Country Inn of Downey

Allegation investigated: Staff do not ensure the resident’s room is free of pests. Staff do not ensure resident's room is in good repair.

On 08/13/26, Licensing Programming Analyst (LPA) Jewel Baptiste conducted a subsequent complaint investigation at the facility listed above. Upon arrival, LPA met with the Assistant Administrator Erika Bacerra, and LPA explained the reason for the visit. During the visit on 8/07/2026, LPA obtained the resident roster, staff roster, three (3) Incident reports dated 8/03/2026, 8/04/2026, and 8/07/2026, and an invoice from pest control dated 6/30/2026. LPA interviewed the Administrator and four (4) staff members, who shall be referred to as Staff #1 through Staff #4 (S1-S4). LPA also interviewed a total of nine (9) residents who shall be referred to as resident #1 through resident #9 (R1-R9). LPA toured the facility with the Med Tech/Assistant Administrator, Erika Becerra. Report continued on 9099C Unsubstantiated The investigation reveals the following: Regarding "Staff do not ensure the resident’s room is free of pests," it is alleged that a fly is present in R1’s bathroom. According to the Administrator, the facility does not have pests. The facility has a pest control company that performs monthly preventive measures. The Administrator further stated that R1 damaged various parts of the room so they could have it repaired the way R1 wanted. In this situation, there were two holes in the bathroom lights. The Administrator stated that it was reported to them on Monday and fixed on Tuesday. 3 out of 4 staff stated they have not seen flies or pests around the facility and confirmed they have seen the pest control company at the facility. 1 out of 4 staff stated they have seen flies outside in the back patio or basement. 3 out of 9 residents stated they have seen one fly or gnats. 6 of 9 residents denied the allegation, stating that the facility is very clean and that they have not seen any flies or pests. LPA toured the facility and did not observe pests. LPA reviewed the invoice from the pest control company. The investigation reveals the following: Regarding " Staff do not ensure resident's room is in good repair," it is alleged that R1’s room has holes and broken floor tiles. According to the Administrator, R1 reported the small holes in the bathroom, and they were repaired the next day. The Administrator further stated that the floor tiles are scratched up by R1 because R1 wants all the floor tiles in the bedroom replaced. They had recently repaired R1’s walls, and the next day the housekeeper noticed that R1 had damaged them again. 4 out of 4 staff members denied the allegation, stating that the facility's floors are fine and that everything is fixed promptly. 1 out of 9 residents stated there are scratches on their bedroom floor and confirmed that the facility fixed the small holes within 1 day of reporting them. 7 of 9 residents denied the allegation, stating that if anything is wrong, the facility takes care of it right away. 1 out of 9 residents reported a loose floor tile that was fixed a while ago but has become loose again. LPA toured the area with the Assistant Administrator and was unable to observe a loose floor tile. LPA also toured R1’s bedroom and did not observe the holes in the light fixtures. The floor titles R1 is referring to is under R1’s couch and they were observed with scratches, but they were not broken or loose. Based on LPA's interviews, the investigation revealed: 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. An exit interview was conducted with Erika Bacerra, and a copy of this record was provided.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 28-AS-20260804133133

Allegation investigated: Staff did not ensure resident's room was not in disrepair.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 07/17/2026 regarding the above allegation. On 05/19/2026, LPA Ramirez conducted an initial complaint investigation visit and a need for further investigation was documented. During today’s visit LPA Ramirez was greeted by Administrator Ana Giron and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster, Staff#1 - 5 interviews (S1 - S5), Resident#1-6 interviews (R1 - R6), and physical plant tour. See 9099-C for continued narrative. Substantiated The investigation revealed the following: regarding the allegation “Staff did not ensure resident's room was not in disrepair.” It is alleged that staff did not repair a leak in R1’s bathroom sink for eight (8) days. Five (5) out of six (6) residents interviewed corroborated this allegation. Resident interviews revealed that on or around 05/07/2026, R1’s bathroom sink began to leak. Staff was alerted about the leak and staff#4 (S4) attempted to repair the leak, however, when S4 turned the water back on, the pipe busted water all over R1’s bathroom floor and into the facility hallway floor. During resident interviews, LPA observed and obtained video evidence that documented on at least five (5) days from 05/09/2026 through 05/14/2026, R1’s bathroom sink was in disrepair, and water was observed throughout the bathroom floor on 05/14/2026. Five (5) out of the five (5) staff interviewed denied this allegation. Interview with S4 revealed that R1’s bathroom sink was leaking on 05/14/2026 and was repaired the same day later in the evening. S4 revealed that R1’s bathroom sink leak never leaked onto R1’s bathroom floor or in the facility hallway. S4 revealed that R1’s bathroom sink was in disrepair for one (1) day only and was repaired by a plumbing company. Interview with witness#1 (W1) revealed they were the plumbing company that was dispatched to fix the leak in R1’s room and other plumbing issues on 05/14/2026. W1 revealed that service notes indicated water was observed in R1’s bathroom floor. During record review, LPA observed facility maintenance report for May 2026. This log recorded one entry; which indicated on 05/14/2026 R1’s sink needed a repair. Based on LPAs observations and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 9099D. An exit interview was conducted with Administrator Giron and a copy of this report, 9099-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Jul 17, 2026 · control 28-AS-20260511092326

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 20, 2026

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: R1's bathroom sink was in disrepair and was not repaired for 8 days. This poses a potential risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Jul 17, 2026

Plan of correction: Administrator agreed to draft a plan on steps the facility will take to ensure complaince with regulation 87303(a).

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit- Deficiencies on 07/17/2026. LPA Ramirez met with Administrator Giron and explained the purpose of the visit. During today’s visit LPA Ramirez discussed with Administrator Ana Giron discrepancies identified between staff#4 (S4) interview statements and the video evidence obtained by LPA on 05/19/2026. Interview statements made by S4 on 05/19/2026, revealed that no water leaked onto R1’s bathroom floor, facility hallway and that R1’s bathroom sink was only in disrepair for one (1) day. Video evidence obtained by LPA Ramirez on 05/19/2026, revealed that R1’s bathroom sink was in disrepair for at least five (5) days from 05/09/2026 through 05/14/2026 and water was observed throughout R1’s bathroom floor on 05/14/2026. Interviews with five (5) out of six (6) residents revealed they remembered on or around 05/07/2026, R1 yelling to “shut off the water!” and when residents opened their bedroom door, they observed water rapidly flowing out of R1’s room and into the facility hallway. Interview with R1 revealed that for eight (8) days R1’s bathroom sink was in disrepair and R1 was unable to use their bathroom sink for grooming needs and was not offered to be relocated to another room while repairs were pending. Interview with Administrator Giron corroborated that R1 was not relocated to another room while R1’s sink was being repaired. Administrator Giron and S4 both denied that R1’s bathroom sink was in disrepair for more than one (1) day and that water flooded R1’s bathroom or facility hallway. Based on interview statements gathered and video evidence obtained, LPA Ramirez issued one (1) deficiency for staff making false or misleading statements regarding the facility and one (1) deficiency for violation of R1’s personal rights. Two (2) deficiencies for violation of California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 809-D.the state’s words, verbatim · CDSS document, Jul 17, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a) · Plan of correction due date: Jul 18, 2026

Personal Rights of Residents in Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: R1 was not relocated or offered to be moved into another room until repairs to their bathroom sink was completed. This poses a potential risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Jul 17, 2026

Plan of correction: Administrator agreed to draft a plan that lists what steps the facility will take to provide safe, healthful and comfortable accommodations for residents while repairs are being made in resident rooms. Plan must be emailed to LPA Ramirez

From the deficiency page — Deficiency type: Type B · Section cited: CCR87207 · Plan of correction due date: Jul 25, 2026

False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by: Staff S4 made false and misleading statements when interviewed by LPA Ramirezthe state’s words, verbatim · CDSS document, Jul 17, 2026

Plan of correction: Licensee will provide staff retraining on this regulation and provide LPA with proof of all staff attendance.

Allegation investigated: Staff do not ensure residents are smoking in the designated area. Staff do not ensure resident is being accommodated concerning room and roommate choices.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the reported allegations. LPA met with Administrator Ana Giron and explained the purpose of today's visit. The investigation consisted of the following: LPA obtained copies of staff/resident rosters, facilities Smokers Responsibility and House Rules, LPA conducted interviews with 4 Staff (S1-S4) and 8 Residents (R2-R9) toured facility including patios and designated smoking areas. R1 was not availble for interview as they are currently hospitalized, LPA attempted to call R1 during visit and there was no answer or response to calls/message. Continued on LIC 9099-C Unsubstantiated Allegation: Staff do not ensure residents are smoking in the designated area. It is alleged that R1’s roommate (R2) smokes in their shared room and staff have done nothing to prevent this. LPA interviewed 4 staff and each denied the allegation, staff stated that they have never seen a resident smoke in their room and although sometimes cigarette butts may be found in their rooms residents have never admitted to smoking inside and haven’t been seen smoking inside the facility/bedrooms. LPA interviewed 8 residents and each denied the allegation and stated they have never seen a resident smoke indoors or in bedrooms, residents stated that sometimes the smokers will begin to light their cigarette in the non-designated area but staff will remind them and escort them to the approved smoking area. LPA toured facility did not see anyone smoking indoors and there were no odors of smoke in the facility. Patio area was toured appeared clean and S2 was observed walking through the patio area to sweep and clean throughout visit, all residents that smoke were observed to be in the designated smoking area during visit. Allegation: Staff do not ensure resident is being accommodated concerning room and roommate choices. It is alleged that R1 has expressed to staff that their new roommate (R2) smokes in the room, almost caused a fire due to smoking, is not compatible to have a shared room with them and staff have not offered accommodations. LPA interviewed staff and each denied the allegation, interviews with S1 and S4 revealed that R1 has mentioned wanting to switch rooms with their current roommate, however, it was not due to issues with roommate but because she wanted to share a room with their partner, the partner of R1 has left facility per their request and is no longer a resident at facility. LPA interviewed 8 residents and each denied the allegation, interview with R2 (R1’s roommate) revealed that they get along with their roommate and have no issues, R2 denied smoking in their room and stated they only smoke in the designated patio area for smokers. Interview with R7 revealed that they previously had a roommate that they did not get along with and rooms were switched after this being mentioned to staff. Based on statements and interviews conducted with staff and residents, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 28-AS-20260629123910

Allegation investigated: Staff do not ensure that residents' dietary needs are met. Staff do not maintain facility clean.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to deliver findings on the reported allegations. LPA met with Tania Janeta and explained the purpose of today's visit. The investigation consisted of the following: On 4/2/26 LPA conducted initial visit and obtained copies of staff/resident rosters, conducted interviews with 2 Staff (S1-S2) and 8 Residents (R2-R9) toured facility including patios and designated smoking areas. On 4/8/26 LPA interviewed 1 Resident (R1) and 4 Staff (S3-S6) via phone calls. During today’s visit LPA delivered findings on the reported allegations. (Continued on LIC9099-C) Unsubstantiated The Investigation revealed the following: Allegation: Staff do not ensure that residents' dietary needs are met. It is alleged that the residents at the facility are not being provided with filling or nutritious meals. LPA toured kitchen and dining area and observed sufficient supply of perishable and non-perishable foods. LPA observed meal being served during dinner hour on 4/2/26 and it was same as what was listed on the weekly menu that was provided to LPA, breaded chicken, potatoes and vegetables, plates being served appeared to be of a good amount/portion of food. LPA interviewed 9 residents and 7 out of 9 residents denied the allegation and stated that the food amount is fine, they feel they are provided with enough food and second servings are provided if asked. LPA interviewed 6 staff and each denied the allegation, S1 and S4 explained that there are 2 rounds for meal times and the first round may be limited as these residents are on monitored diets or diabetic diets, however, if the resident is persistent even after they are reminded of the dietary restrictions an extra plate will be provided. Allegation: Staff do not maintain facility clean. It is alleged that the patio at the facility is filthy with cigarette butts everywhere. LPA toured facility, the front patio appeared clean with very few cigarette butts observed (no more than 6), the back patio area that is designated for smoking did appear to have more cigarette butts on the ground, there were around 8-10 residents smoking in the area, LPA observed 4 of these residents throwing their cigarette butts in a tree planter and on the floor, prior to leaving the facility LPA observed a maintenance staff sweeping the area. LPA interviewed 6 staff and each denied the allegation and stated that although the area may get a bit dirty throughout the day there is a maintenance staff and housekeepers that will sweep and try to maintain the area as clean as possible, staff mentioned that a majority of the residents are smokers and will throw the cigarette buts on the ground rather than the ash tray or trash cans that are placed in the area for their convenience. LPA interviewed 9 residents and each stated they notice that the patio does get messy with cigarette butts, however, staff are seen cleaning the area in the morning and throughout the day. Based on statements and interviews conducted with staff/residents and LPA’s observations, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 12, 2026 · control 28-AS-20260325113402

Allegation investigated: Licensee did not ensure that facility was in good repair.

Licensing Program Analysts (LPAs) Elena Mallett, Jewel Baptiste along with Licensing Program Manager (LPM) Fernando Fierros conducted and unannounced subsequent visit to the facility and met with Assistant Adminstrator Erika Becerra and the reason for the visit was discussed. Later on, Administrator, Ana Giron joined the visit. Due to additional information obtained the findings are being changed to Substantiated. On 11/04/2025, LPA Sanjay Vaid conducted the intital visit and met with Assistant Administrator Erika Becerra and Administrator Ana Giron. During the visit, LPA Vaid requested and obtained the resident roster, staff roster. Residents #1-#3( R1-R3), face sheet, Physcian's Report, Preplacement Report. Administrator Giron and LPA Vaid toured the facility. LPA Vaid interviews Administrator Giron and four(4) staff and eight(8) residents, including Resident #1( R1). Report continued on LIC 9099-C Substantiated On today's visit LPAs Mallett and Baptiste toured the physical plant along with Assistant Administrator Becerra, including a tour or Room #7, common area and outside courtyard. LPAs did not observe any health and safety concerns. LPAs interviewed Administrator Giron, four (4) staff and two (2) additional residents. LPAs obtained staff and residents' roster, maintenance records, vendor estimates for repair and incident report dated 11/23/23 regarding Resident #1's behaviors. It is alleged that the facility is in disrepair, a resident's room has a broken window and broken floor tiles which the facility has not repaired in about six months. Interviews with seven staff revealed that one of seven staff was aware of Room # 7 having a cracked window around November 2025. One of seven staff reported of being aware of the cracked window in Room #7 for about a month. Five out of seven staff were not aware of the facility being in disrepair. Interviews with nine of ten residents revealed that the facility is in good repair and if repairs are reported to staff, repairs are made within 24 hours. One out of ten residents interviewed reported that a resident's room has had cracks in the window for several years, and staff replaced a few broken tiles, however the tiles are mismatching. Administrator stated the facility has obtained two estimates to repair the cracked window in Room #7. The Administrator stated they observed the cracked window in early November 2025, and the window has not been repaired. However the cracked window does not pose an immediate danger to the residents. On today's visit, LPAs Mallett and Baptiste observed that in Room #7, the exterior window pane on the lower right side contained several cracks that traveled through out the window. Based on LPAs observations, interviews with staff and residents, review of pertinent documents, the preponderance standard of evidence has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22 are being cited on the attached LIC 9099-D. Exit interview was conducted with Administrator Giron and a copy of the Licensing Report along with Appeal Rights were given at the time of the visit and were discussed.the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 28-AS-20251029103225

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

Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: As evidenced by observation and record reivew Resident 1's room contained a broken window of which Administrator was aware of since early November 2025 and has not been repaired, which poses a potential health and safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 22, 2026

Plan of correction: The facility will submit proof of correction via a photo to Licensing by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Administrator Ana Giron and explained the purpose for today’s visit. The facility is licensed to serve 150 Ambulatory Elderly Residents ages 60 and above, of which 70 may be Non-Ambulatory. Facility holds a hospice waiver for up to 5 Residents. (there are currently 1 resident utilizing hospice services) The Facility is a 2 story building located in Downey, CA. A tour of the facility included: 1st floor: Multiple resident rooms with private full bath, Kitchen, Dining Area, Laundry Room, Storage Closets (for cleaning/janitorial supplies), TV Room, Medication Room, Staff Restroom, Staff Office, Lobby, Reception Area, Staff Break Room, and Outdoor Patio. 2nd floor: Multiple resident rooms with private full bath, Doctor Room, Staff Restroom, and Library. There is one elevator that LPA observed to be in working condition. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today: Infection Control: Facility has sufficient PPE supplies and maintain the required Infection Control Plan. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with Hospice Plan and training. Facility maintains the required liability insurance with expiration date of 4/1/26. Physical Plant & Environment Safety: LPA toured facility, a total of 8 residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems located in each bathroom and in bedroom that were tested and operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility resident private bathrooms and measured within the required range of 105-120 degrees. There is a large shaded patio area on the first floor for residents. (Continued on LIC809-C) Staffing & Personnel Records-Training: There appears to be sufficient staffing at all times in the facility. Staff have criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, Hospice Services and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no issues observed. Administrator Ana Giron Administrator Certificate is valid and expires on 10/20/26 (verified through CCL website) Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 9 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone at the facility. LPA observed the following posters posted on the first floor: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There is sufficient space both indoor and outdoor for activities. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled, centrally stored and are in their original containers. Staff that assist with medication administration have the needed training in their files. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 12/5/25 (technical violation was issued as these were not being done quarterly as required). Residents with Special Health Needs: Facility accepts residents on Hospice Care and staff files reviewed today all have required training documented. Residents that use Oxygen had the required sign on their room doors that read "No Smoking - Oxygen in Use". Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 16, 2026

Allegation investigated: Lack of supervision resulting in resident being assaulted by another resident. Staff did not ensure that hazards were not accessible to residents.

Licensing Program Analyst (LPA) Gabriela Castro and Licensing Program Manager (LPM) David Sicairos conducted an unannounced complaint visit to deliver findings regarding the above allegations. LPA met with Administrative Assistant Erika Becerra and explained the purpose of the visit. The investigation consisted of the following: On 12/15/25, LPA and LPM obtained copies of staff and resident rosters; Face Sheet/Identification documents; Physician’s Reports for Resident #1 (R1) and Resident #2 (R2); and Resident Appraisal for R2. In addition, LPA conducted interviews with four (4) staff members (S1–S4) and eight (8) residents (R1–R8). (Continued on LIC9099-C) Unsubstantiated Allegation: Lack of supervision resulting in a resident being assaulted by another resident. In regard to the allegation of lack of supervision resulting in a resident being assaulted by another resident: It is alleged that the facility failed to provide adequate supervision, resulting in Resident #1 (R1) reporting concerns regarding her roommate, Resident #2 (R2). During an interview, R1 confirmed the allegation and stated that R2 engaged in behavior including talking to herself and that R1 felt threatened by R2. R1 further alleged that she was sprayed in the face with an unknown chemical substance that smelled like a disinfectant and that her personal belongings were also sprayed and observed to be damp. R1 additionally reported that she has had three (3) previous roommates and stated that those roommates also sprayed her belongings. During an interview with R2, R2 disclosed that she has been unable to get along with R1 due to R1’s difficult personality. R2 denied spraying R1 in the face and denied spraying R1’s personal belongings. Interviews were conducted with other residents (R3–R7); none of the residents interviewed corroborated the allegation or reported concerns related to the alleged incident. LPA interviewed five (5) staff members (S1–S5). All staff stated they did not witness, nor were they aware of, any incidents between R1 and R2. Staff explained that if any incidents occur between residents, staff immediately intervene and address the issue. Administrative staff stated they maintain contact with staff at all times, and staff are aware they are required to report any incidents immediately. Staff further stated that if residents experience difficulties with roommates, staff attempt to address and resolve the issue, including intervening to promote an amicable living environment. (Continued on LIC9099-C) Allegation: Staff did not ensure hazards were inaccessible to residents In regard to the allegation that staff did not ensure hazards were inaccessible to residents: It is alleged that Resident #1 (R1) was sprayed in the face by her roommate, Resident #2 (R2), with an unknown chemical substance while at the facility. R1 reported that the substance smelled like a disinfectant and that her personal belongings were also sprayed and observed to be damp. It was further alleged that the identity and safety of the chemical substance were unknown at the time of the alleged incident. During an interview, R2 denied spraying R1 with any chemicals and denied spraying R1’s personal belongings. LPA and LPM toured the facility and sampled several resident rooms and common areas in an attempt to identify any exposed or accessible chemical substances. During the tour, LPA and LPM observed that facility chemicals were stored in two (2) locked closets located in a hallway near the entrance of the facility. LPA and LPM also observed the housekeeping cart to have a locked cabinet in which all cleaning chemicals were secured while the housekeeper was actively cleaning. No exposed or unsecured chemicals were observed during the tour. LPA and LPM conducted interviews with eight (8) residents (R1–R8). All residents interviewed denied having access to chemicals and stated they are aware that chemicals are not permitted in resident rooms. LPA interviewed five (5) staff members, all of whom confirmed that chemicals are locked at all times, are not accessible to residents, and should never be kept in resident rooms. Staff stated that there should never be resident exposure to chemicals and that staff are expected to closely monitor chemical storage and use at all times. Based on interviews and observations, none of the staff or residents interviewed corroborated the allegation. Based on direct observation, statements and interviews conducted with staff/residents there was not enough supportive evidence to concur with the reported 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. Exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 15, 2025 · control 28-AS-20251208163227

Allegation investigated: Staff did not maintain a comfortable temperature for a resident in care. Staff did not ensure resident's room was not in disrepair.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with MedTech/Assistant Administrator Erika Becerra and explained the purpose of today's visit. The investigation consisted of the following: On 11/25/25 LPA obtained copies of staff & resident rosters, tour of facility, LPA tested temperature and electrical outlets throughout facility during tour. Interviews with 3 Staff (S1-S3) and 9 Residents (R1-R9) were conducted. During todays visit 12/1/25 LPA delivered findings on the above allegations. (Continued on LIC9099-C) Unsubstantiated The Investigation revealed the following: Allegation: Staff did not maintain a comfortable temperature for a resident in care. It is alleged that the facility is without heat and the vents are blowing out cold air only. LPA toured facility a total of 9 resident rooms were toured, LPA observed vents in rooms were operable and blowing cool air, temperatures were tested in each room and measured within a comfortable temperatures that read between 71-80 degrees F. Rooms were also observed to have portable heaters and administrator confirmed that if a resident requests for a personal heater one will be provided to them. LPA also checked thermostats throughout the facility (total of 4) and each were within the appropriate range and measured between 72-75 degrees F. LPA interviews 3 staff and each denied the allegation and stated that if residents express that they are cold they are provided with either a portable heater or additional blankets. LPA interviewed 9 residents and 8 out of 9 residents denied the allegation and stated that although it may get cold at night they are provided with the portable heater and extra blankets if needed and have no issues with the temperature being uncomfortable. Allegation: Staff did not ensure resident's room was not in disrepair. It is alleged that there is an electrical problem at the facility and the electricity shuts down when more than one thing is plugged in. LPA toured facility and tested outlets in 9 resident bedrooms and each outlet was operable. LPA interviewed 3 staff and each denied the allegation. Interview with Administrator revealed that R1 often times has multiple items plugged in on different power strips and will sometimes cause a short in the circuit, Staff will go to circuit breaker once they are made aware and will reset the circuit breaker and power will be operable in R1’s room. During tour LPA inspected R1’s room and observed multiple devices plugged in to power strips and did not observe any of the outlets being inoperable. LPA interviewed 9 residents and 7 out of 9 residents denied the allegations and stated that they do not have any issues with the electricity in their rooms or throughout the facility. Based on statements and interviews conducted with staff/residents, tour of facility and LPA's observations, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 1, 2025 · control 28-AS-20251119092122

Allegation investigated: Unlawful eviction.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with MedTech/Assistant Administrator Erika Becerra and explained the purpose of today's visit. The investigation consisted of the following: On 11/25/25 LPA obtained copies of staff & resident rosters, copy of House Rules signed by Resident #1 (R1), and conducted interviews with 3 Staff (S1-S3) and 9 Residents (R1-R9). During todays visit 12/1/25 LPA delivered findings on the above allegations. (Continued on LIC9099-C) Unsubstantiated The Investigation revealed the following: Allegation: Unlawful eviction. It is alleged that the Administrator is evicting R1 from facility, R1 is unsure why and has not been provided with a written eviction notice. LPA interviewed R1 and resident stated they did not hear this information from the administrator directly but their social worker has mentioned to them that their housing at the facility is in jeopardy if they continue to drink alcohol. LPA interviewed Administrator and 2 other Staff and each denied the allegation. Interview with administrator revealed that staff have not formally provided an eviction notice to R1 and that R1 was warned by a social worker that works for the agency that provides support and placement for R1 that if R1 continues to drink they will risk losing their housing at the facility. LPA obtained a copy of the House Rules signed by R1 on 8/4/2025 that states under #5 that residents who are non-compliant with the use of alcohol and their doctors orders, or who demonstrate inappropriate behavior in conjunction with the use of alcohol will be considered inappropriate to continue living at facility. LPA interviewed a total on 9 residents and 8 out of 9 residents denied the allegation and stated they have never been threatened to be evicted nor have they ever been issued an eviction notice. Based on statements and interviews conducted with staff/residents and review of R1's file, there was not enough supportive evidence to concur with the reported 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. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 1, 2025 · control 28-AS-20251120162523

Allegation investigated: Staff did not ensure resident's room was not in disrepair

Licensing Program Analyst (LPA) Vaid conducted an unannounced 10-day initial visit to the facility and was met by Assistant Administrator /Med-tech Erika Becerra and the reason of the visit was discussed. LPA Vaid requested and obtained the resident roster, staff roster. Residents #1-#3 (R1-R3)- face sheet, physicians report, preplacement report. Administrator Ana Giron arrived shortly after to assist with the visit. LPA Vaid and Administrator Giron toured the facility and did not observe any health and safety concerns. Regarding the allegation: Staff did not ensure resident's room was not in disrepair. It is alleged that the staff are not ensuring residents’ room was not in disrepair, a broken window and floor tile have not been fixed for over one and half years months (18 months) and staff are not repairing the broken items. Continued on 9099C................................ Unsubstantiated Five (5) of five (5) staff interviewed stated repairs are reported by the staff during their rounds and reported to the administrator (S1), S1 notifies the corporate office to authorize vendor repairs to the facility. According to S1 all large repairs are done through hired vendors, small repairs are handled by the janitorial/maintenance staff. Residents are encouraged to report all repairs to the front office. Small repairs are made immediately by the janitorial/maintenance staff and large repairs are done by authorized vendors within 24 hours depending upon the issue. Seven (7) out of eight (8) residents interviewed stated they report broken items to the staff and repairs are made. Five (5) of eight (8) residents stated they report necessary repairs to the front office and repairs are made within 24 hours for minor repairs. Observations made by LPA to rooms during tour with S1 and did not observe broken window nor missing floor tiles in rooms #6- #10. LPA Vaid did not observe missing tiles, only mismatching repaired floor tiles. LPA Vaid toured R1’s room, bathroom does not have a window, there is only one window in the room and the window is not in disrepair. Observation of floor tiles are not in disrepair. Based on interviews conducted and observations made. 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. Exit interview was conducted and report was provided to Administrator- Ana Giron.the state’s words, verbatim · CDSS document, Nov 4, 2025 · control 28-AS-20251029103225

Allegation investigated: Staff did not provide medication assistance to resident in care.

Licensing Program Analyst (LPA) Nune Margaryan conducted a visit in response to the above allegation. On today's visit, LPA met with Assistant Administrator. Administrator Ana Giron arrived shortly after and assisted with the visit. Purpose of the visit was explained. The investigation consisted of the following: Interviews with Administrator, Staff 1 - Staff 2 ( S1 - S2), interviews with Resident 1- Rsident 8 (R1 - R8). LPA obtained a copy of the Staff and Resident Roster, R1'Medication Administration Record (September / October 2025), Admission Agreement, Face Sheet, Physitian's Report, Resident Appraisal, Appreaisal/ Needs and Services, Transfer/ Discharged Report, SIR dated on 10/01/25. Continue 9099C Unsubstantiated Allegation: Staff did not provide medication assistance to resident in care. It was alleged that R1 asked staff for their prescribed medications, but staff refused to provide them to resident. Interviews conducted with Administrator and staff revealed that facility residents receive their medications on a daily basis as prescribed by their doctor. Facility staff stated that they didn't refuse to assist residents with any medical needs. They always assist residents with their medications, and the medications are given to residents as prescribed by the doctor. interviews revealed that some residents are independent and prefer to handle their own medical needs, R1 is one of them. However, there is an in-house primary physician who visit residents on a monthly basis and this option is offered upon admission. R1 was moved to the facility on 09/15/25 and expressed to staff that they have their own primary doctor and will continue to see them (R1 responsible for own self). Staff obtained the provider information and called the clinic to get updated information and medication orders for R1. After several unsuccessful attempts to get hold of someone from the clinic, staff spoke with R1 and recommended to see one of facility providers and explained that R1 need to be seen by doctors to get their medications. R1 agreed to see an in-house doctor, but when R1 was seen on 10/01/25, R1 mentioned that they have an appointment to see their own doctor on 10/03/25. In house doctor told R1 that it is fine but meanwhile he will prescribe medications so R1 won't be without medication. Interviewed R1 stated that they was not able to contact their own primary doctor since 10/03/25. R1 stated that he/she is getting their medications and facility staff help with medical needs. Interviewed residents stated that facility staff assisted them with medications and didn't refuse to provide medications. They stated they don't have any concerns about this matter. Based on statements and interviews conducted with staff and clients, review of records, there was not enough supportive evidence to concur with the reported 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. Exit interview was held, and a copy of this report was provided to Administrator Ana Giron.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 28-AS-20251001124708

Allegation investigated: Staff did not prevent residents from smoking in non-smoking areas of the facility. Licensee did not ensure facility cleanliness was maintained.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Administrator Ana Giron and explained the purpose of today's visit. The investigation consisted of the following: LPA obtained copies of staff & resident rosters, toured the outside and both 1st and 2nd floors of the facility, and conducted interviews with 3 Staff (S1-S3) and 8 Residents (R1-R8) (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff did not prevent residents from smoking in non-smoking areas of the facility. It is alleged that residents have been observed smoking right outside the building in an area with a sign that says no smoking. LPA toured facility and observed patio area near entrance to have No Smoking signs along with an additional sign that say Smoking Allowed Only When it is Raining, LPA also toured the patio area that is enclosed in the facility. During tour LPA did not observe any of the smokers, smoking in non-designated areas. LPA interviewed 3 staff and each denied the allegation, however, they did explain that when it is raining residents are allowed to smoke in the front patio area, as long as the doors are closed. S1 stated this was implemented because the residents needed a covered area for when it rains to still be able to smoke, S1 further stated that last week there was a day that rained and there were a few smokers that used the front patio to smoke their cigarette and followed the rules. LPA interviewed 8 residents and 7 out of 8 residents denied the allegation, 6 residents stated that although some residents will break the rules and smoke in non-designated areas, staff will go out and remind them of the smoking rules and guide them to the smoking areas. Allegation: Licensee did not ensure facility cleanliness was maintained. It is alleged that the carpets, furniture, and lobby areas are dirty. LPA toured facility and observed the housekeepers doing rounds, they were mopping and cleaning rooms and hallways. LPA did not observe any carpets during the visit, minus the front entrance carpet in the lobby that is used to dust off shoes when you enter the facility. Floors throughout the facility appeared clean and non-sticky, and there were no foul odors observed. LPA interviewed 3 staff and each denied the above allegation, each stated that housekeeping clean throughout the day and feel the facility is being well maintained in that aspect. LPA interviewed 8 residents and each denied the above allegation stating that the housekeepers mop/sweep/take out trash on a daily basis, sometimes 2-3 times a day. Based on statements and interviews conducted with staff/residents, tour of facility and LPA observations, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 28-AS-20250930154352

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tena Herrera made an unannounced Case Management visit to the facility. LPA met with Administrator Ana Giron and explained the reason for the visit. On 9/23/25 the department received an incident report dated 9/18/25 in which it was reported that there was a small fire that had started in R1's room. R1's bed has a small fire and the trash can in the room was also on fire, staff heard the alarm and quickly ran to the room and put out the fire, S1 put the fire out using the fire extinguisher. During todays visit LPA conducted a health and safety check and, toured room #41, the room was empty and there were no signs of smoke damage in the room observed. Per S1 the resident was immediately relocated to a different room and there have been no further incidents. Its believed that the fire started as R1 was leaving their room and threw a cigarette butt in the trash can, that first hit the bed and then fell into the trash. Although there is no proof to this assumption this is believed as R1 is a smoker, the smoking rules were re-explained to R1 after the incident. No deficiencies observed during today's visit. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 7, 2025

Allegation investigated: Due to lack of supervision, resident physically assaulted another resident

Licensing Program Analyst (LPA) Nune Margaryan conducted a visit in response to the above allegation. On today's visit, LPA met with Assistant Administrator. Administrator Ana Giron arrived shortly after and assisted with the visit. Purpose of the visit was explained. The investigation consisted of the following: Interviews with Administrator, Staff 1 - Staff 4 ( S1 - S4), interviews with Resident 1- Rsident 9 (R1 - R9), Family Member 1( FM1) and Family Member 2 (FM2), tour the facility. LPA observed residents in the common area watching television and also sitting outside in the patio area. Review of R1's file and facility staff schedule. Facility Staff and Residents roster were obtained. Continue 9099C Unsubstantiated Allegation: Due to lack of supervision, resident physically assaulted another resident. It was alleged that R1 had a bruise near their eye and R1 did not remember how they got the bruise (it was from falling or R2 hit R1). Interviewed Administrator and staff denied the allegation and stated that there are enough staff on schedule throughout the day and during the night to properly supervise all residents in care as well as to ensure that all residents are safe at all times. Interviewed Administrator stated that R1 has the tendency of making up stories so they can have their way. Interviewed Administrator and staff stated that they were not witnessed that R2 or another resident hit R1. Administrator stated that on Sunday R1's FMs came to visit them and R1 told FMs that R2 just hit them. R2 was in the patio with R1 and R1's FMs at the time of R1's FM visitation. FMs apologize to R2 and told R2 they saw that R2 not gotten close to R1 at all (Copy of SIR dated 9/14/25 was provided to LPA). Interviewed FM1 and FM2 confirmed that R2 did not hit R1. FMs stated that they didn't notice any bruises on R1, but there was a red mark on R1's face close their right eye and could be because of R1's dry skin. Interviewed staff stated that they noticed dry skin by R1 right eye and applied lotion. They remind R1 to always apply lotion and not scratch their face. Interviewed S3 and S4 stated that R1 sleep on their right side and put hands under the face (sometimes R1 put their purse under the face). They stated that R1 has 2-3 big rings on both their hands, and it could be the reason for redness of skin and possibly bruises. Interviewed R1 said that R2 hit them but could not provide any details regarding the incident. Interviewed R2 stated they didn't hit R1. Additional residents interviewed have not observed R2 or any other resident hitting R1 or another resident. LPA did not observe any bruises on R1 but noticed very faint redness on R1's face near right eye. LPA review of staff roster revealed that the facility has adequate staff on schedule. Based on statements gathered from interviews conducted with staff, residents and observations, there was not enough supportive evidence to concur with the reported 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. Exit interview conducted with Administrator and the copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 16, 2025 · control 28-AS-20250911143350

Allegation investigated: Staff did not maintain a comfortable temperature for residents in care.

Licensing Program Analysts (LPA) Luis De Leon conducted an initial unannounced complaint investigation visit for the allegation listed above. LPA met with the Assistant Administrator Erika Becerra and explained the reason for the visit. Administrator Ana Giron joined the visit some time after. The investigation consisted of the following: On today’s visit, LPA De Leon obtained the staff and resident rosters. The LPA toured the first and second floor and common areas. LPA interviewed nine (9) residents and seven (7) staff. Report continues on page LIC-9099c… Unsubstantiated Regarding allegation: Staff did not maintain a comfortable temperature for residents in care. It is alleged that the outside temperature was 90 degrees F, but inside the facility, it felt like 95 degrees. Facility resident asked staff to turn the air conditioning on, but staff did not turn the air conditioning on. The investigation revealed that interviews with seven (7) out of seven (7) staff denied the above allegation. Seven (7) out of seven (7) staff confirmed that facility’s protocol is to report air conditioning concerns to front desk office and staff will be instructed to turn air conditioning on or adjust thermostat settings. Administrator Giron explained that a single air conditioning unit may provide air conditioning up to ten rooms and/or common areas. A single thermostat controls the temperature setting for up to 10 rooms and/or common areas. Administrator Giron explained that depending on residents, some might feel too hot or too cold, but the facility accommodates each resident by providing fans or portable heaters for each room. Interview with residents revealed that eight (8) out of nine (9) residents denied the above allegations. The residents confirmed that the room temperature is comfortable, including during the summer. The residents confirmed that the administration provides fans or heaters when temperature setting in the room is not comfortable for them. LPA measured the temperature of thirteen (13) resident rooms and common areas, and the temperature readings were in the range of 68-85 degrees F as per Title 22 regulations. LPA observed various rooms equipped with portable heaters or fans. LPA observed some residents using heaters and fans in their rooms. Based upon the investigation, resident and staff interviews, and LPA observations, there was no evidence to support the reported allegation. 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 held with Administrator Ana Giron, and findings were discussed. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 28-AS-20250821144327

Allegation investigated: Staff are not providing adequate food service to residents

Licensing Program Analyst (LPA) Nune Margaryan conducted a visit in response to the above allegation. On today's visit, LPA met with Assistant Administrator who assisted with the visit. Administrator Ana Giron arrived shortly after. Purpose of the visit was explained. The investigation consisted of the following: Interviews with Administrator, Staff 1 - Staff 5 ( S1 - S5), interviews with Resident 1- Rsident 8 (R1 - R8), tour the dining room, kitchen, review of facility food supply, and facility menu. Facility Staff and Residents roster were obtained. Continue 9099C Unsubstantiated The investigation revealed the following: Regarding the allegation that Staff are not providing adequate food service to residents. It was alleged that facility only provide dinner and R1 has to purchase their own breakfast, lunch and snacks. Interviewed Administrator and staff denied the allegation. They stated that the facility does provide residents with adequate meals, of good quality three times a day. Also, snacks between meals. Interviews with R1- R8 indicated that the facility serves adequate meals three times a day. They stated that staff also served them snacks. LPA interviewed R1, resident indicated facility did provide adequate food service to residents three times a day. R1 indicated that staff provide snacks between the meals. R1 indicated that they have a good breakfast (French toast, sausage, oatmeal, coffee) and like it. Residents interviewed could not corroborate the allegation. Resident interviews revealed that residents always received three (3) meals a day and snacks between. They stated that they are satisfied with the food service and have no complaints about the food that facility serves. Staff interviews revealed adequate food services were provided to residents and facility serve three meals a day. LPA toured the kitchen and observed food supply was adequate. LPA also obtained a copy of the facility menu for review. LPA toured the dining area during lunch time and observed the meal that was served to the residents. They were served soup, potato salad, sandwiches, juice, fruit cocktails. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No deficiencies cited. Copy of report provided to Ana Giron.the state’s words, verbatim · CDSS document, Jun 6, 2025 · control 28-AS-20250604143251

Allegation investigated: Staff did not provide adequate supervision resulting in resident sustaining a fracture.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced compliant visit. LPA met with Erika Becerra and explained the purpose for todays visit. The investigation consisted of the following: On 3/28/25 LPA Herrera conducted the initial 24hr visit and obtained copies of the staff and resident rosters. From 3/28/25-5/27/25 Investigator C.Ferris with the departments Investigations Bureau (IB) conducted an investigation on the above allegation. During todays visit LPA delivered findings. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff did not provide adequate supervision resulting in resident sustaining a fracture. It is alleged that R1 sustained and unwitnessed fall that caused a non-displaced mandibular fracture, due to lack of supervision. IB investigator C.Ferris investigated the above allegation. Investigator reviewed surveillance footage of the incident that clearly showed R1 accidentally fall from their wheelchair and staff responded immediately to assist. R1 does not require assistance while using wheelchair. Investigator C.Ferris interviewed 1 witness (W1) and they stated they saw when R1 accidentally fell on their own and staff responded immediately. Investigator C.Ferris interviewed R1 and it was stated they were going too fast in their wheelchair and fell out. Investigator C.Ferris conducted file review where it was revealed that R1 is able to leave facility unassisted and able to care for their own needs. Per IB investigator C.Ferris this investigation did not provide sufficient evidence to substantiate the above allegation. Based on statements and interviews conducted with staff, R1 and W1, a review of R1’s file and facility file records, there was not enough supportive evidence to concur with the reported 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. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 5, 2025 · control 28-AS-20250327161501

Allegation investigated: Facility did not maintain a comfortable temperature for residents.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegation. LPA met with Patricia Hernandez and explained the purpose of today's visit, shortly after Assistant Administrator/Med-Tech Erika Becerra arrived to assist with visit. The investigation consisted of the following: LPA obtained copies of staff & resident rosters, toured both 1st and second floors of the facility and toured 7 resident rooms, LPA observed thermostats on 1st and 2nd floors and interviewed Staff (S1-S4) and 8 Residents (R1-R8). (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Facility did not maintain a comfortable temperature for residents. It is alleged that residents room temperatures are maintained at an uncomfortable temperature of 85 degrees F. LPA toured facility both upstairs and downstairs, during tour LPA entered 6 resident rooms (Room #’s 1, 6, 10, 36, 43, 44, 53), each room appeared to be within a cool temperature. Each room that was toured had widows that open/closed properly, vents in rooms were on and were producing cool/cold air. Rooms 1 and 43 had operable fans that were on. LPA was informed that there are multiple air conditioning units in the facility that control different areas/rooms, each unit has a thermostat that controls cooling/heating system for approximately 10 rooms each. LPA observed 2 downstairs thermostats and 3 upstairs thermostats and each had readings that were within the required range of 68-85 degrees F, readings were measured between 77-79 degrees F, LPA measured the temperature with personal thermostat in room #1 and the reading reached 78.8 degrees. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated that although some rooms may get warm due to residents using personal portable heaters, they ensure that rooms temperatures are at a comfortable setting. LPA interviewed 8 residents and 8 out of 8 residents denied the above allegation, some stated that although their rooms can be too cold they are provided with a portable heater for their room, R5 stated it does get warm in their room but they have a fan to keep them cool. Based on statements and interviews conducted with staff/residents, tour of facility and LPA's observations, there was not enough supportive evidence to concur with the reported 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. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 12, 2025 · control 28-AS-20250506141030

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Patricia Hernandez (Receptionist) and explained the purpose for today’s visit, shortly after Administrator Ana Giron arrived to assist with the visit. The facility is licensed to serve 150 Ambulatory Elderly Residents ages 60 and above, of which 70 may be Non-Ambulatory. Facility holds a hospice waiver for up to 5 Residents. (there are currently 0 residents utilizing hospice services) The Facility is a 2 story building located in Downey, CA. A tour of the facility included: 1st floor: Multiple resident rooms with private full bath, Kitchen, Dining Area, Laundry Room, Storage Closets (for cleaning/janitorial supplies), TV Room, Medication Room, Staff Restroom, Staff Office, Lobby, Reception Area, Staff Break Room, and Outdoor Patio. 2nd floor: Multiple resident rooms with private full bath, Doctor Room, Staff Restroom, and Library. There is one elevator that LPA observed to be in working condition. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today: Infection Control: Facility has sufficient PPE supplies and the required Infection Control Plan. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan, Hospice Plan and training. Facility maintains the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, a total of 6 residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems located in each bathroom and in bedroom that were tested an operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility resident private bathrooms and measured within the required range of 105-120 degrees. There is a large shaded patio area on the first floor for residents. (Continued on LIC809-C) Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training: Staff have criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, Hospice Services and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no issues observed. Administrator Ana Giron Administrator Certificate expired on 10/20/24 LPA was able to verify renewal in CCL website and Administrator is in the pending list with receipt date of 9/26/24. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 7 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone at the facility. LPA observed the following posters posted on the first floor: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities with a monthly calendar and the required full-time staff that conduct and evaluate planned activities. There is sufficient space both indoor and outdoor for activities. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled, centrally stored and are in their original containers. Staff that assist with medication administration have the needed training in their files. LPA reviewed 7 Residents medications during visit with no issues. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. The last drill was conducted on 12/19/24. Residents with Special Health Needs: Facility accepts residents on Hospice Care and staff files reviewed today all have required training documented. (there are currently no residents using hospice services) Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held, a copy of this report will be emailed to Ana Giron at giron_counrtyinnofdowney@yahoo.com.the state’s words, verbatim · CDSS document, Jan 31, 2025

Allegation investigated: Staff are not safeguarding resident's personal property. Staff confiscated resident's nonprescription PRN medication without cause.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegation. LPA met with Erika Becerra (Med-Tech/Assistant Administrator) and Administrator Ana Giron and explained the purpose of today's visit. The investigation consisted of the following: LPA obtained copies of staff & resident rosters, House Rules, and Admission Agreement. LPA reviewed a total of 5 residnets files including R1 to verify medication management. LPA interviewed 4 Staff (S1-S4) and 8 Residents (R1-R8). (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff are not safeguarding resident's personal property. It is alleged that S3 rummaged through R1’s dresser, refrigerator and bathroom cabinets in search for R1’s wallet during a deep cleaning; and that several residents have reported that S3 has stolen money from them. LPA spoke with R1 and it was stated that they have never had anything missing from their personal belongings but has heard stories and doesn’t want to be a victim of theft. LPA reviewed house rules which includes that staff will deep clean and if potential hazardous items are found they will be confiscated, it also indicates that residents with a small refrigerator will be monitored for proper storage by staff. LPA interviewed 8 residents and 6 out of 8 residents denied the above allegation and stated they have not had any items stolen while living at facility and that they do not feel that staff invade their privacy by going through their belongings. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated that per house rules deep cleaning is done once a week, when cleaning staff will open drawers to make sure there is no spoiled food, illegal substances or medication being kept in room and that they have never stolen any items from residents or have witnessed other staff doing this. Allegation: Staff confiscated resident's nonprescription PRN medication without cause. It is alleged that S3 was cleaning R1’s room and while cleaning S3 found over the counter medication and confiscated the medication, R1 allegedly does not have limitations that prevent them from having over the counter medication, is not on medication management and does not have a roommate or have medication stored where it is accessible to other residents. LPA interviewed R1 and they stated they purchased the medication at a local pharmacy. LPA reviewed R1’s file and it was observed that per physician report medication management is needed. LPA reviewed House Rules and it indicates that all medications must prescribed by physician and be centrally stored by facility (including PRN). LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated that all medication at facility (including PRN) must be ordered by the physician and centrally stored in the medication room, if medication is found in a residents room it will be confiscated, taken to the medication room and explained why to the resident. LPA interviewed 8 residents and 7 out of 8 residents denied the above allegation and stated that they do not keep any medication, PRN or over the counter supplements/vitamins in their room and understand that the medication room holds all their medications. Based on statements/interviews conducted with staff/residents, review of resident files, admission agreement and house rules, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report will be emailed to Administrator.the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 28-AS-20250113095523

Allegation investigated: Staff do not ensure resident is accorded personal privacy.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegation. LPA met with Erika Becerra (Med-Tech/Assistant Administrator) and explained the purpose of today's visit. Shortly after LPA met with Administrator Ana Giron who assisted with the visit. The investigation consisted of the following: LPA obtained copies of staff & resident rosters and interviewed 2 Staff and 8 Residents. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff do not ensure resident is accorded personal privacy. It is alleged that the licensee/administrator allowed the police to install spy cameras in R1’s bedroom/bathroom fixtures, and a 2-way mirror in R1’s bedroom for police to be able to spy on R1. LPA toured R1's room along side of R1 and did not observe anything that appeared to be spyware within the room. LPA interviewed 2 staff and both staff denied the above allegation, they confirmed that this has been an ongoing accusation made by R1 and both staff and law enforcement (along with licensing in recent visits) have investigated this accusation and have not found any signs spyware being in R1's room. LPA interviewed R1 and resident stated that they still feel as though they are being watched, resident confirmed that law enforcement visited them on 1/3/25 and did not find any spyware in their room. LPA interviewed a total of 8 residents and 7 out of 8 residents denied the above allegation and stated that they do not feel as though they are being spied on by staff and feel staff provide them with privacy. Based on statements and interviews conducted with staff and residents, along with tour LPA conducted with R1 in their private room, there was not enough supportive evidence to concur with the reported allegations. 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. \Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 28-AS-20250102130055

Allegation investigated: Staff did not ensure residents medications were properly managed.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegation. LPA met with Erika Becerra (Med-Tech/Assistant Administrator) and explained the purpose of today's visit. Shortly after LPA met with Administrator Ana Giron who assisted with the visit. The investigation consisted of the following: LPA obtained copies of staff & resident rosters, reviewed 10 Residents Medications and interviewed 2 Staff (S1-S2) and 8 Residents (R1-R8). (Continued on LIC9099-C) Substantiated The investigation revealed the following: Allegation: Staff did not ensure residents medications were properly managed. It is alleged that R1 ran out of their prescribed inhaler on 1/2/25 and staff are having trouble getting the prescription refilled. LPA reviewed 10 residents medication and 9 out of 10 residents medications were properly labeled, accounted for and appeared to be administered per physicians orders. LPA noticed that R9's medication bubble pack still had the am medications for 1/9/25 in the package at 12pm, when LPA asked S2 what happened to the medication it was determined that there was a medication error and R9 missed their morning medication for 1/9/25 (citation will be issued and detailed in the LIC9099-D page). LPA interviewed 8 residents and 7 out of 8 residents stated that they haven't had any missed medications or experienced their medication missing/not being refilled in a timely manner and believe staff are administering medication per physicians orders. Based on LPAs observations during medication review, 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. Exit interview held, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 9, 2025 · control 28-AS-20250102130055

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jan 10, 2025

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidence by: While LPA was reviewing medication 1 out of the 10 residents medications reviewed appeard to have missed their am medications as the bubble pack for R9's AM medications (for 1/9/25) were still in bubble pack, S1 investigated this error and it was discovered that the medication was missed as the medtech from the evening shift (on 1/8/25) experienced an emergency in the middle of prepping meds for the following morning (1/9/25) and did not pop the medications, causing the medication to be missed in the moring of 1/9/25. This error was discovered at approx. 12:40pm on 1/9/25.the state’s words, verbatim · CDSS document, Jan 9, 2025

Plan of correction: Administrator/Licensee to conduct a medication training for all staff that assist with administering medications. A copy of the training materials, scheduled date of training and list of participants to be emailed to LPA by end of day 1/10/24. Administrator to send LPA a copy of the signed participant list once training is completed (training to be conducted no later than 1/23/24).

Allegation investigated: Staff does not accord resident privacy. Staff does not accord resident respect.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Administrator Ana Giron and explained the purpose of today's visit. The investigation consisted of the following: LPA obtained copies of staff & resident rosters and conducted interviews with 5 Staff and 7 Residents. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff does not accord resident privacy. It is alleged that staff are spying on residents and access the roof when spying. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation. Staff stated that they always announce themselves before entering a room and have never observed any suspicious spying activities from staff or residents. Staff stated they do not access the roof for unnecessary reasons, and access to roof does not happen often. LPA interviewed 7 residents and 6 out of 7 residents denied the above allegation and stated that they do not feel that their privacy is being invaded by staff. Residents confirmed that staff always announce themselves before entering their rooms and will not enter if they are asked not to. Allegation: Staff does not accord resident respect. It is alleged that staff (S1&S2) harass R1 by making unnecessary noise at night in efforts to be disrespectful towards resident. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation. S1 confirmed there aren’t any renovations going on where there will be excessive noise and that they have never intentionally made noise to upset residents, S5 confirmed that they do not make unnecessary noise to upset residents nor do they spy or have seen other staff spy on residents. All staff confirmed that if a resident resides on the first floor there may be noise heard as there is a second floor and some residents have trouble sleeping, causing noises of the elevator, going up and down stairs or moving about in their rooms. LPA interviewed 7 residents and 6 out of 7 residents denied the above allegation. Residents stated that sometimes they can hear noise and its believed that the noise is coming from residents that reside on the 2nd floor dragging their walkers through the halls or in their bedrooms, but the noise isn’t excessive and have no complaints. Based on statements and interviews conducted with Staff and Residents, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Dec 6, 2024 · control 28-AS-20241204125128

Allegation investigated: Staff are mismanaging resident's medication. Staff are not ensuring resident was seen by a physician. Staff are not preventing resident from falling.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Erika Becerra (Med-Tech/Assistant Administrator) and explained the purpose of today's visit. Shortly after LPA met with Administrator Ana Giron who assisted with the investigation. The investigation consisted of the following: LPA obtained copies of staff & resident rosters. LPA obtained the following copies from Resident #1's (R1's) file: Admission Record, Physician Reports, Medication List, Lab Results Paperwork and Doctor Evaluation Notes. LPA reviewed Medication Room and inspected R1's medication along with R6-R8's Medications. LPA interviewed 8 Residents, 2 Staff and Facilitys Doctor during todays visit. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff are mismanaging resident's medication. It is alleged that R1 is not getting their medications, and it was allegedly said by MedTech (S1), that R1 that came to the facility with no medications or orders upon admission, and that on 9/9/24 when R1 was discharged from the hospital R1 had been discharged with medications. LPA reviewed Admission Record (discharge paperwork from previous placement) and there were no medications attached to the paperwork. LPA spoke with Administrator and S1 and both denied the above allegation and stated that when resident was admitted there were no medications or medication list sent with R1. Both staff further stated that R1 has seen a doctor since being admitted and has been prescribed 2 medications in which resident is taking daily. LPA reviewed R1's medication list along with medication and did not observe any issues. LPA spoke to facility doctor during todays visit and doctor stated that resident has been seen by them both today (10/22/24) and on 9/11/24, medication has been prescribed and lab work has been ordered for R1. LPA interviewed a total of 8 residents during todays visit and 4 out of 8 residents stated they have never had any issues with their medication and feel that their medication is being administered per doctors orders. LPA reviewed the remaining 3 residents (R6-R8) medication lists and medications and did not observe any issues. S1 stated that although there may have been slight issues with medication being ordered before the cycle ended, as pharmacy's have been switched, they were able to order the medication with the previous pharmacy to ensure there was no lapse in medications. LPA was able to review medication and confirm there has been no lapse. Allegation: Staff are not ensuring resident was seen by a physician. It is alleged that R1 hasn’t seen a doctor. LPA reviewed R1's file and observed both the physicians report upon admission and physician report completed by the facility doctor on 9/11/24. LPA interviewed facility doctor and it was stated that they had visited with resident both on 9/11/24 and today 10/22/24, there have been medications prescribed to R1 during the initial visit and today labs have been ordered for R1. LPA interviewed 2 staff and both denied the above allegation and stated that residents at facility are assisted with seeing a physician (if needed, as some are self-responsible and have their own primary physicians) and that there is a facility doctor who visits regularly/monthly. LPA interviewed a total of 8 residents during todays visit and 7 out of 8 residents denied the above allegation and stated that they see their doctor often and have never had issues being seen by a physician. (Continued on LIC9099-C) Allegation: Staff are not preventing resident from falling. It is alleged that R1 was not getting physical therapy and had a couple of falls which made them scared to fall again. LPA interviewed R1 and R1 stated that they did experience a slip/fall at facility, couldn't recall when, but that staff did assist them and they did not need to be sent to the hospital. LPA interviewed 2 staff and the facility doctor all denied the above allegation and stated that R1 has never mentioned any falls at facility since admission and that if or when there is a fall, immediate attention is given and ambulance is called if needed. Staff further stated that R1 was not receiving physical therapy upon admission and have not observed that R1 is in need of physical therapy. LPA interviewed a total of 8 residents and 8 out of 8 residents denied the above allegation and stated that staff do respond rapidly if there is a fall and give the residents immediate attention if they fall. Based on statements and interviews conducted with staff, and residents, review of R1's files and Review of Medications, there was not enough supportive evidence to concur with the reported allegations. 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 allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 22, 2024 · control 28-AS-20241018163747

Allegation investigated: Staff are not according privacy to resident in care.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Erika Becerra (Med-Tech/Assistant Administrator) and explained the purpose of today's visit. Shortly after LPA met with Administrator Ana Giron who assisted with the investigation. The investigation consisted of the following: LPA obtained copies of staff & resident rosters. LPA tested the Emergency Elevator button and obtained a copy of the last service that was done on elevator. Tour of Restident #1's (R1) room was conducted. LPA interviewed 5 Staff and 9 Residents. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff are not according privacy to resident in care. It is alleged that staff are not giving the residents privacy at the facility and intentionally listen in on personal phone calls. LPA interviewed 5 staff and 5 out of 5 staff stated that they do not deny privacy to residents and have never listened to a residents phone call. 3 out of 5 staff stated that there have been times that a resident is on a phone call when they enter their room but they give them privacy and return at a later time. Interview with Administrator and Staff #1 (S1), both stated that there are landline telephones and a pay phone that is available for residents who do not have cellular phones to use, both also stated that there is no other receiver that can be used to listen in on the phone call when the phone(s) are in use. LPA interviewed 9 residents and 7 out of 9 residents denied the above allegation and stated they have never been denied privacy and have never experienced staff listening in on their personal phone calls. Based on statements and interviews conducted with staff and residents, there was not enough supportive evidence to concur with the reported 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. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 15, 2024 · control 28-AS-20241009123809

Allegation investigated: Facility is in disrepair.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Erika Becerra (Med-Tech/Assistant Administrator) and explained the purpose of today's visit. Shortly after LPA met with Administrator Ana Giron who assisted with the investigation. The investigation consisted of the following: LPA obtained copies of staff & resident rosters. LPA tested the Emergency Elevator button and obtained a copy of the last service that was done on elevator. Tour of Restident #1's (R1) room was conducted. LPA interviewed 5 Staff and 9 Residents. (Continued on LIC9099-C) Substantiated The investigation revealed the following: Allegation: Facility is in disrepair. It is alleged that the elevator emergency alarm button is not in working order, it was tested by R1 and there was no sound. LPA interviewed Administrator and it was stated that the elevator is serviced monthly and there have been no reports of the emergency button not working. 2 out of 9 residents interviewed stated that there have been occasions where they pressed the emergency alarm button and there was no response, no alarm sounded and appeared to be non-operable. Based on LPAs observations and interviews which were conducted, 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. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 15, 2024 · control 28-AS-20241009123809

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 29, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This standard is not met as evidence by: During visit LPA inspected the elevators emergency alarm button and when button was pushed, there was no sound, no lights, no idication that the emergency button was pressed, which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2024

Plan of correction: Licensee/Administrator to have Elevator Serviced and repair must be made to elevators emergency alarm button by POC due date. An invoice showing repairs have been completed to be emailed to LPA by POC due date. tena.herrera@dss.ca.gov

Allegation investigated: Staff did not ensure air conditioner was working properly.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to investigate the above allegation. LPA met with Erika Becerra and explained the purpose of today's visit. Shortly after Administrator Ana Giron arrived to assist with vist. The investigation consisted of the following: During initial visit on 7/15/24 LPA Alberto Lopez reviewed and obtained copy of staff and resident rosters. During todays subsequent visit LPA Tena Herrera obtained staff and resident rosters, interviewed 3 Staff and 8 Residents, toured facility along side of Erika Becerra and reviewed thermostats throughout facility to ensure temperature was within regulation. LPA toured a total of 7 Resident rooms and toured kitchen where food supply was inspected and the walk-in refrigerator and freezer were inspected. (Continued on LIC9099-C) Unsubstantiated The investigation revealed the following: Allegation: Staff did not ensure air conditioner was working properly. It is alleged that Resident #1's (R1) and several other residents air conditioners were not working, that it is very hot in R1's room, and that it is hotter in the dining area than it is outside. LPA toured a total of 7 resident rooms during todays inspection along with the common areas (dining, library, tv room) and all rooms had temperatures were within the required regulation, although the upstairs rooms did seem a bit warmer than downstairs, the thermostats read within the required regulation on facility temperature which is between 68-85 degrees. The rooms with the warmer temperature readings between 78-85 degrees were equipped with fans per the residents requests. Air conditioners on both floors seemed to be operable during visit and vents were giving cold/cool air. LPA toured the dining area and the thermostat within room read 82 degrees, there were fans that were operable and windows open, air conditioner was also observed to be blowing (at a low speed) cold air. Administrator confirmed that because of the recent heat wave they have the air-conditioning company do an early/additional service to ensure that all units are functioning properly and are scheduled to complete service tomorrow 9/11/24, air conditioning company visited facility on 9/9/24 to do pre-inspection for this service and stated that there is nothing broken and will be doing an early service on units 9/11/24. LPA interviewed 8 residents during todays visit and 7 out of 8 residents denied the above allegation and stated that it has not been hotter inside the facility compared to outside. Some residents stated it has been a little warmer than normal but it has not been intolerable, fans have been provided, cold water is being offered and hydration is being encouraged during these extreme heat conditions. All 8 residents interviewed also stated that they have not fallen ill do to being exposed to extreme heat conditions. LPA interviewed 4 staff and 4 out of 4 staff denied the above allegation and stated that the air conditioner has not been broken as of the past several months. Staff confirmed that there have not been any heat related illnesses and have been providing residents with accommodations such as ice cold water and fans during the most recent heat wave. Based on statements and interviews conducted with staff and residents, tour of facility and resident rooms, there was not enough supportive evidence to concur with the reported 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. Exit interview held, and a copy of this report was provided to Administrator Ana Giron.the state’s words, verbatim · CDSS document, Sep 10, 2024 · control 28-AS-20240711103447

Allegation investigated: Staff disguised non prescribed medications in residents’ food. Staff did not ensure medications were dispensed as prescribed. Staff did not ensure residents were spoken to in an appropriate manner. Staff did not ensure the facility was kept free of pests.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent visit to deliver findings on the above allegations. LPA met with Erika Becerra (Assistant Administrator/MedTech) and explained the purpose of today's visit. The investigation consisted of the following: During the initial visit conducted on 5/28/2024, LPA obtained copies of staff & resident rosters, LPA toured facility alongside of Erica Becerra, Medication Room (Med Room) was toured, LPA reviewed a total of 10 residents’ medications, a total of 7 bedrooms were toured, 3 on 1st floor and 4 on 2nd floor, bedding and mattresses were inspected. LPA interviewed 5 staff (S1-S5) and 10 residents (R1-R10). Due to time constraints, the above allegations needed further investigation. During todays visit LPA met with Erika Becerra, discussed above allegations and delivered findings. (Continued on LIC9099-C) Unsubstantiated The Investigation Revealed the Following: Allegation: Staff disguised non prescribed medications in residents’ food. It is alleged that staff were putting sleeping medication in the food to make the residents fall asleep, which caused some residents to feel symptoms of racing heart beats. LPA observed medication administration during the first round of afternoon lunch/medication at 11:45am, this was done in the dining area and all medication was dispensed in their own cups labeled for each resident and LPA reviewed medication with doctors’ orders and all seemed to be administered per doctors’ orders. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation. 2 of the 5 staff interviewed are Medication Technicians and are able to administer medications and both stated they have never given a resident medication that is not prescribed for them, they also stated that there are many residents who do take medication to help with sleep, but it is doctor ordered and prescribed to that individual. LPA interviewed 10 residents and 10 out of 10 residents denied the above allegation, some stated that they do take sleeping medication but that it has been prescribed to them by their doctor, all residents stated that medication administered to them are doctor ordered. Allegation: Staff did not ensure medications were dispensed as prescribed. It is alleged that the staff give the wrong medications to residents. LPA reviewed 10 residents’ medications in medication room, all were properly labeled in their designated areas, each residents medication were in their own cubbies that are labeled and had each residents photo, PRN medication was stored in a separate cabinet, also properly labeled and in original containers. LPA observed medication being administered at 11:45am with no issues. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation, 2 of the 5 staff were MedTechs and they stated that their medication process is very thorough and leave little to no room for errors, since the medication is securely stored and labeled very clear. LPA interviewed 10 residents and 10 out of 10 residents denied the above allegation. 7 out of 10 residents stated that they look at the medication before they consume it, residents stated their medications are always consistent, and they never have reason to question the medication. 3 out of the 10 residents interviewed stated that they once observed a questionable medication and brought it to the MedTechs attention, it was then determined that the medication was correct, their pharmacy had changed the color/shape of the medication which is what made them question it. (Continued on LIC9099-C) Allegation: Staff did not ensure residents were spoken to in an appropriate manner. It is alleged that the staff yell at the residents. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated they have never yelled at a resident, nor have they witnessed another staff yell at any of the residents. LPA interviewed 10 residents and 10 out of 10 residents denied the above allegation and stated that the staff are friendly and have never yelled at them nor have they observed staff yelling at any other resident. Allegation: Staff did not ensure the facility was kept free of pests. It is alleged that the facility had issues with bed bugs and scabies. LPA toured facility total of 7 bedrooms were entered, beds and linens were inspected and there was no evidence of bed bugs, all beds had plastic cover, mattress pad, sheets, blanket and comforter. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated that they have not had any observations of scabies or bedbugs within the facility. Staff also stated that they have not observed any scabies outbreaks or residents with scabies. 3 of the 5 staff interviewed work directly with the bedding and stated they have never observed any bed bugs on any of the linens or mattress when making beds or when changing the sheets for weekly cleaning. LPA interviewed 10 residents and 10 out of 10 residents denied the above allegation and stated that they have not observed any bed bugs and do not know of any issues with scabies in the facility. Based on statements and interviews conducted with staff and residents, a review of resident medications and tour of the facility, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Erika Becerra.the state’s words, verbatim · CDSS document, Jun 18, 2024 · control 28-AS-20240520150448

Allegation investigated: Staff did not meet resident's diapering needs in a timely manner. Hot water is not made available to residents in care. Staff does not ensure a comfortable temperature is maintained in resident rooms. Facility elevator is in disrepair.

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit for the above-mentioned allegations. LPA met with Lourdes Aguilar, Activities Director and explained the purpose of the visit. Shortly after, Erika Becerra, Med Tech met and assisted LPA with the investigation. Administrator, Ana Y. Giron also assisted LPA with the investigation who arrived later in the day. The investigation consisted of the following: During the initial visit on 01/04/2024, LPA Pena obtained copies of the staff roster, resident roster, and caregiver schedule. A physical plant tour of the facility with a focus on water temperature, temperature and elevator service was conducted. Between 11:45am-12:55pm, LPA conducted water temperature check on random residents’ rooms in the 1st and 2nd floors (Rooms: #3, #7, #12, #13, #17, #51, #56, #59, #64 and #81) and checked the temperature control systems. LPA tested the (1) elevator located next to the reception area. Between 1:30pm-3:00pm, interviews were conducted with Staff #1 (S1)-Staff #5 (S5) and Resident #1 (R1)- Resident #5 (R5). LPA requested the latest/2023 service reports for the elevator, hot water and air conditioning/heater. During today’s visit, LPA conducted a facility tour and tested the elevator once again. LPA obtained copies of the staff roster, resident roster, invoices and service reports for the elevator (E.K. Elevator Co.Dec 2023-Jan 2024), hot water (CCAG Hospitality dated 09/08/2023) and air conditioning/heater (AOL Heating & Air dated 08/11/2023). LPA continued with the interviews and interviewed Staff #6 (S6)-Staff #7 (S7), Resident #6 (R6)-Resident #10 (R10). *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: In regards to the allegation: “Staff did not meet resident's diapering needs in a timely manner.” It is alleged that a staff is usually left alone to care for 40 residents and residents had to be in soiled diapers for a long time because staff would be busy giving showers to other residents. Interviewed staff denied the allegation and stated that they have adequate staffing at this time. Staff stated that they do rounds every 2-3 hours per shift not only to change diapers for incontinent residents, but to check if residents are doing well or need other assistance. Documents reviewed indicated that there are 11 Caregivers on rotated schedules and 2 on call Caregivers staff. Document also showed 2 caregivers on duty per shift. S1 stated that if additional help is needed, she also helps and other staff like Housekeepers, Med Tech, Activities Director and Receptionist can also assist as they are all cross trained. Staff stated that there are 2-3 caregivers per shift, and a caregiver is assigned between 10-15 residents per shift, so the level of care are balanced and not one staff carries a heavy load. None of the staff interviewed complained about being overworked due to short staffing. 10 out of 10 residents interviewed denied the allegation. 5 out of 10 incontinent residents who were interviewed stated that staff assist them all the time in diaper changing and never left them in soiled diapers. Staff interviews, resident interviews and reviewed documentation do not corroborate this allegation. In regards to the allegation: “Hot water is not made available to residents in care.” It is alleged that the hot water for the residents is turned off and only turn it back on when licensing visits the facility. Interviewed staff denied the allegation that hot water is only turned on when licensing visits the facility. S1 stated that with their new hot water system, hot water is automatically shut down at midnight, and turn back on about 3am or 4am when no one is using it. 7 out of 7 staff interviewed stated that hot water is always available when they use it, and no one has complained about hot water issues lately. 10 out of 10 interviewed residents stated that hot water is available for their use all the time. Residents interviewed indicated that they do not have any issues or concerns with hot water. During the initial visit on 01/04/2024, LPA conducted water temperature check on random residents’ rooms in the 1st and 2nd floors (Rooms: #3, #7, #12, #13, #17, #51, #56, #59, #64 and #81). The hot water temperature measured within 105-120 deg. F which is within Title 22 regulations requirement. LPA also reviewed facility records indicating that the tankless water system was last serviced for cleaning and adjustment of water temperature in the kitchen on 09/08/2023. Documentation reviewed and interviews conducted do not corroborate this allegation. In regards to the allegation: “Staff does not ensure a comfortable temperature is maintained in resident rooms.” It is alleged that the resident rooms are really hot right now and staff refuses to turn the heater down or off. It is also alleged that the residents keep complaining to staff about being too hot in the rooms. Interviewed staff denied the allegation and stated that they keep a comfortable temperature for residents all the time. Staff indicated that if some residents feel cold, then they turn up the heat for them. And if some feel hot, they adjust it to their preference. S1 stated she did not receive any complaints about staff refusing to adjust the temperature. Interviewed residents stated that the temperature is comfortable in their rooms and have no issues or problems. Residents indicated that staff always adjust the temperature if they feel hot or cold. During the facility tour, LPA observed the temperature to be comfortable. LPA also checked the thermostat control system (Systems #1-#5) in different areas of the building. The thermostat showed temperatures in various residents rooms were between 70 deg F–76 deg F which is within Title 22 regulation. Documentation reviewed, observations and interviews conducted do not corroborate this allegation. In regards to the allegation: “Facility elevator is in disrepair.” It is alleged that the facility elevator is malfunctioning, and residents keep getting stuck in the elevator. It is also alleged that staff can pry open the elevator doors and help the residents to open the elevator. Interviewed staff denied the allegation and none of the staff know of anyone being stuck in the elevator. S1 stated that the elevator was not broken, but it is serviced monthly. Staff indicated that while elevator is being serviced, it will be out of service for approximately 30 minutes. Staff stated that residents are notified in writing and signs are posted in the common areas, including the elevator. Staff indicated that they also make an announcement prior to the elevator being out of service so residents have enough time to go up and down their rooms. 10 out of 10 residents interviewed stated that they never heard anyone being stuck in the elevator. Residents indicated that they hear the announcement if elevator is going to be out of service and have no issues with that. Residents also indicated that maintenance staff are quick to reset the elevator again, no more than half hour. LPA tested the elevator twice during the initial and subsequent visits and found that the elevator was operating properly at both times. Residents were also observed using the elevator. LPA reviewed documentation from E.K. Elevator Co. which indicated they visited the facility on 12/03/2023 for maintenance and the elevator was operating properly. Therefore, there is insufficient evidence to corroborate the allegation. Based on statements and interviews conducted with staff, residents, review of facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held and a copy of this report was provided to Ana Y. Giron, Administrator.the state’s words, verbatim · CDSS document, Feb 20, 2024 · control 28-AS-20231226115259

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent visit for annual continuation. LPA met with Erika Becerra, Med-Tech who assisted with the inspection. The initial required-1 yr inspection was conducted on 02/02/2024. During the initial visit, Ana Y. Giron, Administrator also assisted LPA with the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools today for the remaining domains and observed the following: Resident Rights-Information: Resident personal rights/non discrimination notice, complaint hotline information and visitors policy posters are posted in the lobby. Per Administrator, facility provides internet services to all residents and have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted in the hallway next to the TV room/Resident's lounge. Currently, the facility does not have a Resident Council. According to the Med Tech, after Covid, none of the residents are interested to join the council, but they will continue to encourage residents to form a council. Food Service: Sufficient food supply is stored in the kitchen consisting of: 2-day perishables, 7-day non-perishables. A separate pantry area stores the emergency food and incontinence supplies. Physician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Incident Medical and Dental: A total of ten (10) centrally stored resident medications were reviewed; containing 30-day supply of medications. Facility uses eMar called point-click to document residents medications. Most medications are bubble packed. A complete first aid kit is maintained in the medication room. Medical and dental transportation is provided. Resident Records/Incident Reports: A total of ten (10) resident files were reviewed. They contained Identification and Emergency Information, Admission Agreements, Physician's Reports, Pre Placement Appraisal, Resident Appraisal, Service and Needs Plans, Personal Rights, Residents Personal Property and Valuables, TB clearance, Functional Capability Assessment, and Medical Consent. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Residents with Special Health Needs: Eleven (11) residents are receiving home health services. Two (2) residents receive hospice care. LPA observed that there are 2 residents (R1/R2) under hospice care but CCL/Licensing was not notified in writing of the initiation of hospice care services. Per California Code of Regulations, Title 22, deficiency was cited and Technical Assistance issued. Exit interview conducted and a copy of the report and appeal rights were provided to Ana Y. Giron, Administrator.the state’s words, verbatim · CDSS document, Feb 3, 2024

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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Med Tech, Erika Becerra and Receptionist, Patricia Hernandez and explained the purpose of the visit. There are currently (66) residents, 60 years and older residing in the facility, of which (2) are under hospice care, no bedridden. Facility has approved hospice waiver for (5) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located at the reception area. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan is up to date. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has not been added to the Plan. Administrator agreed to update the Plan of Operation to include the Infection Control Plan. The facility does not have a Dementia Waiver in place. A maximum of (70) non-ambulatory residents may be in the facility. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 04/01/2024. Surety bond of $20,000.00 is current. Fire drill is conducted every (6) months and was last conducted on 01/08/2024. Physical Plant/Environment Safety: The facility is a 2-story building with a basement located in a residential community. The facility consists of: Basement: Laundry room, Staff lockers, (2) Housekeeping Supplies rooms, Elevator room, and Boiler room. First floor: Lobby/Reception area, Administrative offices, Medication room, (1) Elevator, Dining room, Board room, Kitchen, Pantry for emergency food supplies, Activity room, TV room/Resident lounge, PPEs Storage room, Courtyard/Smoking area, and (32) resident bedrooms. Second floor: (46) resident bedrooms, and Medical office. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. Between 11:00am-12:30pm, LPA inspected (12) random resident bedrooms and tested hot water temperature in rooms (Rooms #2, #12, #18, #24, #25, #28, #35, #40, #47, #64, #66 and #81) in the first & second floors. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Fire service inspection was conducted and total of (23) fire extinguishers were serviced/refilled on 01/09/2024 by DOR Fire Service Inc. LPA observed cameras in the common areas and hallways. Staffing: A total of (29) staff members provide care and supervision to the residents, including the Administrator. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records-Training: Seven (7) staff files were reviewed. Proof of staff training, health clearance, vaccinations, food handling certificates, and 1st Aid/CPR training are current. Administrator's certificate is valid and will expire on 10/20/2024. Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection. Exit interview conducted and a copy of this report was provided to Erika Becerra, Med Tech.the state’s words, verbatim · CDSS document, Feb 2, 2024

Allegation investigated: Staff did not provide resident with copies of admission paperwork. Staff denied resident from using their motorized wheelchair. Staff did not ensure resident had hot water for showers. Staff did not ensure residents room was free from pests. Staff did not ensure residents thermostat was working properly. Staff did not ensure residents plusg are working properly. Staff did not ensure residents motorized wheelchair stayed charged.

Licensing Program Analyst (LPA) Tena Herrera conducted a subsequent unannounced complaint visit to investigate the above allegations. LPA met with Receptionist Patricia Hernandez and explained the purpose of today's visit, Assistant Administrator Erika Becerra later assisted with the visit. The investigation consisted of the following: During initial visit conducted on 11/16/2022, LPA Glen Truman obtained resident/ staff roster and various documents from R1's file.LPA interviewed Administrator and R1, due to insufficient information at the time the allegations needed further investigation. During subsequent visit conducted 12/12/23, LPA Herrera obtained copies of the Staff and Resident Rosters, R1 Physician Report, R1 Signed House Rules, Monthly Pest Control Invoices (dated 9/2022 - 11/2022) and Repair Statement on Repairs Done in R1's room. LPA interviewed 4 Staff (S1 - S4), 9 Residents (R1 - R9) and toured facility. (Continued on 9099-C) Unsubstantiated The Investigation Revealed the Following: Allegation: Staff did not provide resident with copies of admission paperwork. It is alleged that staff were reluctant on providing copies of admission agreement and physician report to R1. Interviews with 4 Staff, 4 out of 4 staff denied the above allegation, 3 staff stated that R1 has asked for copies of paperwork and each time copies have been provided to them. Interviews with 9 Residents, 8 out of 9 residents denied the above allegation and stated that either they were provided copies of their admission paperwork upon admission or that they can't remember but feel confident that the staff will provide them with copies if they were to ask. R1 stated that as of now they do have copies of their admission paperwork and their physician report. Allegations: Staff denied resident from using their motorized wheelchair. Staff did not ensure residents motorized wheelchair stayed charged. It is alleged that staff does not allow R1 to use their motorized wheelchair and the location used to store the motorized wheelchair does not have an outlet to charge them, therefore, wheelchairs remain uncharged. LPA reviewed Facility House Rules (signed by R1) and within the house rules it does indicate that "Unless special arrangements have been made; electric wheelchairs and other personal motorized transportation equipment are not allowed in the facility". LPA reviewed R1's Physician Report and it does not indicate that R1 must use an electric wheelchair to ambulate. Interviews with 4 Staff, 4 out of 4 Staff deny the above allegation and state that R1 is able to use their electrical wheelchair and charging is done within R1's private bedroom. S4 stated that in the case that their is no room in a residents bedroom, residents are able to store and charge their electrical wheelchairs in the facility basement. LPA interviewed R1 in their bedroom and observed two electrical wheelchairs one that they were using and another stored in room, R1 indicated that they are able to use their electrical wheelchair in the facility. Interviews with 9 Residents, 8 out of 9 Residents deny the above allegation and stated that they have never been denied access to their medical equipment, including but not limited to wheelchairs. (Continued on 9099-C) Allegation: Staff did not ensure resident had hot water for showers. It is alleged that the water in R1's shower takes 7-8 minutes to get warm and the water temperature does not get hot. LPA toured facility and tested water temperature in 6 Resident Private Bathrooms all of which were within the required range of 105-120 Degrees F and LPA observed water to reach warm temperature within 1-2 minutes. Interviews with 4 Staff, 4 out of 4 Staff denied the above allegation and stated they have not heard of complaints on the water temperature. S1 stated that maybe in the early morning it may take a little longer than usual for water temperature to warm but it will heat up within 1-2 minutes. Interviews with 9 Residents, 8 out of 9 Residents deny the above allegation and stated that their bathrooms do receive hot water, and stated that early morning the water does tend to take a while to get warm but it takes no more 1-2 minutes. Allegation: Staff did not ensure residents room was free from pests. It is alleged that there are roaches and spiders in R1's room. LPA toured 6 Resident rooms and did not find any evidence of pests, roaches or insects in any of the rooms/restrooms. Interviews with 4 Staff, 4 out of 4 Staff denied the above allegation and stated they have not had any complaints of pests in resident rooms. Interviews with S1 and S4 indicated that R1 did mention to them that they had insects in their room but when toured they did not find evidence of any insects/roaches, both staff stated as a precaution there was a pest control service called in and provided LPA with invoices of pest service from dates 9/2022 - 11/2022. Both staff further indicated that there was a repair made to R1's door to close any gaps there may have been and provided LPA with Repair Statement. Interviews with 9 Residents, 7 out of 9 residents stated that they have never had any issues with roaches/insects or pests in their rooms. (Continued on 9099-C) Allegation: Staff did not ensure residents thermostat was working properly. It is alleged that the temperature in R1's room is not comfortable as it is either too hot or too cold in the room and the thermostat has incorrect readings. LPA toured facility and observed 5 thermostats (2 upstairs and 2 downstairs one in R1's room) each thermostat was within the required range, reading ranged from 69 degrees F - 77 degrees F. The thermostat in R1's room measured at 73 degrees F. Interviews with 4 Staff, 4 out of 4 staff denied the above allegation and stated that the temperature throughout the facility is maintained at a comfortable temperature and if a resident asks for the temperature to be raised or lowered they accommodate the resident. There are a total of 4 different air conditioner units that heat/cool different rooms. Interviews with 9 Residents, 8 out of 9 Residents denied the above allegation and stated that the temperature is comfortable throughout the facility. 2 out of 9 Residents stated they get cold easily and use a space heater instead of raising the temperature and making others uncomfortable. Allegation: Staff did not ensure residents plugs are working properly. It is alleged that there is a plug/outlet in R1's room that gets extremely hot when things are plugged into it. LPA toured R1's Room and outlets seem to be in working order, R1 stated that the outlet issue has since been resolved. LPA toured 6 Resident Bedrooms and all outlets in bedrooms were in working order. Interviews with 4 Staff, 4 out of 4 Staff stated they have not had any complaints on outlets not working. S1 and S4 stated that they do recall R1 mentioning the outlet within their room not working and a repair was made quickly. Interviews with 9 Residents, 8 out of 9 Residents deny the above allegation and stated that they have never had any issues with their outlets not working in their rooms. Based on statements and interviews conducted with staff and residents, and review of R1's files, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided to Erika Becerra.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 28-AS-20221109102338

Allegation investigated: Licensee is financially abusing former resident.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegation. LPA met with Receptionist Patricia Hernandez and explained the purpose of today's visit, Assistant Administrator Erika Becerra later assisted with the visit. The investigation consisted of the following: LPA obtained copies of staff & resident rosters, reviewed Residnet #1 (R1's) file and obtained the following copies from thier file: ID information, Physician Report, Resident Personal Property and Valuables Log, Admission Agreement, Notice of funds refunded to R1 on departure date, and R1's 30-day moving notice. LPA conducted interviews with R1, Administrator at R1's current residence (another licenced facility), and interviews with the 2 administration staff (S1 & S2) that handle payment at Counrty Inn of Downey. (Refer to LIC 9099C for the continuation of this report) Substantiated The investigation revealed the following: Allegation: Staff are financially abusing client. It is alleged that licensee has not forwarded payments that have been received for R1 from July 2023 - September 2023. LPA reviewed R1's file and observed 30-day notice was provided to facility on 5/13/23 and R1's departure date was 6/13/23. R1 also removed all belongings from facility on 6/13/23 and LPA obtained a copy of statement with signatures from R1 and administrator confirming belongings were removed. R1 was issued a partial refund for balance of rent and withdrew Personal and Incidental Money (PNI) funds in full on 6/13/23. Based on interviews with R1 and administrator at R1's new licensed facility, the new facility was not made payee to R1's Social Security Income (SSI) until mid October 2023, no payments were received prior to 10/13/23 to the new facility. Based on interview with Administrator Ana Giron, facility did received payments for R1 for months of July - September 2023. Administrator stated that no call was made to Social Security until August when Administrator became aware that SSI Money was still being deposited into corporate account. Administrator stated that while updating records in August is when she became aware of the deposits and July/August record reviews were conducted done together giving the reason for delay in calling Social Security Office. Administrator stated she did not inform SSI right away of residents departure from facility as resident stated they would take care of the switch and that their new facility will be handling all paperwork with Social Security. Administrator stated that she will be personally visiting the Social Security Office on Wednesday November 15, 2023 to provide a refund check in for the total amount deposited into the corporate account during months of July-September 2023 and Social Security will then be in charge of forwarding those payments to the new payee. Based on interview conducted with both Administrator and S2, when a resident departs from facility it is duty of administration to ensure that SSI becomes aware of switch to avoid continued payments to the licensee. Administrator stated in this case since R1 stated they would be taking care of the change no call was made to Social Security prior to August. The delay of monies returned to R1 or SSI and of urgency to contact SSI upon R1's departure from facility corroborates this allegation. Based on LPA's observation and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, title 22 are being cited on the attached LIC 9099D Exit interview conducted, appeal rights and a copy of this report was provided to Victor Ortiz.the state’s words, verbatim · CDSS document, Nov 9, 2023 · control 28-AS-20231103125227

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(i) · Plan of correction due date: Nov 23, 2023

Safeguards for Resident Cash, Personal Property, and Valuables (i) Upon discharge of a resident, all cash resources, personal property and valuables of that resident which have been entrusted to the licensee shall be surrendered to the resident, or his responsible person. A signed receipt shall be obtained. This standard is not met as evidence by: Per interview with Administrator Ana Giron facility continued to receive payments after R1's departure, payments were received for months July-Sept 2023. Administrator did not notify SSI of departure until August. The delay of monies returned to R1 or SSI and of urgency to contact SSI upon R1's departure from facility corroborates this allegation.the state’s words, verbatim · CDSS document, Nov 9, 2023

Plan of correction: Administrator stated that she will personally refund total amount deposited into the corporate account during months of July-September 2023 on Wednesday November 15, 2023 and Social Security will then take charge of forwarding payments to the new payee. Proof to be submitted to LPA via email by POC due date.

Allegation investigated: Staff failed to meet resident's hygiene needs Staff failed to safeguard resident's personal belongings Staff leave resident in wet saturated clothes for extended periods of time Staff are not taking precautions for COVID-19

On 10/31/23 at 9:43 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted a subsequent unannounced complaint visit regarding the above listed allegations. Upon arrival LPA met with the Med-Tech Ericka Becerra and explained the purpose of the visit. Administrator Ana Giron arrived at 11:34 and LPA explained the reason for the visit. During the initial complaint, LPA was asked to check temperature and fill out a COVID questionnaire. LPA toured the facility with assistant administrator and observed all staff wearing a mask. LPA also observed the facilities Isolation zones in preparation for COVID. LPA toured R1’s bedroom. LPA obtained staff roster, resident roster, Infection control plan, 1 week of incontinence log, R1’s physicians report, R1’s Identification and Emergency information and photo of R1 clothing. Report cointinued 9099c Unsubstantiated During today’s visit LPA obtained the staff roster, resident roster, theft and loss policy, and interviewed seven (7) Residents who shall be referred to as R2 through R8. R1 moved out of the facility on 3/31/2022 and passed away on 4/11/2022. LPA also interviewed the administrator and four (4) staff who shall be referred to as S1 through S4. The investigation reveals the following: Regarding “Staff failed to meet resident’s hygiene needs”. It is alleged that the facility left R1 unkept. The administrator Ana Giron denied the allegation stating all residents are cleaned and R1 was challenging but the facility persisted and assisted with keeping R1 neat clothing. 4 out of 4 staff stated that R1 was clean and had tiny holes due to R1 smoking. Whenever R1 made holes in his clothing, the facility looked for clothing to make sure he was clean. 5 out of 7 residents denied the allegation stating the facility took care of R1’s hygiene needs and R1 was combative. 2 out of 7 residents stated they do not remember R1, but the facility takes care of their hygiene needs. LPA reviewed R1’s incontinent logs dated 11-23-2022 through 11-28-2022 and confirmed R1 was changed three (3) times during the morning shift and three (3) times during the evening shift. The investigation reveals the following: Regarding “Staff failed to safeguard resident’s personal belongings”. It is alleged that R1 was missing personal items. The administrator Ana Giron denied the allegation stating R1 was not missing items while living at the facility. 4 out of 4 staff stated that R1 was not missing items and has never complained to them about missing items. 6 out of 7 residents denied the allegation stating they are not missing items and has not heard other residents complained about missing items. 1 out of 7 residents stated they have been missing items and the issue has not been resolved. The investigation reveals the following: Regarding “Staff leave resident in wet saturated clothes for extended periods of time”. It is alleged that the facility leaves R1 unattended in wet saturated clothing. The administrator Ana Giron denied the allegation stating all residents are cleaned and R1 was challenging but the facility persisted and assisted with keeping R1 clean. 4 out of 4 staff stated none of their residents has been left in wet or saturated clothing. 5 out of 7 residents denied the allegation stating they have never seen residents in wet clothing. 2 out of 7 residents stated they do not remember R1, but staff took residents to their rooms to get changed if they saw residents were incontinent. The investigation reveals the following: Regarding “Staff are not taking precautions for COVD-19”. It is alleged that facility staff was not wearing masks and people were in an out of the facility without taking precautions. The administrator Ana Giron denied the allegation stating the facility followed COVD-19 protocols. 4 out of 4 staff stated the facility followed COVID protocols. 7 out of 7 residents denied the allegation stating the facility was following COVD-19 protocols. Based on LPA's interviews, investigation revealed: 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. Exit interview conducted with Ana Giron and a copy of this record provided.the state’s words, verbatim · CDSS document, Oct 31, 2023 · control 28-AS-20221121155057

Allegation investigated: Facility did not safeguard resident's personal property Administrator did not give accorded dignity in her personal relationships with resident

Licensing Program Analyst (LPA) Alberto Lopez conducted a subsequent complaint investigation for the allegation listed above. LPA arrived unannounced and met with Staff, Erica Beccera, Med Tech. The purpose of the visit was explained. The administrator, Ana Giron, arrived a short time later to assist with the visit. Initial visit was on 09/06/2022 The investigation consisted of the following: LPA obtained copies of the staff and resident rosters, R1 Inventory list at moveout, Interviews were held with 5 Staff S#1-S#5 (S1-S5) including Administrator, and 8 Residents R#1-#8 (R1-R8) The investigation revealed the following: (Continued on 9099C) Unsubstantiated The investigation revealed the following: Allegation: Facility did not safeguard resident's personal property. It is alleged that staff failed to return a wheelchair when resident moved out on June 24, 2021. LPA interviewed Staff and Residents regarding this allegation. Per Administrator, R1 had a moving van arrive at the facility around 12:34 PM on June 24th, 2021, and R1 could not fit the second wheelchair in the van. R1 stated they would return to pick it up the wheel chair later. R1 returned at 4:30 that same day and took the 2nd wheelchair. R1 signed the inventory list acknowledging R1 had taken all R1's property and personal belongings, including both wheelchairs. LPA interviewed 5 staff and 5 of 5 staff denied the allegations. LPA interviewed 8 residents and 7 of 8 residents could not collaborate the allegations and all 7 of them stated they have never lost or had missing personal property. LPA did not find any evidence that the facility failed to give R1 all of their property. Allegation: Administrator did not give accorded dignity in her personal relationships with resident. It is alleged that Administrator ignored R1 when inquiring about his wheelchair and threaten to call the police on him. LPA interviewed 5 staff including Administrator and 5 of 5 staff denied the allegations. LPA interviewed 8 residents and 7 of 8 residents could not collaborate the allegations. Several residents stated that Administrator is very kind and have never witness her been inappropriate with anyone. Some residents stated she is very kind with everyone. LPA could not find collaborating evidence to substantiate 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 observed or cited during the visit. An exit interview was conducted with administrator Ana Giron and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 31, 2023 · control 28-AS-20220829094205