. On 11/05/25 LPA observed standard bed being placed in bedroom per Doctors orders. LPA observed order summary report dated 12/16/24 which indicated that R1 admitted to The Chateau of Long Beach with hospital bed. On 11/05/25 from 1pm-2pm interviews conducted with S1-S5 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 5, 2025 · control 11-AS-20251028132123

Allegation investigated: Staff unlawfully evicted a resident.

On 09/17/25 Licensing Program Analyst (LPA) Troy Watson conducted a subsequent complaint visit. LPA Watson met with the Administrator Esperanza Naaktgeboren and explained the purpose of the visit was to investigate the above allegation. LPA Watson was granted entry into the facility. The investigation consisted of the following: On 08/01/2025 LPA Watson requested and obtained the following: Resident Roster, Staff Roster, and an (SIR) Special incident Report. LPA Watson conducted interviews with Staff#1 - Staff #3 (S1-S3). On 09/17/2025 LPA Watson conducted interviews with Resident #1- Resident #8. CONTINUED ON LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff unlawfully evicted a resident On 08/01/2025 between 10:18AM – 12:15PM LPA Watson conducted interviews with Staff #1 – Staff #3 (S1-S3). Of those interviewed 3 out of 3 staff denied the above allegation. On 09/17/25 between 3:14PM – 4:00PM the department conducted interviews with Residents #1- Residents #8 (R1-R8) 8 out of 8 residents interviewed denied the above allegation. LPA Watson interviewed C1 and R1 and both parties stated that no eviction was ever given. Based on interviews, record reviews, observations and information gathered, there is insufficient evidence to support the allegation: Staff unlawfully evicted a resident. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited so no citation was given. An exit interview with the Administrator Esperanza Naaktgegeboren was completed and a copy of the report provided.the state’s words, verbatim · CDSS document, Sep 17, 2025 · control 11-AS-20250724125527

Allegation investigated: Facility does not employ enough staff to meet the residents' needs. Staff do not provide assistance to residents in a timely manner. Staff do not provide residents with adequate food service.

On 09/04/25 Licensing program analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Olivia Alvarado as the purpose of the visit was explained. The investigation consisted of the following: On 08/20/25 LPA Villegas obtained a copy of the following documents: staff, and resident rosters, employee schedule, facility menus for June 2025-August 2025, alternative menu, meal and snack portion size, kitchen sanitation and safety report dated 07/17/25, and call button logs. On 08/20/25 LPA requested the following documents for resident #1 (R1): emergency ID form, pre -appraisal, service plan, physicians report, and incident reports involving. LPA tested the call button response time. On 08/20/25 from 1:00pm-2:30pm LPA Villegas conducted interviews with residents #1-10 (R1-R10). On 08/20/25 LPA conducted a pull cord response test. On 08/20/25 and 09/04/25 LPA conducted interviews with staff # 1-5 (S1-S5), and 08/20/25 and 09/04/25 LPA observed lunch service. The investigation revealed the following: Unsubstantiated Allegation: Facility does not employ enough staff to meet the residents' needs. It is being alleged that the facility is short staff, which causes the residents not to receive services such as having resident bedrooms cleaned properly. On 08/20/25 from 1:00pm-2:30pm LPA Villegas conducted interviews with R1-R10 regarding the allegation above. 10 of the10 residents interviewed denied the allegation above, however 1 of 10 residents reported staff is removing trash can from resident’s bedroom without consent. On 08/20/25 while conducting tour of the facility LPA observed housekeeping staff cleaning bedrooms on both the first and second floors. On 08/20/25 LPA conducted a review of the staff schedule provided; LPA observed there are 4 direct care staff, 1 med tech, and 4 supervisors from 6am-2pm, 4 care staff, and 1 med tech scheduled from 2pm-10:30 pm, and 3 care staff, and 3 med techs scheduled from 10pm-6:30am. On 08/20/25 LPA reviewed the housekeeping schedule, LPA observed that there are 3 housekeepers on shift in the morning, and each housekeeper is scheduled to clean 5-6 bedrooms each daily. On 08/20/25 and 09/04/25 LPA conducted interviews with S1-S5 regarding the allegation above 3 of the 5 staff interviewed denied the allegation above, 2 of 5 staff interviewed reported having no knowledge of resident bedroom cleaning procedures. Allegation: Staff do not provide assistance to residents in a timely manner. It is being alleged that residents in care must wait up to an hour to receive the requested services such as obtaining a clean towel. On 08/20/25 from 1:00pm-2:30pm LPA Villegas conducted interviews with R1-R10 regarding the allegation above. 9 of the 10 residents interviewed denied the allegation above and reported waiting a few minutes when requesting linen supplies from staff. 1 of 10 residents interviewed confirmed the allegation above. On 08/20/25 and 09/04/25 LPA conducted a pull cord response test, staff were observing responding to pull cord within 6-10 minutes. On 08/20/25 and 09/04/25 LPA conducted interviews with S1-S5 regarding the allegation above 3 of the 5 staff interviewed denied the allegation above and reported linen and towels are exchanged weekly, however residents are provided with additional linen supplies upon request. 2 of the 5 staff interviewed reported having no knowledge of linen exchange procedures. Allegation: Staff do not provide residents with adequate food service. It is being alleged that residents in care do not have access to water, and menu options are decreasing. On 08/20/25 from 1:00pm-2:30pm LPA Villegas conducted interviews with R1-R10 regarding the allegation above. 9 of 10 residents denied the allegation above, 9 of 10 residents reported being able to choose meals from an alternative menu and reported having access to water. 1 of the 10 residents interviewed confirmed the allegation and reported that non ambulatory residents must wait long periods of time for staff to provide meals and beverages. On 08/20/25 and 09/04/25 LPA observed lunch service, LPA observed 1 staff member preparing meal trays, 2 staff members providing meal trays to the residents, and 2 staff members pushing carts that obtained an assortment of beverages. LPA reviewed the facility monthly menus as well as the alternative menu, LPA observed that the menu items are different every day. LPA also observed that the meal and snack portions are being provided to residents as instructed by dietician. On 08/20/25 LPA also conducted a review of the alternative menu, LPA observed that the alternative menu went from 6 options to 4 options. Per 3 of 5 staff interviewed 2 items were removed from the alternative menu due to those items not being requested by residents. On 08/20/25 and 09/04/25 LPA conducted interviews with S1-S5 regarding the allegation above, 5 of the 5 staff interviewed denied the allegation above and reported there are water stations located in the lobby for residents to self serve, there is water in the med room, and in the dinning room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 11-AS-20250813085339

Type of visit: Required - 1 Year

On 09/04/25 Licensing Program Analyst's (LPAs) Villegas and Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Olivia Alvarado as the purpose of the visit was explained. The facility is licensed to serve residents 60 and above. The facility is cleared for 178 non ambulatory residents, and (6) bedridden residents in bedrooms #102, 104, 105,106, 107, and 108. The facility is approved for (12) hospice residents. Facility fees are current, liability insurance is active with expiration date of 01/01/26, surety bond The facility is a two-story structure located in a commercial neighborhood that consists of the following: reception area, (80) resident bedrooms with a bathroom in each unit, (4) public bathrooms, an activity room, kitchen, a large dining room, laundry room, medication room, a PT room, administrative offices, (3) outside patios, and storage areas for personal hygiene, cleaning supplies, emergency food/water supply were observed. A land line and internet service were observed. LPA checked both downstairs and upstairs bedrooms, beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Call buttons, smoke and carbon monoxide detectors are operable. LBFD conducted fire testing service on 05/16/25. All fire extinguishers were charged and were operable. LPA observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. The kitchen was inspected LPA observed ample perishable and non-perishable food available.Sharps and toxins were stored and not accessible to residents. There were no bodies of water, fire arms, nor obstructions on the premises. A review of 5 staff personnel files, 5 resident files, and (5) medication Administration Records (MAR) was conducted. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 4, 2025

Allegation investigated: Resident developed stage 3 pressure injury while in care. Licensee is retaining a resident with a higher level of care need.

On 08/29/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted a subsequent visit on to deliver findings regarding the allegations listed above. LPA met with Assistant Administrator, Olivia Alvarado and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 02/03/2025, the department requested and gathered Resident 1’s (R1) records. R1’s records consisted of: Admission Agreement dated 10/18/2025; Personal Rights dated 10/18/2025; Identification and Emergency Information dated 10/18/2025; Physician’s Report dated 10/15/2024; and other pertinent information. From 02/20/2025 to 04/29/2025, department interviewed Resident 1 (R1) to Resident 3 (R3), Staff 1 (S1) to Staff 6 (S6), and Witness 1 (W1). On 07/31/2025, the department reviewed the Investigation Case Report along with Attachments dated 05/19/2025. Substantiated Investigation revealed the following: Allegation: “Resident developed stage 3 pressure injury while in care”, it is being alleged that R1 developed a stage 3 pressure injury while in care. Records reviewed revealed the following: Physicians Report dated 10/15/2024 indicates that R1 has a history of pressure injuries. R1’s Admission Agreement is dated 10/18/2024. R1 began Home Health on 11/10/2024 and the report indicates that R1 had a risk of pressure injuries but had no pressure injuries at the time of assessment and the goal for R1 was not to develop any pressure injury. From 11/10/2024 to 12/24/2024, R1 received Home Health services; Home Health staff instructed facility caregivers to check skin for any signs of pressure injuries and change position of R1 every two hours. R1 was hospitalized on 12/24/2024 and was discharged on 12/28/2024. There are no records of Home Health services provided to R1 from 12/25/2024 to 01/28/2025. On 12/28/2024, Progress Notes indicates that the Primary Physician diagnosed R1 with a stage 2 sacral decubitus ulcer measuring 0.5cmx0.5cmx0.1cm, there is no documentation indicating that R1’s Primary Physician performed wound care from 12/28/2024 to 01/28/2025. The facility did not maintain a record of R1 being repositioned every two hours or of care provided with all aspects R1’s pressure injury. On 01/28/2025, hospital and medical records indicate that during admission R1 was diagnosed with stage 3 and stage 4 pressure injuries in the buttocks area. Interviews conducted revealed the following: On 02/27/2025, R1 confirmed that staff would not reposition them every two hours. On 04/29/2025, 2 out of 6 staff indicated that staff would not reposition residents if they were in wheelchairs, unless residents requested it; 5 out of 6 staff confirmed that on December 2024 they saw an injury (e.g., the size of a bean, Q-Tip, and quarter) right above R1’s behind (e.g., buttock, coccyx). Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An immediate civil penalty of $500.00 is being assessed please see LIC421IM. Allegation: “Licensee is retaining a resident with a higher level of care need”, it is being alleged that R1 was retained at the facility even though R1 required a higher level of care. Records reviewed revealed the following: Physicians Report dated 10/15/2024 indicates that R1 has a history of pressure injuries. R1’s Admission Agreement is dated 10/18/2024. R1 began Home Health on 11/10/2024 and the report indicates that R1 had a risk of pressure injuries and the goal for R1 was not to develop any pressure injury. R1 was hospitalized on 12/24/2024 and was discharged on 12/28/2024. On 12/28/2024, Primary Physician Progress Notes diagnosis R1 with a stage 2 sacral decubitus ulcer measuring 0.5cmx0.5cmx0.1cm. There are no records of Home Health services provided to R1 from 12/25/2024 to 01/28/2025. From 12/28/2024 to 01/28/2025, there is no documentation indicating that R1’s Primary Physician performed wound care. The facility did not maintain a record of R1 being repositioned every two hours and did not provide documentation of all aspects of care performed to address R1’s pressure injury. On 01/28/2025, hospital and medical records indicate that during admission R1 was diagnosed with stage 3 and stage 4 pressure injuries in the buttocks area. Interviews conducted revealed the following: On 02/27/2025, R1 confirmed that they developed a pressure injury while in care at the facility. On 04/29/2025, 5 out of 6 staff confirmed that on December 2024 they saw a pressure injury (e.g., the size of a bean, Q-Tip, and quarter) right above R1’s behind (e.g., buttock, coccyx); 2 out of 6 staff confirmed that on December 2024, after R1 came back from the hospital (on 12/28/2024), R1 was no longer receiving Home Health services. Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Deficiencies were cited. At this time, an additional civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An exit interview was conducted, and a plan of correction was developed. A copy of this report and appeal rights were provided to the Assistant Administrator, Olivia Alvarado.the state’s words, verbatim · CDSS document, Aug 29, 2025 · control 11-AS-20250131083643

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Aug 30, 2025

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the section cited above. On 01/28/2025, upon arrival to the hospital, R1 was diagnosed with stage 3 and stage 4 pressure injuries near the buttock area. The licensee retained R1 while having a stage 3 pressure injury while in care. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: The Assistant Administrator, Olivia Alvarado agreed to create a plan to ensure that the facility will not admit or retain residents with stage 3 or stage 4 pressure injuries. Proof of corrections will be emailed to Socorro.Leandro@dss.ca.gov.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 30, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the section cited above. The licensee did not ensure that R1 received wound care services from 12/28/2024 to 1/28/2025 which resulted to R1 developing stage 3 and stage 4 pressure injuries while in care. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: The Assistant Administrator, Olivia Alvarado agreed to create a plan to ensure that residents with stage 1 and stage 2 pressure injuries receive continuous wound care with skilled professionals (e.g. Home Health, Physician, LVNs, Palliative Care, Hospice Care). Proof of corrections will be emailed to Socorro.Leandro@dss.ca.gov .

Allegation investigated: Due to lack of supervision, residents are going into residents rooms Due to lack of supervision, residents are having inappropriate interactions

On 08/27/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Administrator, Esperanza ‘Espe’ Naaktgenboren, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit LPA inspected the facility, interviewed Staff S1-S8, interviewed Residents R1-R11, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Basic Fact Sheet, Physician’s Report (dated 09/14/2024), Resident Assessment Form (dated 03/21/2025), Individualized Service Plan (dated 03/21/2025), Narrative Charting (dated 08/15/2025 and 08/14/2025), and Admission Agreement (dated 04/14/2021). The investigation revealed the following: Unsubstantiated Allegation: Due to lack of supervision, residents are going into resident rooms The allegation alleges that staff do not prevent residents from going into another resident’s room. During the facility inspection, LPA observed the Resident Rights and House Rules posted in the hallway in the entrance of the facility. Additionally, LPA observed there are cameras in common areas and hallways in the facility. LPA received and reviewed the Admission Agreement (dated 04/14/2021 that states on Page 8, number 12, titled Facility Visiting Policy states “b) Rooms are available for confidential visits and d) Visiting between facility residents should be done in common areas in the facility. Such visiting in shared resident rooms is permissible providing the resident's roommate does not object to such.” Additionally, LPA received and reviewed the Attachment 2 - House Rules - page 17 number 13. that states Visiting is encouraged to take place in common areas. LPA reviewed resident’s Narrative Charting that states R1 was observed, by staff entering the wrong room and was redirected to the correct room. LPA was informed name plaques were added to doors for residents to know which room is theirs. During interviews with Staff S1-S8, were asked how they ensure unwanted residents or visitors do not enter a residents room uninvited, eight (8) out of eight (8) stated they supervise residents and if they see a resident enter another residents room they go ensure it is okay for them to be in there by both residents who’s room it is. Additionally, Staff S1-S8 were asked if there have been any incidents or complaints of a resident or visitor entering a resident’s room uninvited, four (4) out of eight (8) no, there have been no complaints or incidents of a person entering a resident’s room uninvited. Two (2) out of eight (8) stated a resident complained their roommate brought visitors into their room. And two (2) out of eight (8) stated a resident wandered into a room that was not theirs. During interviews with Residents R1-R11, were asked if they feel there is enough staff to provide supervision to the residents, ten (10) out of eleven (11) stated they feel there is enough staff to provide supervision to the residents. Additionally, Residents R1-R11, were asked if they had another resident or visitor enter their room without their permission, two (2) out of eight (8) stated they have had a visitor or resident enter their room uninvited, one stated a resident wandered in and the other stated their roommate brought visitors into their room without asking. Allegation: Due to lack of supervision, residents are having inappropriate interactions. The allegation alleges that a resident is having inappropriate interactions with a visitor. During the facility inspection, LPA observed Residents Personal Rights posted in the lobby of the facility. During record review, LPA reviewed R1's Personal Rights in Privately Operated Residential Care Facilities for the Elderly (LIC613-C), signed and dated by R1 on 04/13/2025. Both listings of Residents Personal Rights, states that residents have the right “(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.” It additionally states residents have the right “(8) to make choices concerning their daily life in the facility.” During interviews with Staff S1-S8, were asked if any residents have reported unwanted inappropriate interactions with another resident or a visitor, eight (8) out of eight (8) stated no residents have reported unwanted inappropriate interactions. Additionally, staff S1-S8, were asked if any residents have reported another resident or visitor forcing themselves on them, eight (8) out of eight (8) stated there have been no report of a resident or visitor forcing themselves on a resident. Staff S1-S8 were asked what the procedure is if it becomes known that residents are having a sexual interaction, eight (8) out of eight (8) stated the residents will be spoken to individually to ensure the encounters are consensual. During interviews with Residents R1-R11, were asked if they have experienced unwanted inappropriate interaction with a resident or visitor, eleven (11) out of eleven (11) stated no they have not experienced unwanted inappropriate interactions with another resident or a visitor. Additionally, Residents R1-R11 were asked if they feel safe in the facility, eleven (11) out of eleven (11) stated yes, they feel safe living in the facility. During the course of the investigation, LPA was unable to find evidence to support the allegations. Although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. LPA did not observe or cite any deficiencies. An exit interview was conducted with Wellness Director, Kristen Sison, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 11-AS-20250819095816

Allegation investigated: Staff do not ensure that resident's dietary needs are met.

On 7/23/25 at 10:45 am Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Olivia Alvarado as the purpose of today’s visit was explained. The investigation consisted of the following: On 7/17/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1 (R1) face sheet, Physicians report dated:3/27/25, service plan dated: 3/21/25, pre appraisal dated: 1/30/25, resident assessment form dated: 3/21/25, MAR for July 2025, conservatorship paperwork, diet slip dated 2/6/23, and unusual incident reports dated: 3/28/25, and 7/16/25. On 7/17/25 LPA conducted interview with staff #1 (S1). On 7/23/25 at 11:30 am LPA conducted a tour of facility kitchen, and at 12pm LPA observed lunch service. On 7/23/25 from 1pm-1:45 pm LPA conducted interviews with resident 2-10 (R2-R10), R1 refused to be interviewed. On 7/23/25 from 2pm-2:45 pm LPA conducted interviews with S2-S5. The investigation revealed the following: Unsubstantiated Allegation: Staff do not ensure that resident's dietary needs are met. It is being alleged that R1 is the last to be fed, is served leftovers, and sometimes is not served food. On 7/23/25 from 1pm-1:45 pm LPA conducted interviews with R2-R10 regarding the allegation above, 9 of 9 residents interviewed denied the allegation above. Per 9 of 9 residents interviewed, there are no concerns about the meals being provided. 9 of 9 residents report that they are provided with 3 meals are provided along with snacks in between. On 7/23/25 R1 refused to be interviewed. On 7/17/25 and 7/23/25 LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above. On 7/23/25 3 of 5 staff interviewed reported that the food served at the facility is made fresh daily, and report that the quantity of food made is enough to give residents a second serving upon request. On 7/23/25 at 11:30 am LPA conducted a tour of facility kitchen, LPA observed kitchen pantry, walk-in refrigerator and freezer to be stocked and dated. LPA also observed an emergency food and water supply to be available if needed. On 7/23/25 LPA observed Lunch service, LPA observed residents being seated promptly and observed meals being served within 5-10 minutes. LPA observed R1 to have lunch. On 7/23/25 LPA conducted a review of R1's assessment form dated: 3/21/25, and Physicians report dated:3/27/25, per reports R1 is able to self feed nor requires a tray service. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is unsubstantiated.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 11-AS-20250711095008

Allegation investigated: Staff do not respond to residents' requests for assistance in a timely manner. Staff member did not accord dignity to resident in care. Staff do not report incidents involving residents as necessary.

This report serves to clarify investigation findings and is created to supersede the LIC 9099 and LIC 9099-C reports created on 04/11/25. Although this report supersedes the previous report, the complaint investigation findings remain the same. On 05/29/2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint investigation visit. LPA met with Administrator Esperanza Naaktgeboren, and the purpose of today’s visit was explained. On 04/11/2025, at 08:00 AM, LPA Richard made a subsequent complaint visit to the facility above. LPA met with the Administrator, and Assistant Administrator, and the purpose of the visit was explained. The Investigation consisted of the following: On 03/13/2025, LPA toured the facility, interviewed seven Staff #1-7 (S1-S7), interviewed seven residents #1-7 (R1-R7), and reviewed and collected, Resident Roster (dated 03/13/2025) staff roster (dated 03/13/2025), Physician Report (dated 12/16/2024, 03/07/24, and 01/27/25), Incident Report (dated 02/03/2025 to 03/05/25). Response by room number (dated 03/01/25 to 03/13/25) and APS/Ombudsman/Long Beach Police Department (LBPD) report. Reports continued LIC9099-C Unsubstantiated Allegation #1: The Staff does not respond to the resident's requests for assistance in a timely manner. This complaint alleges that staff take hours to respond to call lights after residents request assistance. On March 13, 2025, between 11:00 AM and 1:00 PM, LPA Richard interviewed seven residents #1-7 (R1-R7). Six out of seven residents denied the allegation, stating that most of them are independent and that the staff always tries to assist when they press the call button or when they are outside on the grounds and need help. On the same day, between 2:00 PM and 3:00 PM, LPA Richard interviewed seven staff members #1-7 (S1-S7). All seven staff members denied the allegation, stating that when a resident presses the call light, anyone available will go to assist the resident. They emphasized that staff do not pick and choose whom to assist; it is their job to ensure that all residents who need help receive it. Additionally, on March 13, 2025, at 10:00 AM, LPA Richard inspected two residents' bedrooms, #233 and #238. LPA Richard pressed the call light and found that the facility staff responded in less than two minutes. Based on the interviews, observation, and record reviews, there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is Unsubstantiated. Reports continued LIC9099-C Allegation #2: Staff member did not accord dignity to the resident in care. This complaint alleges that a staff member refused to listen to a resident. On March 13, 2025, between 11:00 AM and 1:00 PM, the Licensing Program Analyst (LPA) interviewed seven residents #1-7 (R1-R7). Five out of the seven residents denied the allegation, stating that the staff treated them with respect and dignity. They also mentioned that residents should treat the staff as they would like to be treated themselves. Resident R3 noted that sometimes residents yelled and cursed at the staff. The residents also expressed their satisfaction with the quality of care provided at the facility. On the same day, between 2:00 PM and 3:00 PM, the LPA interviewed seven staff members #1-7 (S1-S7). All seven staff members denied the allegation and emphasized that they strive to treat all residents with dignity and respect, especially since they know that this is the residents’ home. Based on the interviews and observation, there was not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is Unsubstantiated. Reports continued LIC9099-C Allegation #3: Staff do not report incidents involving residents as necessary. This complaint alleges that there have been four separate physical altercations between residents, but the facility has not reported these incidents to the Licensing Department. On March 13, 2025, the Licensing Program Analyst (LPA) reviewed one month of the Unusual Incident Reports, dated from February 2, 2025, to March 5, 2025. These reports indicated that the facility did report a fight to the Licensing Department, Adult Protective Services (APS), the Ombudsman, and that the Long Beach Police Department (LBPD) was contacted on March 1, 2025. On March 13, 2025, during the time frame of 11:00 AM to 1:00 PM, the LPA interviewed seven residents #1-7 (R1-R7). Six out of the seven residents denied the allegation, stating that the police typically arrive at the facility after a resident fight. Resident #3 (R3) specified that staff called 911 after resident was insulted by another resident, resulting in police intervention. resident is pressing charges against the other resident for battery and is scheduled to appear in court. Between 2:00 PM and 3:00 PM on the same day, the LPA interviewed seven staff members #1-7 (S1-S7). All staff denied the allegation and stated that the facility would contact the Long Beach Police Department (LBPD) if any fights were serious. They also confirmed that they would complete the Unusual Incident/Injury Report to inform Licensing and APS/Ombudsman and send it out. Reports continued LIC9099-C Staff member S1 noted that any incident occurring at the facility would be reported immediately to the appropriate agency, regardless of whether an injury occurred. Based on the interviews and record reviews, there was not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is Unsubstantiated. No deficiencies were cited. Exit interview was conducted. A copy of this report was provided to Administrator Esperanza Naaktgeboren.the state’s words, verbatim · CDSS document, May 29, 2025 · control 11-AS-20250304155108

Type of visit: Case Management - Other

On 05/23/25 Licensing Program Analyst (LPA) Villegas conducted an unannounced case management visit to issue citation observed during complaint investigation 11-AS-20250423162106, LPA met with Administrator Esperanza Naaktgeboren as the purpose of the visit was explained. During complaint investigation visit on 05/01/25 LPA noted facility failed to provide resident #1 (R1) with packaged delivered to the facility. On 05/01/25 LPA Villegas interviewed Residents #1-9, 2 of 9 residents interviewed stated that packages delivered to the facility are being opened and withheld by facility staff. On 05/01/25 during complaint investigation LPA interviewed A1, and staff #1-2 (S1-S2), during interviews with A1 and S1-S2 it was disclosed that residents are called down to facility lobby to open packages in the presence of staff. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 809D. Exit interview conducted, appeal rights explained, copy of the report was provided.the state’s words, verbatim · CDSS document, May 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87468.1(a)(15) · Plan of correction due date: Jun 6, 2025

87468.1 Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To send and receive unopened correspondence in a prompt manner. Based on interviews the facility failed to provide residents with mail correspondence as residents are being made to open their mail in the presence of a staff member which is a personal rights violation to resident in care.the state’s words, verbatim · CDSS document, May 23, 2025

Plan of correction: Licensee/Administrator to develop a plan on how the facility will ensure resident(s) personal rights are not violated moving forward, Licensee/Administrator to submit plan to LPA by POC due date. Licensee/Administrator will conduct an in-service regarding mail correspondence procedures and on residents personal rights. Copy of in-service sign in sheet to be sent to LPA by POC due date.

Allegation investigated: Staff is opening resident’s mail.

On 05/01/25 at 9am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Administrator (A1) Esperanza Naaktgeboren as the purpose of the visit was explained. The investigation consisted of the following: On 05/01/25 LPA obtained copies of the following; staff roster, client roster, and copies of the following for residents #1-3 (R1-R3), facesheet, physicians report, physicians orders, needs and service plan, medication list, and admission agreement. On 05/01/25 from 10am-11:50 am LPA conducted interviews with residents #1-9 (R1-R9) and from 1:00pm-2:00pm LPA conducted file review for R1-R3. On 5/1/25 from 2pm- 3:10pm LPA conducted interviews with (A1), and staff # (S1). The investigation revealed the following: Allegation: Staff is opening resident’s mail It is being alleged that someone at the front desk is opening selective pieces of residents mail. Unsubstantiated On 05/01/25 from 10am-11:50 am LPA conducted interviews with R1-R9 regarding the allegation above, 7 of 9 residents interviewed denied the allegation above and reported they have not received any open mail from staff. 2 of 9 residents interviewed confirmed the allegation above and reported that staff did not notify residents that their packages were delivered and that the package was placed in the med room. On 5/1/25 from 2pm- 2:20pm LPA conducted interviews with (A1), and staff #1-2 (S1-S2). During interview with A1 on 5/1/25, A1 denied the allegation above and reported that mail is only opened upon consent from residents with visual impairments. A1 Continued to report that if a resident receives a package that is suspected to be medications that package will be provided to the med room staff. On 5/1/25 LPA conducted interviews with S1-S2 regarding the allegation above 2 of 2 staff interview denied the allegation above and reported medication packages are sent to the med room, med room staff will have the resident open the package, and if the resident does not have an order for the medication delivered the resident is informed that the medication will be kept in the med room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 1, 2025 · control 11-AS-20250423162106

Allegation investigated: Staff did not seek timely medical attention for resident. Staff are not mitigating the spread of infectious outbreaks in the facility.

On 04/16/25 at 9am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Executive Director (ED) Esperanza Naaktgeboren as the purpose of the visit was explained. The investigation consisted of the following: On 04/16/25 LPA obtained copies of the following; staff roster, client roster, April 2025 cleaning schedule, laundry schedule, Orkin service reports (dates: 01/17/25, 02/20/25, 3/28/25). On 04/16/25 LPA obtained copies of the following for clients #1-2 (C1-C2), facesheet, physicians report, physicians orders, needs and service plan, pre appraisal, MAR for March 2025-April 2025, and shower logs. On 04/16/25 from 11am- 12:10 pm LPA conducted interviews with clients #1-8 (C1-C8) and from 1:00pm-2:35pm LPA conducted interviews with ED, and staff #1-4 (S1-S4). On 04/16/25 from 2:35pm- 3:05 pm LPA conducted toured 5 bedrooms and checked 10 mattresses. The investigation revealed the following: Unsubstantiated Allegation: Staff did not seek timely medical attention for resident. It is being alleged that staff sis not seek timely medical attention to resident in care. On 04/16/25 from 11am- 12:10 pm LPA conducted interviews with C1-C8 regarding the allegation above, 6 of 8 clients interviewed denied the allegation above, 1 of 8 clients interviewed reported having to wait 2 hours for EMT services, 1 of 8 clients interviewed reported not having to need any medical attention. On 04/16/25 from 1:00pm-1:30pm LPA conducted interview with ED, regarding the allegation above, ED denied the allegation above. On 04/16/25 from 1:30pm-2:35pm LPA conducted interviews with S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above, 2 of 4 staff interviewed added that a client will be assessed by med tech, ALW nurse, or Wellness director prior to 911 being called. Allegation: Staff are not mitigating the spread of infectious outbreaks in the facility. It is being alleged that a client in care was bitten by insects that felt like bed bugs. On 04/16/25 from 11am- 12:10 pm LPA conducted interviews with C1-C8 regarding the allegation above, 7 of 7 clients interviewed denied the allegation above, 1 of 8 clients interviewed reported being pocked by an unknown bug. On 04/16/25 from 1:00pm-1:30pm LPA conducted interview with ED, ED denied the allegation above and reported that there are procedures in place for if bed bugs were observed at the facility. Per ED, pest control services the facility once a month, but are called for additional service if needed. On 04/16/25 from 1:30pm-2:35pm LPA conducted interviews with S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported that if bed bugs were observed client(s) in the bedroom would be isolated, provided with treatment, mattress would be bagged, all laundry would be washed, and pest control would be contacted as needed. Per 4 of 4 staff interviewed reported body checks are conducted by caregivers, med techs, or ALW nurse. On 04/16/25 LPA conducted tour of 5 bedrooms and checked 10 mattresses. The mattresses in the following rooms were checked, 111, 123, 209, 213, and 214, LPA observed all mattresses to be clean and in good condition, have a mattress cover, rooms were cleaned, no insects or bed bugs were observed. On 04/16/25 LPA conducted a review of C1's file, there are no body checks documented as C1 does not require assistance with showers. On 04/16/25 LPA conducted a review of Orkin service reports dated: 01/17/25, 02/20/25, and 3/28/25, there is no indication that the facility has been treated for bed bugs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 16, 2025 · control 11-AS-20250408082511

Allegation investigated: Staff do not respond to residents's for assistance in a timely. Staff member did not accord dignity to resident in care. Staff do not report incidents involving residents as necessary.

On 04/11/2025, at 08:00 AM, Licensing Program Analyst (LPA) Antonine Richard made a subsequent complaint visit to the facility above. LPA met with the Administrator Esperanza Naaktgeboren and Assistant Administrator Jennifer Rivas, and the purpose of today's visit was explained. Investigation consisted of the following: On 03/13/2025, LPA toured the facility, interviewed seven Staff #1-7 (S1-S7), interviewed seven residents #1 (R1-R7), and reviewed and collected, Resident Roster (dated 03/13/2025) staff roster (dated 03/13/2025), Physician Report (dated 12/16/2024, 03/07/24, and 01/27/25), Incident Report (dated 02/03/2025 to 03/05/25). Response by room number (dated 03/01/25 to 03/13/25) and APS/Ombudsman/Long Beach Police Department (LBPD) report. Unsubstantiated Allegation #1: Staff do not respond to residents' requests for assistance in a timely manner. It is being alleged that staff take hours and hours to respond to the call light after residents request assistance, which is concerning because someday a resident could be on the floor with their head cracked open or something. On 03/13/25, between 11:00 am to 1:00 pm, LPA Richard interviewed seven (7) residents (R1- R7). 6 out of 7 denied the allegation and stated that most of us are independent, the staff always tried to assist when we pushed the call button or when we outside in the ground and need assistance. On 03/13/25, between 2:00 pm to 3:00 pm LPA interviewed seven (7) staff (S1-S7), 7 out of 7 denied the allegation and stated that the facility has a call light system, when a resident presses the call light anyone available would go and assisted the resident, we don’t choose who to assist or not to assist. This is our job to make sure all the residents who need assistance get to be assisted. On 04/11/25, at 10:40 am, LPA inspected two residents' bedrooms, # 233, and # 238, LPA pressed the call light and found the facility staff answered the call light in less than 2 minutes. Based on the interviews, observation, and record reviews, there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is Unsubstantiated. Continued LIC9099C Allegation #2: Staff member did not accord dignity to resident in care. It is being alleged that staff refused to listen to the resident and slammed the facility door closed. On 03/13/25 between 11:00 pm to 1:00 pm, LPA interviewed seven (7) residents (R1- R7). 5 out of 7 residents denied the allegation and stated that staff treated them with respect and dignity. They also stated that the residents need to treat the staff how they want to be treated themselves. R3 stated that the residents sometimes yelled and cursed at the staff. They also stated the facility gives them quality care and expressed their satisfaction living here. On 03/13/25, between 2:00 pm to 3:00 pm, LPA interviewed seven (7) staff (S1- S7). 7 out of 7 denied the allegation and stated they tried their best to treat all residents with dignity and respect, especially since we know this is their home. Based on the interviews and observation, there was not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is Unsubstantiated. Allegation #3: Staff do not report incidents involving residents as necessary. It is being alleged that there have been four different physical fights/altercations between residents and residents, but the facility doesn’t report these incidents to the Licensing Department. Continued LIC9099C On 03/13/25, LPA reviewed and obtained one (1) month of the Unusual Incident Report (dated 02/02/25 to 03/05/25), which indicated that the facility did report the fight to the Licensing Department, APS, and the Ombudsmen, and the Long Beach Police Department (LBPD) was called on 03/01/25. On 03/13/25, between 11:00 am to 1:00 pm, LPA interviewed seven (7) residents (R1- R7). 6 out of 7 denied the allegation and stated that the police usually come to the facility after a resident fight. LPA interviewed R3, who stated that the staff did call 911 when was insulted by another resident, and the police came, and R3 is pressing charges against the other resident for battery and R3 is going to court. On 03/13/25, between 2:00 pm to 3:00 pm, LPA interviewed seven (7) staff (S1- S7). All denied the allegation and stated that the facility would call the LBPD if the fights were serious and fill out the Unusual Incident/Injury Report to Licensing and APS/Ombudsman and send it out. LPA interviewed S1, who stated that when an incident happened at the facility, they would immediately report the incident to the right agency whether any injury occurred. Based on the interviews and record reviews, there was not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is Unsubstantiated. No deficiencies were cited. Exit interview conducted. A copy of this report was provided to the Administrator Esperanza Naaktgeboren.the state’s words, verbatim · CDSS document, Apr 11, 2025 · control 11-AS-20250304155108

Allegation investigated: Staff are not knowledgeable of residents current health conditions. Staff do not ensure adequate care and supervision is being provided to resident’s care.

On 03/27/25 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Administrator Esperanza Naaktgeboren as the purpose of the visit was explained. The investigation consisted of the following: On 03/14/25 LPA obtained copies of the following: staff and resident roster, cleaning schedule, room checklist, list of what staff are assigned to each resident, in-service sign in sheets for August 2024-December 2024, in services for January 2025-February 2025, copies of reliase training topics, and documentation on procedures for Day of admission, personal rights, and death of resident. On 03/14/25 LPA requested copies of incontinent logs, list of incontinent residents, and call button response report. On 03/14/25 from 9:30am- 12:25pm LPA conducted Interviews with residents #1-7 (R1-R7), and between 12:45pm-1:40 pm LPA conducted interviews with staff #1-3(S1-S3). On 03/14/25 LPA conducted a tour of the facility and conducted a call button test. On 03/20/25 at 10am LPA conducted interviews with staff #4-5 (S4-S5). Unsubstantiated The investigation revealed the following: Allegation: Staff are not knowledgeable of residents current health conditions. It is being alleged that facility staff is unable to communicate residents health conditions to emergency personal. On 03/14/25 from 9:30am- 12:25pm LPA conducted Interviews with R1-R7, 7 of 7 residents interviewed denied the allegation above and reported feeling safe when assisted by staff. On 03/14/25 and 03/20/25 LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above and reported staff are comfortable communicating with emergency personal. Allegation: Staff do not ensure adequate care and supervision is being provided to resident’s care. It is being alleged that residents in care have been left on the ground before facility staff will assist. On 03/14/25 from 9:30am- 12:25pm LPA conducted Interviews with R1-R7, 3 of 7 residents interviewed denied experiencing falls while receiving care at the facility, 1 of 7 reported having a witnessed fall and received help in real time, 2 of 7 residents interviewed reported having an un-witnessed fall that did not require staff assistance, and 1 of 7 residents reported having an un-witnessed fall and received assistance within minutes after calling for help. On 03/14/25 and 03/20/25 LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above and reported that when a resident is observe to be on the ground a med tech is called to assess the resident before the resident is moved and before the staff calls 911 if needed. 5 of 5 staff also reported that caregivers will respond to call light/pull light right away or will ask med techs to assist if the caregiver is unable to respond right away. On 03/14/25 LPA conducted a tour of the facility and conducted a call button tests, LPA observed caregivers to respond to call within 5 minutes. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 27, 2025 · control 11-AS-20250307142022

Type of visit: Case Management - Incident

On 03/27/25 Licensing program analyst (LPA) Villegas conducted an unannounced case management visit in regards to incident report dated 03/23/25 that was sent to the department on 03/25/25. LPA met with Executive Director Ezperanza Naakgebored as the purpose of the visit was explained. During the visit LPA obtain the following documents for resident #1 (R1); emergency ID form with date 7/7/22, physicians report dated 1/9/25, physicians orders dated 03/01/25, resident assessment form dated 3/26/26, preplacement appraisal dated 7/6/22, and psychiatric evaluations dated 12/5/24, 1/9/25, crisis plan dated 3/17/25, and summary report from ROADS community clinic dated 3/3/25. On 03/27/25 LPA conducted a tour of the facility, and took pictures of the window in the bedroom where the incident occurred. Due to insufficient information available at this time, the visit requires a need(s) further investigation.the state’s words, verbatim · CDSS document, Mar 27, 2025

Allegation investigated: Facility staff are not preventing altercations between residents.

On 03/20/25 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Administrator Esperanza Naaktgeboren as the purpose of the visit was explained. The investigation consisted of the following: On 03/14/25 LPA obtained copies of the following: staff and resident roster, as well as the following documents for residents #1-2 (R1-R2), emergency ID form, physicians report, physicians orders, service plan, resident assessmnet form, and admission agreement.On 03/14/25 LPA obtain copies of in-services held on the following topics; synergy (hospice), proper body mechanics,medication, personal rights,team building, work place violience, how to disfuse altercations, and mandated reporting. On 03/14/25 from 9:30am- 12:25pm LPA conducted Interviews with residents #1-7 (R1-R7) , and between 12:45pm-1:40 pm LPA conducted interviews with staff #1-3 (S1-S3). On 03/20/25 LPA conducted interviews with staff #4-5 (S4-S5). Unsubstantiated The investigation revealed the following: Allegation: Facility staff are not preventing altercations between residents. It is being alleged that facility staff are not preventing altercations between residents. On 03/14/25 from 9:30am- 12:25pm LPA conducted Interviews with R1-R7, 7 of 7 residents interviewed denied the allegation above and reported staff assist when needed. On 03/14/25 and 03/20/25 LPA conducted interviews with S1-S5, 5 of 5 staff interviewed denied the allegation above and reported that when am altercation is observed staff will separate residents involved, assess residents, call 911 as needed, and submit report to CCLD. On 03/20/25 LPA conducted a review of R1s and R2's physicians report and service plans, LPA did not observe any documentation on aggressive or inappropriate behaviors. On 03/20/25 LPA conducted a file review and did not observe an unusual incident reports regarding R1 and R2 submitted to CCLD. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 11-AS-20250311082723

Allegation investigated: Staff does not ensure the facility is kept clean and sanitary for residents in care Licensee does not ensure staff are in good physical health to perform assigned tasks Staff do not ensure residents receive adequate incontinence care in a timely manner

On 03/20/25 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Administrator Esperanza Naaktgeboren as the purpose of the visit was explained. The investigation consisted of the following: On 03/14/25 LPA obtained copies of the following: staff and resident roster, cleaning schedule, room checklist, list of what staff are assigned to each resident, in-service sign in sheets for August 2024-December 2024, in services for January 2025-February 2025, copies of reliase training topics, and documentation on procedures for Day of admission, personal rights, and death of resident. On 03/14/25 LPA requested copies of incontinent logs, list of incontinent residents, and call button response report to be emailed to LPA by 03/17/25. On 03/14/25 from 9:30am- 12:25pm LPA conducted Interviews with residents #1-7 (R1-R7), and between 12:45pm-1:40 pm LPA conducted interviews with staff #1-3(S1-S3). On 03/14/25 LPA conducted a tour of the facility and conducted a call button test. On Unsubstantiated 03/20/25 at 10am LPA conducted interviews with staff #4-5 (S4-S5). The investigation revealed the following: Allegation: Staff does not ensure the facility is kept clean and sanitary for residents in care It is being alleged that the facility is unsanitary, and feces left on the ground has been observed. On 03/14/25 from 9:30am- 12:25pm LPA conducted Interviews with R1-R7 regarding the allegation above, 7 of 7 residents denied the allegation above. On 03/14/25 and 03/20/25 LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff denied the allegation above and reported house keeping cleans the facility daily and attends to any accidents right away when reported. On 03/14/25 LPA conducted a tour of the facility and observed the facility to be clean and sanitary. On 03/20/25 LPA conducted review of cleaning schedule, LPA observed there are 4 janitors scheduled daily. Allegation: Licensee does not ensure staff are in good physical health to perform assigned tasks It is being alleged that the facility has staff on light duty and are left alone to care for residents. On 03/14/25 from 9:30am- 12:25pm LPA conducted Interviews with R1-R7 regarding the allegation above, 7 of 7 residents denied the allegation above and reported feeling safe when assisted by staff. On 03/14/25 and 03/20/25 LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above and reported there is no staff with work restrictions. On 03/14/20 during facility tour LPA observed staff to be in good health. On 03/20/25 LPA reviewed staff schedule and did not observe any staff to be on light duty, LPA also observed that there are 3 caregivers per shift, 2 med techs per shift, and a administrator, assistant administrator, wellness coordinator, and an ALW nurse that are at the facility from 8am-5pm. Allegation: Staff do not ensure residents receive adequate incontinence care in a timely manner It is being alleged that residents’ incontinence needs are not being met. On 03/14/25 from 9:30am- 12:25pm LPA conducted Interviews with R1-R7 regarding the allegation above, 5 of 7 residents denied the allegation above, 2 of 7 residents reported they do not need incontinence care. On 03/14/25 LPA conducted a tour of the facility and conducted a call button/pull string test, LPA observed staff responded to call within 5 minutes. On 03/14/25 and 03/20/25 LPA conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above and reported residents are changed as needed, and are checked every 2 hours. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 11-AS-20250307142022

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility did not issue a refund to a resident in care.

THIS REPORT SUPERSEDS REPORT DATED 6/12/24 TO ADD ADDITIONAL INFORMATION AND CHANGE INVESIGATION FINDINGS. On 03/06/25 at 10:00 am licensing program analyst (LPA) Villegas conducted a subsequent visit to deliver complaint findings. LPA met with Jennifer Rivas as the purpose of the visit was explained. The investigation consisted of the following: On 03/06/24 LPA Villegas requested copies of the staff and resident rosters, communication documentation regarding R1’s discharge from facility dated 05/29/24, narrative charting notes dated 01/01/24-05/08/24, admission agreement dated 04/09/09, physicians report dated 05/02/24, preplacement appraisal dated 04/09/09, and rent invoice for May 2024. On 06/12/2024 The Department obtained copies of the staff roster, resident roster, reviewed 7 out of 7 residents file, admission agreements, medication administration records, discharge paperwork, and requested copies of eviction documents. The department interviewed staff#1-5 (S1-S5), and Residents #2-7 (R2-R7). On 03/06/25 LPA Villegas conducted phone interview with Staff #6 (S6). Substantiated Allegation: Facility did not issue a refund to a resident in care. It is being alleged that the facility did not refund a resident after resident moved out of the facility. On 06/12/2024 The department conducted interviews with S1-S5, 5 of 5 residents interviewed denied the allegation above. On 06/12/24 The department conducted interviews with R2-R7 regarding the allegation above, 6 of 6 residents interviewed denied the allegation above. On 06/12/24 The department was unable to interview R1 due to R1 no longer receiving services at Chateau Long Beach. On 03/05/25 LPA Villegas conducted phone interview with former Administrator (A1) regarding the allegation above, Per A1 A1 was no longer working for the facility and A1 has no information on the allegation above. On 03/06/25 LPA Villegas conducted phone interview with (S6) regarding the allegation above, S6 denied the allegation above and stated R1 was removed from the facility by family at the end of the month therefore there was no refund issued. Per S6 R1’s belongings were picked up by family member on 5/29/24. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8)are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided. On 03/05/25 LPA Villegas conducted phone interview with former Administrator (A1) regarding the allegation above, A1 denied the allegation above and stated the facility wanted to ensure the facility could met R1’s care needs. On 03/06/25 LPA Villegas conducted phone interview with (S6) regarding the allegation above, S6 denied the allegation above and reported resident no longer met the criteria upon in per son re-assessment. On 03/06/25 LPA Villegas conducted a records review for R1, LPA did not observe an eviction notice in R1’s file. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 6, 2025 · control 11-AS-20240603132824

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(5)(D) · Plan of correction due date: Mar 20, 2025

Admission Agreements The refund of prepaid monthly fees for any condition listed in (C)1. and (C)2. above shall be given as specified below: If the resident does not provide the above 5-day notice the licensee shall refund a proportional daily amount of any prepaid monthly fee(s) within seven days from the date that the resident leaves the facility, and the unit is vacated. The licensee did not comply with the section above as Facility failed to provide R1 with refund when the residents belongings were removed from the facility by family on 05/29/24.the state’s words, verbatim · CDSS document, Mar 6, 2025

Plan of correction: Submit a plan to dept outlining the steps they will take to get into compliance with title 22 regulations. Plan to be submitted to LPA by POC due date.

Type of visit: Case Management - Other

On 03/06/25 at 10:00 am licensing program analyst (LPA) Villegas conducted an unannounced case management visit to issue citation observed during complaint investigation 11-AS-20240603132824. LPA noted during complaint investigation facility failed to properly reappraise resident #1 (R1). Deficiency cited on 809D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 6, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Mar 20, 2025

The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition...the licensee did not comply with the section anove as there is no proof of written/documented re-appraisal for R1 which poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2025

Plan of correction: Licensee/Administrator will review title 22 regulations and submit statement acknowledging the review and understanding of the regulation. Licensee/ Administrator will train staff to ensure staff understand regulations. Statement to be submitted to LPA by POC due date.

Allegation investigated: Facility staff mismanaged residents medication. Residents are not provided adequate meals. Staff do not provide adequate shower assistance to residents in care. Facility administrator is not qualified.

This amendement is to clarify the narrative on one 9099-C page and does not change the determination findings. The investigation consisted of the following: On 10/18/24, Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegations. LPA Cloyd spoke Administrator Cindy Nicolson-Bolong and explained the purpose of the visit. LPA Cloyd received facility records, observed lunch, and interviewed residents and staff. On 12/19/24, LPA Cloyd conducted a subsequent complaint investigation, met with Administrator and explained the purpose of the visit. During today’s visit, LPA interviewed staff and residents and reviewed facility documents. Regarding the allegation "Staff mismanaged residents’ medication," it is being alleged that staff has given the wrong medication to several residents resulting in hospitalization. Specifically Resident #2 (R2) was given the wrong medication in September 2024. Continue to LIC9099-C. Unsubstantiated September and October 2024 Medication Administration Record (MAR) for R2 did not reveal medication errors. Interview with R2 indicated staff has not made medication errors. Record reviewed revealed five residents (R3 – R7) with unusual incident reports that resulted in hospitalization in September – October 2024. On 10/16/24, R3 went to the hospital due to shortness of breath. Interview with Wellness Director indicated R3 takes three medications for diagnosis and an inhaler. October MAR revealed that R3 took the three medications daily and had access to R3’s inhaler from 10/01/14 – 10/15/24. Interview with R3 indicated there hasn’t been any medication errors and hospitalization was not caused by medication errors. R4 and R5 MAR’s did not reveal medication errors. R6 went to the hospital for primary diagnosis and MAR revealed R6 took medication prior to hospitalization. R6 was unavailable for interview. R7 went to the hospital for diagnosis. Interview with Wellness Director indicated that R7’s medication list is reconciled by the Nurse after every hospitalization. Interview with R7 indicated staff have not made medication errors and hospitalization was not caused by medication errors. Five out of seven staff interviews indicated there were no medication errors in September and October 2024. One staff member was unsure. Six out of ten residents indicated there were no medication errors in September and October 2024. Regarding the allegation “Staff mismanaged residents’ medication," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Allegation: Regarding the allegation "Residents are not provided adequate meals," it is being alleged that the facility does not provide fresh food and recycles previous meals from the week to make a different dish. Also, it is being alleged that the facility only provides half portion of the meals and it constantly cause diarrhea. Record review revealed fruit and vegetables are available upon request for morning and afternoon snack, vegetables and occasionally fruit are served for lunch, and vegetables and soup of the day are included at dinner. Three staff interviews clarified that unserved ingredients from lunch are used in the soup at dinner time. One of the three staff members (S5) have a food handler certificate valid from 04/16/24 to 04/16/27. Six staff interviews indicated there has not been an increase of diarrhea at the facility. Week 6 menu revealed Sunday’s lunch included baby back ribs, mac & cheese, baked beans, sliced pears, and assorted beverages. Continue to LIC9099-C. Sunday’s dinner included soup of the day, cold cut sandwich with lettuce and tomato, corn chips, tapioca pudding, and assorted beverages. Interview with S2 indicated that the menus (week 1 – week 6) rotate every six weeks. Interview with the Administrator (S1) indicated that the former Head Cook gave larger portions. Since then, the facility has chefs from other facilities who has been strict with serving sizes and the topic has been discussed with the residents. However, the kitchen will provide additional food items if available. Interview with the Director of Operations (S2) indicated that the Licensee has a standardized menu created by a Consultant Dietician, seconds are available to residents, and the facility make sure residents receive their 2000 calories. Record review revealed residents can receive up to (per weekday) 8 oz of protein, 2 servings and ½ cup of fruit, 4 servings and ½ cup of vegetables, 4 servings of carbohydrates, and desserts and bacon/sausage are based on discretionary calories. Seven out of ten staff interviews indicated adequate meals are served to the residents. Two out of ten staff interviews indicated residents have complained about the portion sizes. One staff was unaware if adequate meals were served. Nine out of nine resident interviews indicated that the food quantity is good. Six out of seven resident interviews indicated not experiencing diarrhea. LPA observed residents eating lunch. Two residents said the facility will provide seconds if there is enough food. One resident interjected and said they never make enough food. Resident stated the change in quantity is because they have new cooks. Regarding the allegation “Residents are not provided adequate meals," based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Allegation: Regarding the allegation "Staff do not provide adequate shower assistance to residents in care," it is being alleged that staff have cut down on showering residents and/or do not shower residents due to having two caregivers work each shift. Record review revealed that 28 out of 90 residents need assistance with showers. Shower assistance is provided in the morning and in the evening amongst the two caregivers on shift. Record review revealed there are at least two caregivers and one MedTech working per shift. The three Department Supervisors work at least five days per week (mainly weekdays). Six out of seven staff interviews indicated there are at least two caregivers working per shift. Interview with the Wellness Coordinator and Wellness Director indicated that residents receive at least two showers per week depending on their incontinence needs. Continue to LIC9099-C. Four out of nine resident interviews indicate there are 1 – 2 caregivers per shift. Four out of nine resident interviews indicated 3-6 staff members per shift. One out of nine resident interviews indicated he/she was unsure about the number of staff members per shift. Two out of eight resident interviews indicated they receive at least two showers per week. One out of eight resident interviews indicated they get at least one shower per week. Five out of eight residents indicated they did not need showering assistance. Regarding the allegation “Staff do not provide adequate shower assistance to residents in care," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Allegation: Regarding the allegation "Facility administrator is not qualified," it is being alleged that the Staff #11 (S11) is not certified to act as the Administrator. Personnel Report revealed that S11 works as the Business Manager and has been employed since 04/23/2018. Interview with S11 indicated that S11 predominantly provides assistance with the business. The facility’s former Administrator departed on 08/06/24. The current Assistant Administrator (S12) was designated responsible on 08/06/24 and was supported by the Regional Director (S2). Record review revealed S2’s RCFE Certification expired on 08/26/24 and S2 is on the Administrator Certification Bureau (ACB) RCFE certification renewal list as of 07/05/2024. S12 has an active RCFE certification from 02/23/2024 – 02/23/2026. S2 and S12 both have at least two years of college and three years of RCFE experience. The Current Administrator (S1) was hired as Administrator on 08/11/2024, completed training, and started in the facility on 09/10/24. Interview with S1 and S12 indicated S11 did not serve as the acting administrator. Regarding the allegation “Facility administrator is not qualified," based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was reviewed and provided to the Administrator Cindy Nicolson-Bolong.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 11-AS-20241015132426

Allegation investigated: Staff locked resident out of his room. Staff comitted resident to a mental health facility without cause. staff handled resident in a rough manner. Staff facility is in disrepair (heater). Staff refused to provide resident records upon request. Staff did not safeguard resident funds.

The purpose of the amendment is to clarify the narrative on the LIC9099 and LIC9099-Cs and it does not change the investigation findings. On 03/05/2025 Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint visit at the above mentioned facility. LPA met with the Administrator Esperanza Naaktgeboren and explained the purpose of the visit. LPA and Administrator toured the faiclity. On 12/04/2024, the department conducted a subsequent complaint investigation and met with the administrator Cindy Nicolson-Bolong to deliver findings. The investigation consisted of the following: During the investigation on 06/20/2024, the department conducted a complaint investigation at the above facility to address the following allegation(s). The department met with Administrator Khatera Bahadory and Assistant Administrator Jennifer Rivas and explained the purpose of the visit. The investigation consisted of the following: During today's investigation, the department conducted a record review, interviewed 8 residents and 6 staff members, and obtained documents. See Continued LIC9099-C Unsubstantiated Allegation #1: Staff locked the resident out of his room. It is alleged that the staff changed the locks on the resident's bedroom door and required police assistance to enter the room. Interviewed with Administrator #1 (A1), and the staff denied the allegation. An interview with A1 stated that all residents have keys to access their rooms. The staff accessed the rooms to clean and deliver food to residents. In the case that they were sick and could not go downstairs to the dining room. The department interviewed eight residents (R1-R8) and 7 out of 8 residents stated that the facility provided them with a key. (R1-R8) 7 out of 8 residents also stated that the facility never locked them out of their rooms. The records reviewed showed that the facility called the police on 11/28/2023 not on 11/29/23. The department interviewed six staff (S1-S6), and all 6 stated that the residents had keys to their rooms while the staff were only allowed to go in the residents’ rooms to change bed sheets, clean, and check heaters and ventilators. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation(s) did or did not occur; therefore, the allegation is Unsubstantiated. Allegation #2: Staff committed the resident to a mental health facility without cause. It is alleged that the staff illegally committed the resident to a mental health hospital without cause or seen as a threat to anyone. On 06/20/2024 the department interviewed administrator #1 (A1) who stated that they were concerned about the resident on the morning of 11/31/2023 due to R1’s yelling. The department records reviewed on 12/01/2023 revealed the resident (R1) was seen by a psychiatric team who recommended that the resident be admitted to the mental health because of the danger they pose to others and self. The administrator stated that the facility psychiatrist and the resident (R1) were communicated about what needed to be done about R1’s state of mind before agreeing voluntarily to treatment. The records also showed communication between the facility and the Los Angeles Downtown Medical Center about R1’s treatment plan for admission to mental health. On 06/20/2024, the department interviewed six staff (S1-S6) 4 out of 6 stated that no one can force any resident to be admitted to a mental health hospital other than the psychiatrist's approval. See continued LIC9099-C See continued LIC9099-C Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Allegation #3: Staff roughly handled the resident. It is alleged that the staff handled the resident in a rough manner that caused the resident to be agitated. The department interviewed administrator #1 (A1) who stated that they did not receive any reports that residents had been handled roughly. The department reviewed the staff roster and found that the staff named in the complaint was the administrator who denied the allegation. The department interviewed eight residents (R1-R8), and 7 out of 8 residents denied the staff roughly handling them. Within that same group (R1-R8), 4 out of 8 stated that the staff have been disrespectful, pushing, and physically abused by the residents. The department interviewed six staff (S1-S6) with all of the staff denying the allegations, while also stating that staff members do not handle residents roughly nor do they ever see any staff roughly handling a resident. Although the allegation 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. See continued LIC9099-C Allegation #4: The facility is in disrepair (heater). It is alleged that the facility is in disrepair and that the heater does not work. The resident stated that the heater in disrepair resulted in the staff providing the resident with a space heater that was labeled can causing cancer. The department and Administrator #1 (A1) toured the facility and inspected ten resident rooms (10) out of the (76) rooms inspected with heaters. In all 10 rooms, the ventilators were found working properly with comfortable temperatures observed. The department did not observe that the facility was unkept or in disrepair condition. A1 stated that the facility has a maintenance crew that is on call for regular minor services. The facility has a staff on call 24/7 in case any repair is needed. The department inspected the resident’s electrical outlet for any short circuits, and none were observed. The department observed the facility has fully functioning central air and heating. A1 stated that the facility has procedures in place for beginning and ending work shift duties to clean the facility. A1 stated that no repairs are being conducted in the facility and that the facility is not in disrepair. The department interviewed eight residents (R1-R8) with 7 out of 8 stating that the heater in their room was working fine. The same group of residents also stated a portable heater was given to the residents in case the resident didn’t want to use the wall heater. The department was not able to inspect R1's room. The department interviewed six staff members (S1-S6) with all 6 stating that the facility is cleaned daily. The department toured the outside grounds, and no bodies of water were observed. All exits and walkways around the facility were free of debris and hazards. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. See continued LIC9099-C See Continued LIC9099-C Allegation #5: Staff refused to provide resident their records upon request. It is alleged that the staff refused to provide the resident with records of video footage, police reports, and eviction documents upon request. The department interviewed administrator #1 (A1) who stated that if a resident wanted a copy of their records, the facility would provide it to them. Also stated that R1 requested a copy of a police report dated 11/29/23 however, the facility did not have any police report for that date. The facility then provided R1 with the identification card police left upon their arrival at the facility on 11/28/23. Administrator #1 also stated that the resident requested a 1 years’ worth of video footage and an eviction notice. The facility did provide R1 with the eviction notice documents, but the facility could not provide video footage from a year from 11/29/23, because after seven days the footage is no longer available. R1 did confirm received the eviction documents for court. The department interviewed eight residents (R1-R8) with 6 out of 8 stating that the facility does provide them with a copy of their records when requested. The residents also stated that they received a copy of their admission agreement. The department interviewed six staff (S1-S6) with 4 out of 6 stating that when residents request a copy of a record within their facility file, they typically provide said record to the resident. The department reviewed the facility video log along with seven days of footage. The records revealed that the facility has a process before giving a resident a 30-day eviction notice, with approval from the Community Care Licensing. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Allegation #6: Staff did not safeguard resident funds. It is alleged that staff did not safeguard the resident’s funds which resulted in the resident missing money. The department interviewed eight residents (R1-R8) with 7 out of 8 denying the allegation. The same group also stated that they all have keys to their rooms and that no staff are allowed to enter their rooms without notice. The department records revealed that the resident is mostly responsible for keeping their room locked when they are not in the room. See continued LIC9099-C See continued LIC9099-C The Department interviewed eight residents (R1-R8) with 7 out of 8 denying having any issues with their funds at the facility. (R3-R4) mentioned that their main income is Supplemental Security Income (SSI), and that the facility is the payee. The basic monthly fee (rent) is deducted each month, and the rest is their Personal and Incidental (P&I). (R2 and R4) verified that they do not have an issue with the facility handling their funds, and they have had no discrepancies with their (P&I) funds. The Department interviewed administrator #1 (A1) who stated that not all residents’ funds are being handled by the facility as some of the residents handle their funds. As a result of the Department reviewing (R1-R8) Admissions Agreement 2 out of 8 residents’ Records of Client’s/Resident’s Safeguarded Cash Resources (dated: 11-29-23 through 06-20-24), there are no records of residents reporting any missing money in 2023. The department interviewed six Staff (S1-S6) 6 out of 6 and eight residents (R1-R8) 6 out of 8 revealed they had not heard or observed any staff withholding residents’ money. 2 out of 8 residents admitted they did have some money missing but they didn’t report it, because they were not sure where they lost it. Based on interviews conducted, there is no sufficient evidence to corroborate the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies cited. Exit interview conducted. A copy of the report was provided to the Administration Esperanza Naaktgeboren..the state’s words, verbatim · CDSS document, Dec 4, 2024 · control 11-AS-20240619103658

Allegation investigated: Licensee is not addressing pests at facility.

On 11/21/24 Licensing program analyst (LPA) Villegas conducted an initial complaint visit regarding the allegations above. LPA met with Administrator (A1) Cindy A. Nicolson-Bolong as the purpose of today’s visit was explained. The investigation consisted of the following: On 11/21/24 between 9:00am-11:30am LPA conducted interviews with residents #1-9 (R1-R9), and between 11:30am-12:20pm LPA conducted interviews with staff #1-4 (S1-S4). On 11/21/24 at 12:20pm LPA attempted to reach W1 for an interview, at 12:30pm LPA onducted interview with A1. On 11/21/24 LPA obtained copies of the following: Staff and resident rosters, invoice from Orkin dated 11/15/24, service report from Orkin dated 10/24/24 and 11/15/24, and housekeeping logs from January 2024-November 2024. On 11/21/24 LPA obtain copies of documents pertinent to the complaint for R1. Unsubstantiated The investigation revealed the following: Allegation: Licensee is not addressing pests at facility. It is being alleged that the facility is infested with rats that crawl on the residents during the nigh, and the license hasn't hired a pest control company to address the matter. On 11/21/24 between 9:00am-11:30am LPA conducted interviews with R1-R9 regarding the allegation above 8 of 9 residents denied the allegation above. 1 of 9 residents interviewed confirmed the allegation above and reported feeling "critters" crawling on resident at night. On 11/21/24 between 11:30am-12:20pm LPA conducted interviews with S1-S4 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above and reported rats have not been observed at the facility. On 11/21/24 LPA called W1 regarding the allegation above, however no contact was made. On 11/21/24 LPA conducted a review of housekeeping logs, invoice from Orkin pest control dated 11/15/24, service report from Orkin pest control dated 10/24/24 and 11/15/24. LPA observed documentation detailing there are exterior bait stations placed around the building perimeter for rodent control. LPA toured the inside and outside of the facility and there were no health or safety concerns observed. On 11/21/24 at 12:30pm LPA conducted interview with A1 regarding the allegation above and reported the facility has a contract with Orkin pest control who comes out once a month or when needed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Administrator Cindy A. Nicolson-Bolong, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 11-AS-20241115123254

Allegation investigated: Facility staff are not providing resident with a reasonable amount of privacy while in their bedroom.

On 11/14/24 at 9:18 a.m., Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation above. LPA met with Assistant Administrator Jennifer Rivas as the purpose of todays visit was explained. The investigation consisted of the following: On 11/14/24 between 9:25am - 11am LPA conducted interviews residents # 1-9 (R1-R9), between 11am- 11:25am LPA conducted telephone interview with Administrator (A1), and between 11:25am- 12:20pm LPA conducted interviews with staff #1-3 (S1-S3). LPA obtain copies of documents pertinent to the complaint investigation for R1 and R2. The investigation revealed the following: Allegation- Facility staff are not providing resident with a reasonable amount of privacy while in their bedroom. It is being alleged that people in the facility are coming into resident bedrooms without announcing themselves. Unsubstantiated On 11/14/24 between 9:25am -11am LPA conducted interviews with R1-R9 regrading the allegation above, 8 of the 9 residents interviewed denied the allegation and reported that staff are knocking and announcing themselves before entering bedrooms. 8 of 9 residents interviewed reported having enough privacy at the facility. 1 of 9 residents interviewed reported staff will jiggle the door knob prior to opening the bedroom door and sometimes announce themselves after being asked who is entering the bedroom. 1 or 9 residents interviewed reported being unsure if they have enough privacy. On 11/14/24 between 11am- 11:25am LPA conducted telephone interview with A1 regarding the allegation above, A1 denied the allegation above and reported there are procedures in place for when entering a residents bedroom. Per A1, in-services on residents rights are held regularly to ensure privacy is being provided. On 11/14/24 between 11:25am- 12:20pm LPA conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above and reported knocking, and announcing themselves before entering a residents bedroom. Per 3 of 3 staff interviewed, staff will enter a residents bedroom without consent if staff knocks on the bedroom door twice and there is no answer, this is done as a safety check. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Assistant Administrator Jennifer Rivas, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 11-AS-20241106121253

Type of visit: Required - 1 Year

On 07/25/24, Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Khatera Bahadory and explained the purpose of today’s visit. The facility is licensed to serve (184) of which (178) non-ambulatory and (6) bedridden elderly adults ages 60 and above. The facility is approved for (12) hospice residents. Facility fees are current, liability insurance is active with expiration date of 03/01/25. The facility is a two-story structure located in a commercial neighborhood that consists of the following: reception area, (80) resident bedrooms with a bathroom in each unit, (4) public bathrooms, an activity room, kitchen, a large dining room, laundry room, medication room, a PT room, administrative offices, (3) outside patios, and storage areas for personal hygiene, cleaning supplies, emergency food/water supply were observed. A landline and internet service were observed. LPA checked both downstairs and upstairs bedrooms, beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Call buttons, smoke and carbon monoxide detectors are all operable conditions. Last fire safety check was conducted on 06/07/24. There were no bodies of water, fire arms, nor obstructions on the premises. LPA observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Sharps and toxins were stored and not accessible to residents. All fire extinguishers were charged and were operable. A review of (6) resident files (4) staff personnel files, medication Administration Records (MAR), no discrepancies were observed. During today’s visit no discrepancies were cited. Exit interview conducted with Administrator Khatera Bahadory, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 25, 2024

Allegation investigated: Facility illegally evicted a resident in care. Facility did not issue a refund to a resident in care.

**This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 06/12/2024.** On 06/12/2024 at 09:00 am Licensing Program Analyst (LPA) David España conducted an initial complaint investigation visit for the allegation listed above. Upon arriving at the facility, LPA España met with Administrator Khatera Bahadory who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA España was granted access and allowed to enter the facility to conduct investigation. COMPLAINT INVESTIGATION REPORT LIC 9099C CONTINUED Unsubstantiated This page intentionally left blank Investigation consisted of the following: On 06/12/2024 LPA España requested a copy of the staff roster, resident roster, reviewed 7 out of 7 residents file, admission agreements, Medication Administration Records, discharge paperwork, and requested copies of eviction documents. LPA España interviewed staff 1-staff 5 (S1-S5) and Resident 1-Resident 7 (R1-R7). The investigation consisted of the following continued: Allegation: Facility illegally evicted a resident in care. On 06/12/2024 LPA Espana interviewed Staff 1-Staff 5 (S1-S5). S1-S5 confirmed that the facility adheres strictly to state regulations regarding resident discharges, providing written notice at least 60 days in advance, with no exceptions. S1-S5 also reported no attempts to transfer or relocate residents in the past 90 days. S1-S5 stated no resident was illegally evicted. On 06/12/2024 LPA Espana interviewed Administrator Khatera Bahadory who stated that 1 resident required a higher level of care and left the facility on May 29, 2024. The resident's doctor and family were informed, and the family managed the resident's transition to a skilled nursing facility. The administrator presented documentation showing a signed acknowledgment from the family for discharge on the specified date. On 06/12/2024 LPA España attempted (by telephone) to interview R8, but they were unavailable. On 06/12/2024 LPA Espana interviewed Resident 1-Resident 7 (R1-R7) who were unaware of any recent transfer attempts or issues with illegal evictions. They were also unfamiliar with the facility's eviction process. On 06/12/2024 LPA España attempted (by telephone) to interview R8, but they were unavailable. Based on LPA’s observation, interviews conducted and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Facility did not issue a refund to a resident in care. On 06/12/2024 LPA España interviewed the Administrator Khatera Bahadory who reported no discharges due to nonpayment in the last 90 days. The facility provides residents time to seek financial assistance before any discharge. The Administrator Khatera Bahadory also explained that the facility's eviction policy requires a 60-day notice, and there has not been refund issues with any resident, all procedures are followed accordingly. On 06/12/2024 LPA España interviewed S1-S5 confirmed that detailed documentation is maintained for any discharge process, including reasons and notices provided. On 06/12/2024 LPA España interviewed R1-R7 who were unaware of any refund issues or illegal evictions. R1-R7 confirmed that the facility's discharge procedures are consistently followed and had no knowledge of involuntary discharges. On 06/12/2024 LPA España attempted (by telephone) to interview R8, but they were unavailable. Based on LPA España’s observation, interviews conducted and records reviews, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with Jared Mikos, Director of Operations and a hard copy was provided.the state’s words, verbatim · CDSS document, Jun 12, 2024 · control 11-AS-20240603132824

Allegation investigated: Staff did not properly safeguard the facility grounds. Staff did not properly safeguard a resident's personal belongings. Staff are not preventing an unauthorized individual access to the facility.

On 04/15/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent complaint visit at the above mentioned facility. LPA was met by Administrator Khatera Bahador and the purpose of the visit is to deliver the findings from the previous visit. On 04/10/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPA met with Administrator Khatera Bahadory and Assistant Administrator Jennifer Rivas and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA toured the facility, conducted record review, and interviewed 8 residents and 9 staff members. Continue to LIC9099-C Unsubstantiated Allegation(s): Staff did not properly safeguard the facility grounds. Staff are not preventing an unauthorized individual access to the facility. The investigation revealed the following: Regarding the allegation "Staff did not properly safeguard the facility grounds and Staff are not preventing an unauthorized individual access to the facility,” it is being alleged that a former resident snuck onto the property and stole a resident’s clothes. Interviews conducted indicate the following: the (2) facility entry doors and parking lot gate are secured and monitored by video surveillance and the facility utilizes a Call Light system. LPA observed an alarm device on the main entry gate and the pathways lead to the office and dining hall. Interviews indicated that the alarm device comes on once the first floor office staff departs around 7:00 PM. LPA observed video surveillance cameras monitoring the dining hall and office entryway. LPA observed video surveillance desk monitors in the main office on the first floor and in the Medtech room on the second floor. Interviews indicated that the Receptionist and night staff (Medtechs and Caregivers) utilize the Call Light system that alerts staff of opened doors. The second entry gate is also monitored by cameras. Based on the interviews and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation(s): Staff did not properly safeguard a resident's personal belongings. Staff are not preventing an unauthorized individual access to the facility. The investigation revealed the following: Regarding the allegations, "Staff did not properly safeguard a resident's personal belongings and Staff are not preventing an unauthorized individual access to the facility,” it is being alleged that a former resident been given keys to the facility to access other resident's rooms. Interviews conducted indicate the following: the former resident moved away from the facility six month ago, keys are only issued at the time of move-in and reissued when lost, residents can lock their doors, and the rooms contain lockboxes to safeguard additional items. During the facility tour, LPA observed some locked and unlocked bedroom doors on the second floor and lockboxes in the rooms. Continue to LIC9099-C Record review indicates that the facility tracks lost keys and inventories a resident’s personal property. R1 stated that R1 declined to have R1’s personal items inventoried at admissions. Based on the interviews, observations, and record reviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.the state’s words, verbatim · CDSS document, Apr 15, 2024 · control 11-AS-20240408000759

Allegation investigated: Staff did not properly safeguard the facility grounds. Staff did not properly safeguard a resident's personal belongings. Staff are not preventing an unauthorized individual access to the facility.

The purpose of the amendment is to provide additional information and it does not change the investigation findings. On 04/15/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent complaint visit at the above mentioned facility. LPA was met by Administrator Khatera Bahadory and the purpose of the visit is to deliver the findings from the previous visit. On 04/10/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPA met with Administrator Khatera Bahadory and Assistant Administrator Jennifer Rivas and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA toured the facility, conducted record review, and interviewed 8 residents and 9 staff members. Continue to LIC9099-C Unsubstantiated Allegation(s): Staff did not properly safeguard the facility grounds. Staff are not preventing an unauthorized individual access to the facility. The investigation revealed the following: Regarding the allegation "Staff did not properly safeguard the facility grounds and Staff are not preventing an unauthorized individual access to the facility,” it is being alleged that a former resident snuck onto the property and stole a resident’s clothes. Interviews conducted indicate the following: the (2) facility entry doors and parking lot gate are secured and monitored by video surveillance and the facility utilizes a Call Light system. LPA observed an alarm device on the main entry gate and the pathways lead to the office and dining hall. Interviews indicated that the alarm device comes on once the first floor office staff departs around 7:00 PM. LPA observed video surveillance cameras monitoring the dining hall and office entryway. LPA observed video surveillance desk monitors in the main office on the first floor and in the Medtech room on the second floor. Interviews indicated that the Receptionist and night staff (Medtechs and Caregivers) utilize the Call Light system that alerts staff of opened doors. The second entry gate is also monitored by cameras. Based on the interviews and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation(s): Staff did not properly safeguard a resident's personal belongings. Staff are not preventing an unauthorized individual access to the facility. The investigation revealed the following: Regarding the allegations, "Staff did not properly safeguard a resident's personal belongings and Staff are not preventing an unauthorized individual access to the facility,” it is being alleged that a former resident been given keys to the facility to access other resident's rooms. Interviews conducted indicate the following: the former resident moved away from the facility six month ago keys are only issued at the time of move-in and reissued when lost, residents can lock their doors, and the rooms contain lockboxes to safeguard additional items. During the facility tour. LPA observed some locked and unlocked bedroom doors on the second floor and lockboxes in the rooms. Continue to LIC9099-C Record review indicates that the facility tracks lost keys and inventories a resident’s personal property. R1 stated that R1 declined to have Rl’s personal items inventoried at admissions. Based on the interviews observations, and record reviews, the Department found no evidence to support the allegation mentioned above- Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted and a copy of this report was provided to the Administrator Khatera Bahadory.the state’s words, verbatim · CDSS document, Apr 15, 2024 · control 11-AS-20240408000759

Allegation investigated: Facility is not providing heat to the residents.

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Monday, February 26, 2024, Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Administrator Khatera Bahador. LPA Bunker explained the purpose of today's visit. LPA Bunker interviewed staff 1-3 (S1-S3) and residents 1-9 (R1-R9) LPA Bunker asked questions relevant to the nature of the complaint. S1-S3 and R1-R9 stated the facility is providing heat to the residents. S1-S3 and R1-R9 stated that throughout the facility the building is at comfortable room temperature. During the visit, Administrator Khatera and LPA Bunker toured the following eight rooms to check the room temperature in rooms 104, 223, 233, 234, 236, 240, 242, and 246. The wall and electric heaters in each room were working in an operable condition. LPA Bunker requested copies of supporting documents. See LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Allegation #1: The Facility is not providing heat to the residents. Staff 1-3 (S1-S3) and residents 1-9 (R1-R9) interviewed stated the facility is providing heat to the residents. S1-S3 and R1-R9 stated that the facility has heat throughout the facility and it is in working condition. Both S1-S3 and R1-R9 denied the allegation. The investigation consisted of the following: Staff members 1-3 (S1-S3) and residents 1-9 (R1-R9) have collectively affirmed that the facility ensures the provision of adequate heating to all residents. They confirmed that the heating systems within resident rooms are fully operational, ensuring a warm and comfortable environment. Additionally, should any resident require further warmth, the facility is equipped to provide electric heaters for individual use, further enhancing comfort levels. Both staff and residents have reported that a consistently comfortable temperature is maintained throughout the facility, aligning with the preferences and well-being of all residents. Staff S1-S3 have also verified that the temperature settings in occupied rooms adhere to Title 22 Regulations, thereby meeting established standards for residential environments. In light of these comprehensive statements, the allegation regarding inadequate heating has been unequivocally denied by both staff members S1-S3 and residents R1-R9, highlighting the facility's commitment to maintaining optimal living conditions. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099 and LIC9099-C was provided to the facility Administrator Khatera Bahadory. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Feb 26, 2024 · control 11-AS-20240221141518

Allegation investigated: Staff are not adressing a resident hitting another resident.

On 12/12/23 at 9:00am, Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegation above. LPA met with Administrator (A1) Khatera Bahadory as the purpose of today’s visit was explained. The investigation consisted of the following: On 12/12 /23 LPA interviewed A1, staff #1-5 (S1-S5), witness #1 (W1), and interviewed residents # 2-9 (R2-R9). LPA obtained copies of the following for R1 and R2; facesheet, physicians report, physicians orders, preplacement appraisal information, needs and service plan, incident reports, and a staff and resident roster. The investigation revealed the following: Allegation- Staff are not addressing a resident hitting another resident. It is being alleged that staff are not addressing a resident hitting another resident. On 12/12/23 LPA interviewed Administrator (A1) regarding the above allegation, A1 denied the allegation above stating Unsubstantiated that no resident has disclosed being hit by another resident. Per A1, R2 resident uses his hands to move about the facility due to his visual impairment and R2 has no history of aggression. On 12/12/23, LPA interviewed S1—S5, 5 out of 5 staff interviewed denied the above allegation. 5 of 5 staff interviewed stated they did not have any knowledge of any resident being hit by another resident. On 12/12/23 LPA interviewed R2-R9 regarding the above allegations, 8 out of 8 residents interviewed denied the allegation and reported feeling safe at the facility. LPA was unable to interview R1 as R1 is no longer at this facility; however, LPA was able to interview W1 via telephone. On 12/12/23 LPA Conducted review of R2’s physician’s report and there was no aggression nor behavioral concerns listed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Administrator (A1) Khatera Bahadory, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 11-AS-20231204113203