Crescendo Senior Living

Allegation investigated: Lack of care and supervision resulting in resident sustaining multiple falls

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Wellness Director (WD) Alex Gutierrez and explained the purpose of the inspection. Complaint alleges Lack of care and supervision resulting in Resident 1 (R1) sustaining multiple falls. During the course of the investigation, LPA obtained a copy of Incident Report (LIC624) which indicated that on February 20, 2026, R1 was found on the floor in a seated position next to their bed with R1 indicating they slid from their wheelchair; no injuries were reported or observed. LIC624 identifies S1 as the person who observed the incident. S1 was interviewed and stated they could not recall specific details regarding the incident and were unsure how long R1 had been on the floor prior to being found. (Cont. LIC9099-C) Unsubstantiated LPA obtained a copy of a separate LIC624, which indicated that on March 2, 2026, R1 had been found on the floor by Staff 2 (S2). R1 was unresponsive and pale, however, no signs of any injuries were observed. 911 was called and R1 was transported to the hospital. S2 was interviewed and stated that at the time of the incident they were doing physical rounds and check-in on residents, when they found R1 on their bedroom floor. Per S2, they were unsure how long R1 had been on the floor prior to being found and stated R1 was initially unresponsive. S2 stated they called 911 and by the time paramedics arrived R1 was speaking and stated they had slid down their bed. Per S2, R1 had not sustained any injuries, however, they had made the decision to call 911 for further evaluation as R1 was not at baseline. During interview, R1’s responsible party, Witness 1 (W1), stated they were unable to recall the exact dates and times but estimated R1 sustained approximately “three or four” falls while residing at the facility. W1 denied the falls were a result of lack of care and supervision and stated, “it didn’t appear and it does not appear to be an issue with staff.” Per W1, R1 was relocated to a skilled nursing facility not only due to falls, but due to increasing physical and medical needs. LPA attempted to interview R1, however, a phone number where they could be reached was not available. Based on information gathered, the Department did not find sufficient evidence to support the allegations, “Lack of care and supervision resulting in resident sustaining multiple falls”. 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 above allegation is Unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 22-AS-20260312162646

Allegation investigated: Facility locked resident inside a room.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Wellness Director (WD) Alex Gutierrez and explained the purpose of the inspection. Complaint alleges Facility locked Resident 1 (R1) inside their room. During the course of the investigation, LPA conducted a tour of the facility and observed resident room doors automatically lock from the outside, however, they remain unlocked from the inside, regardless of the positioning of the locking mechanism on the doorknob, and residents are able to open their bedroom doors by simply turning the doorknob. Interviews were conducted with seven facility residents, three staff, and one witness. Five of seven residents interviewed denied being locked inside their room and denied having any knowledge of any resident being locked inside their room. Two of seven residents were unable to confirm or deny allegation. (Cont. LIC9099-C) Unsubstantiated Per three of three staff interviewed, the locking mechanism on resident room doors is meant to protect residents’ privacy and safeguard personal belongings and is not designed to lock residents in. Three of three staff denied witnessing or having any knowledge of any resident being locked inside their room. During interview, R1’s responsible party, Witness 1 (W1), stated they spent the night at the facility with R1 for six weeks and did not observe R1 or any other resident being locked inside their room. W1 denied ever witnessing R1's doorknob being placed on backwards to lock R1 inside their room. LPA attempted to interview R1, however, R1 no longer resides at the facility and a phone number where they could be reached was not available. Based on information gathered, the Department did not find sufficient evidence to support the allegation, “Facility locked resident inside a room”. 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 above allegation is Unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 22-AS-20260514112026

Allegation investigated: Lack of care and supervision resulted in resident being hit by another resident

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above. LPA met with Wellness Director (WD) Alex Gutierrez. Complaint alleges lack of care and supervision resulted in Resident 1 (R1) being hit by another resident. On July 29, 2026, the Department received an incident report from the facility indicating that on July 28, 2026 at approximately 5:40 p.m., staff responded to screaming coming from the first-floor communal restroom in memory care and observed R2 standing in front of R1, with R2 indicating that R1 had pushed them first and they pushed them back. During the course of the investigation, interviews were conducted with two residents, two staff, and one witness. One of two staff interviewed stated R1 often wanders the facility, looking for open doors and stated that at the time of the incident R2 had been using the restroom, when R1 walked in, leading to R2 pushing R1 onto the floor. (Cont. LIC9099-C) Unsubstantiated Per two of two staff interviewed, staff response time was immediate upon hearing the screams. During interview, R1 was unable to confirm or deny the allegation. During interview, R2 denied hitting R1 and stated R1 had hit them as they were attempting to exit the restroom. R2 was unable to confirm or deny if staff were present at the time or what their response time was following the incident. During interview, R1’s responsible party, Witness 1 (W1) stated they were aware R1 had been hit by another resident while both residents were in the restroom, however, stated they did not believe it was as a result of lack of care and supervision due to R1 and other residents being able to use the restroom independently, and stated facility staff are “usually on top of it.” W1 denied having any concerns pertaining to the care or supervision at the facility. Based on information gathered, the Department did not find sufficient evidence to support the allegations, “Lack of care and supervision resulted in resident being hit by another resident”. 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 above allegation is Unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Aug 10, 2026 · control 22-AS-20260731143612

Allegation investigated: Staff does not ensure facility plumbing is in good repair.

An unannounced Complaint Investigation was conducted on this day regarding the allegation mentioned above by Licensing Program Analyst (LPA) Claudia Gutierrez. LPA met with Executive Director (ED) Laurie Galal and the purpose of the inspection was discussed. Interviews were conducted with eight facility residents and four staff. During their interview, Resident (R1) stated they have had plumbing issues on and off during the entire time they have been residing at the facility, approximately five years. Per R1, in January 2026, the floor in their bedroom and bathroom became flooded and they were informed the leak was coming from Resident 2’s (R2’s) and Resident 3’s (R3’s) bathroom. R1 stated they were hospitalized in February 2026 and a dry washcloth was placed next to their bathroom sink and it should have been dry as no one should have been using the sink in their bathroom, however, the washcloth was wet. Per R1, Resident 4 (R4) and Resident 5 (R5) have also had plumbing issues, as well as Resident 6 (R6), however, R6 recently passed away and could not be interviewed. (Cont. LIC9099-C) Unsubstantiated During their interview, Resident 2 (R2) denied personally having any plumbing issues in their room and was unable to confirm or deny if any other residents have had plumbing issues. Resident 3 (R3) denied having any plumbing issues and stated they were unaware if any other residents have had plumbing issues. During their interview, R4 stated their room became flooded after a pipe in R5’s room burst approximately three months, however, stated they have not had any plumbing issues since. During their interview, R5 was unable to confirm or deny if they have had any plumbing issues or if the pipe in their room burst. Three additional facility residents were interviewed and denied personally having any plumbing issues and denied having any knowledge of any other resident having plumbing issues. During the course of the investigation, LPA did not observe any plumbing issues at the facility and observed resident bathroom and bedroom floors to be free of any liquids, fluids, or puddles. During their interview, two of four staff interviewed denied having any knowledge of any plumbing issues at the facility. During their interview, Staff 3 (S3) denied a pipe bursting in any resident’s room and denied the facility having any chronic or recurring plumbing issue. S3 stated although residents’ toilets do occasionally clog, due to large wipes down being flushed the toilet, the toilets are unclogged immediately by Staff 4 (S4). During their interview, S4 denied a pipe bursting in any resident’s room and denied the facility having any chronic or recurring plumbing issue. Per S4, residents’ toilets do clog occasionally, due to large wipes down being flushed the toilet, however, stated the toilets are immediately unclogged by them personally or a professional plumber, in the event they are unable to unclog the toilet themselves. Due to the allegation being uncorroborated during interviews conducted, the Department is unable to determine if Staff does not ensure facility plumbing is in good repair. Although the above 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 at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Mar 11, 2026 · control 22-AS-20260303085841

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint investigation #22-AS-20260224164536. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA reviewed training records for Staff 1 (S1). S1 does not have required training hours. Based on observations made during today’s inspection, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was provided.the state’s words, verbatim · CDSS document, Mar 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c) · Plan of correction due date: Mar 16, 2026

Licensees shall maintain in the personnel records verification of required staff training and orientation. This req is not met as evidenced by: Based on record review, Licensee failed to ensure S1 had required annual training, This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 2, 2026

Plan of correction: Licensee to conduct training and forward proof to LPA by POC due date.

Allegation investigated: Staff is mismanaging resident's medications. Staff does not provide adequate supervision resulting in resident sustaining multiple falls.

On February 23, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to initiate the investigation into the allegations listed above and to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Director of Wellness Alex Gutierrez was notified via telephone and later arrived to assist with the inspection. During the course of the investigation, LPA conducted resident interviews, staff interviews, reviewed medication and medication administration records, reviewed and collected pertinent documents for this complaint. Regarding the allegation, staff is mismanaging resident's medications, the following has been concluded: It was alleged that staff are mismanaging Resident #1 (R1) medication. LPA reviewed the medications, the prescribed orders, and the medication administration records for R1. LPA observed that staff were providing the routine medications to R1 according to his prescribed orders, as per regulations. However, LPA observed the facility did not physically have R1's prescribed Hydroxyzine Pam 50 MG medication and Systane Balance 0.6% eye drops, which are as needed medications. CONTINUED ON LIC9099-C Substantiated LPA observed that R1's Hydroxyzine Pam 50 MG medication was prescribed on January 29, 2026. LPA observed that R1's Systane Balance 0.6% eye drops were prescribed on December 12, 2025. LPA reviewed R1's medication orders as of February 23, 2026, which confirmed both medications still had active orders. Two staff present during the visit confirmed the facility did not have R1's prescribed Hydroxyzine Pam 50 MG medication or his Systane Balance 0.6% eye drops physically present, or available to R1 if they were needed. Additionally, LPA observed the facility did not have discontinue orders on file for these two as needed medications for R1, and therefore, these medications should be available at the facility. LPA attempted to conduct an interview with R1, however, R1 was unable to be qualified for an interview. LPA attempted to conduct an additional five resident interviews. However, none of the residents were able to be qualified for an interview. Regarding the allegation, staff does not provide adequate supervision resulting in resident sustaining multiple falls, the following has been concluded: It was alleged that staff does not provide adequate supervision resulting in R1 sustaining multiple falls. LPA reviewed R1's records. LPA observed that R1 was admitted to the facility on December 12, 2025. LPA reviewed R1's resident assessment dated November 15, 2025, which states that R1 is a fall concern. LPA reviewed R1's patient visit summary dated February 13, 2026, which stated that R1 has a history of repeated falls, and is an increased risk for falls due to confusion, muscle weakness, and immobility. LPA observed that R1 has sustained four documented falls while at the facility, including on February 8, February 10, and twice on February 12, 2026. LPA observed that the fall R1 sustained on February 8, 2026, required R1 to be sent out to the hospital due to multiple skin lacerations, as well as R1 refusing first aid treatment from staff. LPA observed the three other falls did not require R1 to be sent to the hospital, however, R1 sustained skin tears as a result of the falls. LPA conducted four staff interviews. Four out of the four staff interviewed confirmed R1 has sustained multiple falls while at the facility. LPA observed that there are no re-assessments on file for R1, despite having four documented fall at the facility, to determine if there was a change in condition or if more supervision is necessary. Furthermore, there are no documented fall prevention techniques in place despite R1 having four documents falls at the facility between February 8, and February 12, 2026. Based on the evidence gathered during this investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited on the attached LIC9099-D. An exit interview was conducted with Director of Wellness Alex Gutierrez. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 22-AS-20260218185737

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(b) · Plan of correction due date: Mar 6, 2026

87465 Incidental Medical and Dental Care: (b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a .. nonprescription PRN medication, facility staff shall be permitted to assist the resident.. This requirement was not evidenced by: Based on records reviewed and interviews conducted, the Licensee did not ensure that all presribed PRN medications were present at the facility, and available to Resident #1 if needed. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: The Director of Wellness stated that he will order the two PRN medications for Resident #1, or obtain discontinue orders for those medications. The Director of Wellness agreed to provide LPA proof that the PRN medications are at the facility, or dicontinued, via email or fax by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Mar 6, 2026

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not evidenced by: Based on records reviewed and interviews conducted, the Licensee did not ensure that Resident #1 has sufficient supervision, or a sufficent care plan, to address his frequent falls at the facility. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: The Director of Wellness stated that he will create a care plan for Resident #1 to address his frequent falls. The Director of Wellness agreed to provide LPA the care plan for Resident #1 via email or fax by POC date.

Allegation investigated: Staff are discriminating against a resident. Staff are not allowing resident to participate in activities.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to investigation the above identified complaint allegations and deliver findings. LPA Martinez met with Laurie Galal, Executive Director and explained the purpose of the visit. During the course of the investigation, interviews were conducted, a tour of the physical plant of the facility was conducted, a review of facility records was completed and copy of pertinent documents obtained. It is alleged that staff are discriminating against a resident, specifically being told they cannot speak Spanish at the premises. Interview with staff stated that they do not tell residents what language to speak, there are staff that speak various languages and can communicate with residents without a problem. The facility has various residents that their primary language isn’t English, and they do not interfere with their Continued on LIC9099-C Unsubstantiated preference of what to speak. Interview with 9 of 9 residents stated that they have never been told that they can’t speak another language at the facility. They speak the language they want when communicating with others. There are staff at the facility that speak other languages and can accommodate them when needed. It is alleged that staff are not allowing resident to participate in activities, specifically being told that resident (R1) is not allowed in any activities where they speak English. Interview with R1 stated that they do not recall that they were told they could not do activities. They do activities all the time and when needed staff help them on a 1 to 1 basis. When I do not participate in activities, I do other things here at the facility because there is a lot to do here. Interview with 2 of 2 staff stated that they do not tell residents when they can or can’t do activities because all residents are welcome to do activities when they want to. The activities calendar is posted and also printed out and available for residents to see what activities are for that day and time. Staff stated that various residents did complain that when doing Bingo, it would take longer because it was being translated in Spanish only when there are other residents that speak other languages other than Spanish. As a solution the facility has purchased a rolling TV as well as a Bingo application to display the bingo numbers largely for all residents to see. Where it no longer required for staff to say the number out loud in any language other than English. Interview with 8 of 8 residents stated that they have not been told they can’t participate in the activities regardless of their primary language. They have not had issues with doing activities. LPA toured the physical plant of the facility and observed a large posting of the activities calendar throughout the facility as well as printed copies available for residents to take with them. Based on the information mentioned above, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted with the Executive Director and a copy of this LIC9099 report was left at facility.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 22-AS-20260126142017

Allegation investigated: Facility did not accept resident back after hospital stay.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez. LPA met with Executive Director (ED) Laurie Galal and explained the purpose of the inspection. Complaint alleges Facility did not accept Resident 1 (R1) back after their hospital stay. On December 16, 2025, R1 was hospitalized and placed on a psychiatric hold. On December 22, 2025, the Department received a request for prior approval of 3-Day eviction of R1 from the facility. On December 24, 2025, the Department denied the facility’s request, and Wellness Director (WD) Kim Mims was notified of the Department’s decision by phone. Denial letter was also sent via certified mailed to Licensee’s mailing address. (Cont. LIC9099-C) Substantiated On today's date, LPA conducted an interview with ED, who indicated WD had informed them of the Department’s decision, however, R1 has not been accepted back to the facility and remains at the hospital due to Licensee refusing to accept R1 back to facility following their hospital stay. Based on interviews and records review, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was provided at the end today's inspection.the state’s words, verbatim · CDSS document, Dec 26, 2025 · control 22-AS-20251223164221

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a)(4) · Plan of correction due date: Dec 27, 2025

(a) The licensee may evict a resident... Thirty (30) days written notice to the resident is required... (4)... it is determined that the resident has a need not previously identified... and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement is not met as evidenced by: Based on interviews and records review, the Licensee did comply with section cited above as R1 has not been issued a 30-day eviction notice and has not been accepted back to the facility following their hospital stay.the state’s words, verbatim · CDSS document, Dec 26, 2025

Plan of correction: R1 will be immediately accpeted back to the facility and will be issued a 30-day eviction notice.

Allegation investigated: Staff handled resident roughly

An unannounced complaint investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above. LPA met with Executive Director (ED) Laurie Galal and discussed the purpose of the inspection. Regarding the allegation, Staff handled resident roughly, the following was revealed: it is alleged (Staff 1) S1 grabbed Resident 1 (R1) and had them "dangling" for about five to seven minutes. Interviews were conducted with R1, four additional facility residents, S1, and two additional staff. During their interview, R1 corroborated the allegation and stated S1 handled them in a rough manner while assisting them with Activities of Daily Living (ADLs). Per R1, S1 lifted them up in a rough manner using their arms, however, was unable to go into further detail or indicate if S1's actions led to an injury. During their interview, four of four additional residents interviewed denied being handled in a rough manner and denied having any knowledge of staff handling any resident, including R1, in a rough manner. (Cont. LIC9099-C) Unsubstantiated During their interview, S1 denied the allegation and stated they are never alone with R1 as it takes at least four care staff to assist R1 with ADLs, and they would be physically unable to lift R1 independently due to R1’s weight. Per R1’s Physician Report (LIC602A), R1’s weight is 335 lbs and R1 requires assistance with repositioning and transferring. During their interview, S2 stated R1 had informed them S1 had handled them in a rough manner by cradling them and lifting them up in the air. Per S2, they were unsure how the events had unfolded, but stated they were unsure S1 would be able to lift R1 as described, due R1’s weight. During their interview, S3 stated R1 had informed several staff members that S1 had lifted them by the head and neck area and swung R1 around for 10 to 15 minutes. Per S3, due to R1's size and weight, all care staff present on shift are necessary to assist R1 with ADLs, and they were unsure of how S1 would have been able to lift or swing R1 by the head and neck. Due to the allegation being uncorroborated during interviews conducted, the Department is unable to determine if Staff handled resident roughly. Although the above 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 at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 22-AS-20251211114703

Allegation investigated: Staff did not ensure resident received medication as prescribed. Resident sustained unexplained bruising while in care. Staff did not provide adequate supervision resulting in resident sustaining multiple falls. Staff did not notify resident's responsible party of change in resident's condition. Staff did not safe guard resident's personal belongings.

An unannounced complaint investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegations mentioned above. LPA met with Executive Director (ED) Laurie Galal and discussed the purpose of the inspection. Regarding the allegation, Staff did not ensure resident received medication as prescribed, the following was revealed: it is alleged Resident 1 (R1) did receive a routine medication from January 05, 2025 to January 12, 2025 due to facility staff not refilling the medication. During the course of the investigation, LPA conducted record review of R1’s Medication Administration Records (MARs) and observed routine medication in question to have been administered every day for the month of January 2025. During their interview, R1 was unable to confirm or deny allegation. LPA attempted to contact R1’s responsible party, Witness 1 (W1) on three separate occasions, however, W1 could not be reached to confirm or deny allegation. LPA conducted interviews with five additional residents. Three of five residents stated they manage their own medication and were unsure if staff ensure other residents receive medication as prescribed. (Cont. LIC9099-C) Unsubstantiated Two of five additional residents were unable to confirm or deny allegation. Regarding the allegation, Resident sustained unexplained bruising while in care, the following was revealed: it is alleged R1 sustained unexplained bruising. Per Incident Report (LIC624), on February 10, 2025 at 2:40 a.m., R1 stood up and threw themselves on the floor hitting their head on their wheelchair in the process. Per Narrative Charting for R1 dated February 10, 2025, paramedics were called and upon R1’s return from the hospital, R1’s responsible party, W1 observed bruising on R1’s right forearm. The Department obtained pictures of the bruising on R1’s forearm, which was observed to be round in shape and approximately the size of a quarter. LPA attempted to contact W1 on three separate occasions, however, W1 could not be reached to confirm or deny allegation. During their interview, R1 denied the allegation and pulled their shirt back by the neck and pointed to a scab the size of a thumbtack right below their neck. R1 stated the scab was from thousands of mosquitos and does not go away because they scratch it, and the scab comes off but it always comes back. During their interview, R2 stated they had sustained a bruise and pointed to a round, quarter size spot of discoloration on their forearm. Per R2, the bruising was from the hospital, when they attempted to insert an IV. LPA observed discoloration on R2’s forearm to be consist in size and shape as that of R1’s bruising. Interviews were conducted with four additional facility residents. One of four residents was unable to confirm or deny allegation and three of four residents denied sustaining unexplained bruising or having any knowledge of any other resident sustaining unexplained bruising. Regarding the allegation, Staff did not provide adequate supervision resulting in resident sustaining multiple falls, the following was revealed: it is alleged staff did not provide adequate supervision resulting in R1 sustaining multiple falls. During the course of the investigation, LPA conducted record review of Incident Reports (LIC624) submitted by the facility to Community Care Licensing (CCL), and observed four incidents in which it was reported R1 sustained a fall from December 3, 2024 to February 10, 2025, with two of the incidents taking place on the same date, February 10, 2025. Per Narrative Charting for R1 dated December 3, 2025, R1 as found on the floor in a sitting position and noted redness on one side of R1’s back with no other visible injuries. R1 was monitored through the shift and observed to be doing well. On December 20, 2024, R1 was found on the floor right next to their wheelchair. Redness was observed to R1’s back toward the upper side. R1 reported pain to the touch on the redness on their back and a PRN for pain was administered. On February 10, 2025, at 2:40 a.m., R1 stood up and threw themselves on the floor hitting their head on their wheelchair in the process, paramedics were called and R1 was transported to the hospital. (Cont. LIC9099-C) R1 returned from the hospital on the same date and later that night, R1 was found on the floor and bruising was observed to R1’s right upper arm and R1’s responsible party was notified. LPA attempted to contact W1 on three separate occasions, however, W1 could not be reached to confirm or deny allegation. During their interview, R1 denied sustaining a fall at the facility. Regarding the allegation, Staff did not notify resident's responsible party of change in resident's condition, the following was revealed: it is alleged staff did not notify R1’s responsible party of R1’s change in condition. During the course of the investigation, LPA conducted record review of Incident Reports (LIC624) submitted by the facility to CCL, and reviewed facility Narrative Charting for R1 and observed R1’s responsible party was notified following all incidents involving R1. LPA attempted to contact W1 on three separate occasions, however, W1 could not be reached to confirm or deny allegation. During their interview, R1 was unable to confirm or deny allegation. Interviews were conducted with five additional facility residents. One of five residents was unable to confirm or deny the allegation and four of five residents stated their responsible party is notified of any changes in their condition. Regarding the allegation, Staff did not safeguard resident's personal belongings, the following was revealed: it is alleged staff did not safeguard R1’s hearing aids. During the course of the investigation, interviews were conducted with R1, five additional facility residents and three staff. During their interview, R1 stated their hearing aids are stolen, and they are given "junk" and then the "junk" gets stolen. R1 identified “the neighbor of the guy that orders [their] hearing aids” as the individual stealing the hearing aids. LPA attempted to contact W1 on three separate occasions, however, W1 could not be reached to confirm or deny allegation. During their interview, R2 stated they had cash go missing in the last day or two, however, stated they had yet to report the missing cash to facility staff. During their interview, R3 denied having any personal belongings stolen or missing, however, did recall R1 would often misplace their hearing aids and staff would assist them in locating them. Per R3, R1’s hearing aids would frequently be found in R1’s pocket or amongst R1’s personally belongings. Two of three additional residents interviewed were unable to confirm or deny the allegation, and one of three residents denied having any personal belongings stolen or missing. Three of three staff interviewed stated R1 would frequently remove their hearing aids and misplace them, however the hearing aids would eventually be located amongst R1’s personal belongings or in their laundry basket. (Cont. LIC9099-C) Based on record review of R1’s Narrative Charting, LIC624s, and MARs, and due to the allegations being uncorroborated during interviews conducted, the Department is unable to determine if Staff did not ensure resident received medication as prescribed, if Resident sustained unexplained bruising while in care, if Staff did not provide adequate supervision resulting in resident sustaining multiple falls, if Staff did not notify resident's responsible party of change in resident's condition, or if Staff did not safe guard resident's personal belongings. Although the above 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 at this time the above allegations are unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 22-AS-20250226154531

Allegation investigated: Staff does not ensure facility plumbing is in good repair.

An unannounced Complaint Investigation was conducted on this day regarding the allegation mentioned above by Licensing Program Analyst (LPA) Claudia Gutierrez. LPA met with Executive Director (ED) Laurie Galal and Wellness Director (WD) Kim Mims Interviews were conducted with four facility residents regarding the allegation, Staff does not ensure facility plumbing is in good repair. During their interview, Resident (R1) denied the allegation. During their interview, Resident 2 (R2) denied having any plumbing issues in their private bathroom, however, stated that Resident 3 (R3) has had plumbing issues due to their toilet being clogged and stated they believed R3 was flushing large wipes down the toilet. During their Resident 3 (R3) stated their toilet had been clogged but was immediately repaired by maintenance staff with no impact to their living accommodations. During their interview, R4 denied having any plumbing issues pertaining to their private bathroom, however, stated that R3's toilet had been clogged due to R3 flushing large wipes down the toilet. During the course of the investigation, LPA did not oobserve any plumbing issues at the facility. (Cont. LIC9099-C) Unsubstantiated R2 stated their bedroom carpet became so saturated that their feet became submerged completely upon stepping on the carpet. Per R2, the carpet was cleaned by maintenance staff however, was not thoroughly cleaned or disinfected, as waste water debris remains on the carpet and hallway baseboards. R2 continues residing in the same bedroom which was flooded. During their interview, Resident 3 (R3) confirmed that their toilet had clogged but had only caused a puddle in their room. Per R3, R2’s room, however, did flood and were unsure how extensive the flooding had been in R2’s room. During their interview, Resident 4 (R4) also stated R2’s bedroom had flooded with waste water from R3’s toilet. Per R4, carpet in R2's room was cleaned by maintenance staff however, was not thoroughly cleaned or disinfected as debris from the waste water remained on the hallway baseboard and R2’s carpet. During the course of the investigation, LPA observed waste water residue on R2’s carpet and hallway baseboard. Interviews were conducted with four facility residents regarding the allegation, Staff did not answer resident's requests in a timely manner. During their interview, R1 stated that upon being moved to another bedroom, facility maintenance staff assisted with moving their large furniture, however, were not responsive to other aspects of the move, including providing them with a chair. During their interview, R2 stated that upon their bedroom flooding with waste water on the second occasion during the week of November 17th, 2025, the carpet became so saturated they worried about water damage to their belongings and began to move items independently, as staff were unavailable to help. R2 stated that they were temporarily moved to another room on November 23, 2025, and were also not assisted by staff with that move. LPA obtained a copy of an email dated November 13, 2025, from R2’s responsible party, which stated R2 had been assisted by facility maintenance staff to move furniture and boxes, however, the email read in part, “[R2’s] room was impacted by water tonight for a second time this week due to a neighbor clogging [their] toilet with wipes… [R2] has been forced to sleep on [their couch] this week because many of [their] things are being temporarily stored on [their] bed while the fans dry the carpeting.” As of today’s date, R2 has returned to the same room which flooded and continues sleeping on their couch. During their interview, R4 corroborated the allegation and stated R2 had moved most, if not all, of their belongings on their own. Based on resident interviews and records review, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was provided at the end today's inspection. Due to the allegation being uncorroborated during interviews conducted, the Department is unable to determine if Staff does not ensure facility plumbing is in good repair. Although the above 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 at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.the state’s words, verbatim · CDSS document, Nov 25, 2025 · control 22-AS-20251123164608

From the deficiency page — Deficiency type: Type A · Section cited: HSC 87470(a)(2)(C) · Plan of correction due date: Nov 26, 2025

(C) Spills of blood and other potentially infectious materials and surfaces shall be promptly cleaned and disinfected. This requirement is not met as evidenced by: Based on resident interviews and observation, the Licensee did not comply with the section cited above as waste water residue was observed in R2’s carpet and hallway base board, which poses an immediately health and personal rights risk to person in care.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: ED stated R2's carpet and hallway will be immediately disinfected and all waste water residue removed and proof provided to LPA via email by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a) · Plan of correction due date: Nov 26, 2025

(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 is not met as evidenced by: Based on resident interviews and observation, the Licensee did not comply with the section cited above as R2 has been sleeping on their couch due their bed being inaccessible, which poses an immediate safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 25, 2025

Plan of correction: ED stated R2's bed and all furnishings will be made available to R2 and proof provided to LPA via email by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Administrator (AD) Laurie Galal and Wellness Director (WD) Kim Mims and explained the purpose of the inspection. During the inspection, LPA, AD, and WD conducted a tour of the inside and outside of the facility, common areas, resident rooms, dining rooms, kitchen, and observed the following: The facility consists of a two-story building for assisted living and an adjacent two-story building for memory care. Select resident bedrooms were inspected and observed to have the required furnishings. LPA observed resident beds had linens and blankets. There are two courtyards, and each have a shaded sitting area. LPA observed residents socializing, engaging in leisure activities, such as listening to music, and resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 109.9-119.6 degrees Fahrenheit. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguishers which are located at the end of every hallway were observed to be fully charged with service tags dated April 28, 2025. Kitchen appliances, and laundry washers and dryers were all inspected and observed to be operable. Medication was observed to be centrally stored and locked. LPA reviewed centrally stored medication for select residents and did not observe any discrepancies. LPA reviewed eight resident files and five staff files. Files were observed to contain required documentation. LPA interviewed select residents and staff. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 23, 2025

Allegation investigated: Facility staff did not give the resident's medication as prescribed.

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the investigation, LPA toured the facility and interviewed staff and resident. Regarding the allegation that facility staff did not give the resident's medication as prescribed, the investigation revealed the following: Resident 1 (R1) is diagnosed with Dementia per physician report dated 04/26/2024. Per review of facility charting, resident is having instances of hallucinations. LPA interviewed the resident who denied being poisoned by the facility with medications or vinegar. Resident stated having vinegar for cleaning needs. Review of the resident's medication orders and medication administration record indicated resident is receiving medications as prescribed. Facility manages resident medications. Based on interviews conducted and record review, the allegation is deemed unfounded, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to facility representative. Unfoundedthe state’s words, verbatim · CDSS document, Feb 19, 2025 · control 22-AS-20250214132731

Allegation investigated: rDue to lack of supervision, resident had an unwitnessed fall

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegation listed above. LPA was greeted and granted entry by Executive Director Laurel Galal after explaining the purpose of the visit. An initial investigation visit was held on October 1, 2024. During this visit, LPA requested and obtained the facility's census for the assisted living and memory care buildings. Resident records including physician report, individual needs and services plan, resident assessments as well as hospital visit reports for 2023 and 2024 were provided for resident R1. An interview with R1 was conducted along with two memory care staff interviews. Additional witness interviews were conducted via telephone. CONTINUED ON FORM LIC9099-C Unsubstantiated CONTINUED FROM FORM LIC9099 Regarding the allegation that Due to lack of supervision, resident had an unwitnessed fall, the following has been concluded: On September 20, 2024, resident R1 experienced a fall incident while attempting to use their unit's restroom/bathroom and was found shortly thereafter by a facility caregiver who heard calls for help. The bathroom was confirmed to be equipped with grab bars and slip mats. R1 was verified to have been assessed to receive stand-by assistance for toileting care but was stated by multiple parties to be believed to have attempted to shower unassisted. R1 was taken to the hospital for evaluation after paramedics were called, and returned to the facility the same day with no major injuries assessed per the hospital visit reports obtained during the investigation. Based on the evidence gathered, the fall incident reported does not appear to have resulted from negligence and/or lack of care and supervision from the facility's staff. As a result, the allegation is found to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Oct 9, 2024 · control 22-AS-20240923104800

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection to follow up on corrections identified during visit on August 6, 2024. LPA met with designated Administrator (AD) Laurel “Laurie” Galal and Wellness Director Kim Mims. An application to operate a Residential Care Facility for the elderly (RCFE) for (210) capacity, (0) ambulatory, (200) non-ambulatory, and (10) bedridden residents was received by CCL on December 14, 2023. At 11:30 a.m. LPA toured the facility and observed the following: · Water temperatures in memory care tested between 112.2 – 115.5 degrees F. All items noted from visit on August 6, 2024 have been addressed. Component III: was conducted during this inspection, information provided about how to operate the facility within compliance and reporting requirements. The facility is ready to be licensed. The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau (CAB) in Sacramento. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Aug 26, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Laurel “Laurie” Galal and Wellness Director Kim Mims. An application to operate a Residential Care Facility for the elderly (RCFE) for (210) capacity, (0) ambulatory, (200) non-ambulatory, and (10) bedridden residents was received by CCL on December 14, 2023. At 2:40 p.m. LPA toured the facility and observed the following: · Water temperatures tested between 127.5-129.5 degrees F in memory care. · LPA observed fire clearance granted to indicate the approval of delayed egress in memory care. · A supply of extra linen available in the linen closet. The following corrections to be addressed by 08/26/2024: · Water temperature in memory care to be adjusted to meet regulation of not more than 120 degrees Fahrenheit. LPA will make an additional announced inspection to follow-up on corrections listed above. An exit interview was conducted, and a copy of this report was provided to designated AD.the state’s words, verbatim · CDSS document, Aug 6, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 210 Census (if any clients in care): 86 COMP II Participants: Laurel (Administrator), Steven (corp member) Interview Method: Telephone interview On June 14, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staffing/Medications 3. General provisions/pre licensing readinessthe state’s words, verbatim · CDSS document, Jun 14, 2024