Crestavilla

Allegation investigated: Staff did not address a carbon monoxide hazard in a timely manner.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegation listed above. LPA met Executive Director Myra Aragones and explained the reason for the visit. During the course of the investigation, Department staff inspected the facility, interviewed staff, witnesses and reviewed records, including resident roster, staff roster, staff schedule, Resident 1’s (R1) physician’s report dated November 9, 2023, R1’s preplacement appraisal dated November 9, 2023, R1’s functional capabilities assessment, R1’s resident and services agreement dated November 16, 2023, Fire incident reports dated November 19 and November 23, 2025, and Fire Alarm Inspection reports dated November 6 through November 19, 2025. The investigation into the allegation, Staff did not address a carbon monoxide hazard in a timely manner, revealed the following. Substantiated R1 moved into the facility on November 18, 2023. On October 22, 2025, R1’s responsible party began staying with R1 at the facility after a medical procedure. R1’s responsible party reported that they heard an alarm go off in R1’s room frequently without staff responding to the alarm. All resident rooms at the facility have smoke detectors/carbon monoxide detectors. R1’s responsible party reported that staff did not come to the room to investigate the cause but assured her the room was safe. R1 reported that they had heard the alarm go off in their room on a few occasions and called the front desk, which resulted in the alarm being silenced but no one coming to the room to check on anything. R1’s responsible party purchased two portable Carbon monoxide (CO) detectors as a precaution. On November 19, 2025, the two portable CO detectors began to alarm and R1’s responsible party called 911. Orange County Fire Authority responded and found R1’s room had no measurable CO. Facility staff ordered a technician to find the cause of the CO and the fire department advised not to re-enter the room until a professional technician advised it was safe. No cause for the CO alarm was found, and no action was taken at that time. On November 23, 2025, CO detectors began to alarm, and the room alarm went off. R1’s responsible party called 911. The Orange County Fire Authority responded to the call. A review of the incident report from Orange County Fire Authority shows CO was detected in R1’s room with readings from 8 to 220 parts per million (ppm). The California Department of Industrial Relations (DIR) and Cal/OSHA enforce a Permissible Exposure Limit (PEL) for carbon monoxide (CO) of 50 parts per million (ppm) as an 8-hour time-weighted average (TWA) in any enclosed space. First responders stayed at the facility until readings went to zero. R1 and their responsible party had already vacated the room when the alarms went off. During the incident the Facilities Director reported that they would shut down the pool pump which may have been causing the CO issue. A review of records for the fire safety alarm system show that gas (CO) was detected 53 times from November 6, 2025, to November 19, 2025. The Facilities Director reported that when the first alarm went off on November 6, 2025, they assumed the CO sensor was faulty and had the sensor replaced on November 8, 2025. The Facilities Director was unable to explain why they failed to further investigate the cause of the CO alarm to continue to go off or to take further action to prevent possible life-threatening injury from CO exposure. 2 of 2 staff interviewed who had worked at the front desk reported that when the alarm company called about R1’s room alarm going off because of gas, they were instructed to tell them it was because of a faulty sensor. Both staff members verified that the alarm company called on multiple occasions to report to the facility that the gas alarm in R1’s room was going off. The Administrator reported that the Facilities Director oversaw the alarm system and was unaware that the CO alarm had been sounding regularly after the CO sensor was replaced. The Administrator reported that had they known they would have relocated R1 to a safe environment until it was confirmed the sensor was faulty or the source of the CO identified. The pool heating system pump was found to be the cause of the CO. The pool was closed until the heating system vent was relocated to a safe area where it doesn’t pose a threat to residents. During the course During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation, staff did not address a carbon monoxide hazard in a timely manner See LIC9099D for cited deficiencies 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 were discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, May 27, 2026 · control 22-AS-20251124165355

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Jun 3, 2026

The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by the Carbon monoxide alarm in R1’s room went off 53 times from November 6, 2025, to November 19, 2025, and the facility staff took no action. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 27, 2026

Plan of correction: Licensee to train all staff on CCR 87465 and to submit proof of training to LPA. Licensee is to submit a written plan on how to ensure carbon monoxide notification is responded timely. Licensee to relocate pool heating pump vent to a safe location in compliance with applicable building codes. License to submit proof to LPA when completed.

Allegation investigated: Relocated Pool heater without proper permits

Licensing Program Analysts (LPAs) Joseph Alejandre and Garli Tat made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPAs met with Executive Director (ED) Myra Aragones and explained the reason for the visit. The investigation into the allegation revealed the following. It was reported that the facility relocated the pool heater vent and started operating the pool and the pool heater on or around February 22, 2026 without the proper city permit. According to city code enforcement the project at the facility of relocating pool heater vent requires a permit. LPA interviewed the Executive Director and Facilities Management Director who reported that the facility pool heater vent was relocated in January and was inspected by the Gas Company. The ED reported that the pool and the pool heater was up and running on February 22, 2026. The ED reported that the permit process was started on February 13, 2026. The ED reported that the city inspector is scheduled to come to the facility to sign on off and issue the permit for the pool heater vent today. Substantiated Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulation. An exit interview was conducted and a copy of the report provided along with appeal rights.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 22-AS-20260313153514

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87305(a) · Plan of correction due date: Mar 27, 2026

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidenced by, The facility failed to obtain the city permit prior to relocating and operating the pool and pool heater vent. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: Licensee agrees to obtain the proper city permit for the pool and pool heater vent. Licensee to submit proof of correction to LPA by POC due date.

Allegation investigated: Staff are not safeguarding resident's personal belongings Staff steal money from resident Staff mishandle residents medication Staff open resident’s mail

Licensing Program Analyst (LPA) Joseph Alejandre made an unannouced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director Myra Aragones and explained the reason for the visit. The investigation into the allegation, staff are not safeguarding resident's personal belongings revealed the following, it was reported that facility staff take Resident 1's (R1) personal items from their room, such as jewelry, clothes and cleaning supplies. R1 could not provide specific item descriptions except for one jewelry item that was a necklace. R1 reported that the theft has been ongoing since they moved in back in 2023 and could give any specific dates as to when anything was taken. R1 reported that law enforcement was contacted but after talking to them they did not even take a report. R1 could not provide any names of the staff who took the items or the dates when items were taken. A review of records shows R1 moved in with one necklace which is documented on their property inventory list (only item listed) which LPA observed and R1 verified it was the necklace they were currently wearing. The Executive Director reported that R1 reported missing items and staff offered to assist R1 in looking for the items but R1 declined assistance and contacted law enforcement, who took no action. Unfounded 4 out of 4 staff interviewed and the Executive Director reported they have never taken anything from any resident and have never witnessed any staff member steal anything. 4 out of 4 residents interviewed reported they have never had anything stolen since they moved into the facility. Staff and the Executive Director reported they do not enter resident rooms without resident permission. Room entry is via a key card which tracks when and who enters any residents' room. A review of records shows R1 was the only person to enter their room except for one entry by staff member allowing a visitor for R1 to enter the room, R1 verified this information. A review of incident reports for the facility for 2026 shows no thefts have been reported by the facility. There is no evidence to corroborate the allegation, therefore the allegation is deemed unfounded meaning, that the allegation was false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, staff steal money from resident, revealed the following. It was reported that staff take money from R1's room when they are not there or when they are asleep. No specific details were provided. R1 could not provide dates and times when cash was taken or the amounts of money that have been taken. R1 reported that they contacted law enforcement who left after a few minutes and they didn't do anything. R1 reported that they did not know who took their cash or when. R1 did not respond when asked if it was possible they spent the money or possibly put in the bank or somewhere else they forgot about. 4 out of 4 staff reported they have never witnessed or taken any money from any resident. 4 out of 4 residents reported they have never had any money taken from them at the facility. None of the evidence gathered supports the allegation. The allegation is deemed unfounded meaning, that the allegation was false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, staff mishandle residents medication, revealed the following. It was reported that staff take R1's medication and it was witnessed by Resident 2 (R2). R2 denied the report. 4 out of 4 staff reported that they have never taken R1's medication or any residents' medication. A review of records shows R1 handles their own medication. R1 reported that over the years all of their medicaiton has been taken but did not provide any other details. Staff 1 who is authorized to handle resident medication reported that until a resident's medication is handled by the faciltity they do not handle their medication in any way. None of the evidence gathered supports the allegation, therefore the allegation is deemed unfounded meaning, that the allegation was false, could not have happened and/or is without a reasonable basis. The investigation into the allegation, staff open resident’s mail, revealed the following. It was reported that R1 orders items that are mailed and staff open the mail and steal the contents. R1 reported that their mail has never been stolen or opened by anyone. R1 reported that the items they have ordered and that were mailed were stolen later after they were received but not before they received them in the mail. 4 out of 4 staff reported they don't have access to resident's mail and have never stolen or opened anyone's mail. 4 out of 4 residents interviewed reported they have never had an issued with mail being stolen or open. Based on the evidence gathered the allegation, staff open resident’s mail, is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 22-AS-20260223143903

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. The Agency received a report that the facility had an increase in calls for emergency services (calls to 911) as compared to last year. LPA met with Executive Director (ED) Myra Aragones and explained the reason for the visit. LPA consulted with the ED regarding PIN 25-06-ASC Calling 9-1-1 In Residential Care Facilities For The Elderly (RCFE). LPA discussed the PIN with the ED who stated all care staff will be retrained on PIN 25-06-ASC. LPA consulted with ED regarding reporting requirements. The ED reported that the priority of the facility is the health and safety of the residents and reported that 911 is only called when it is required. No deficiencies observed during the visit. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Dec 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by receptionist. LPA met with Myra Aragones, Executive Director, and LPA explained the nature of the visit. The facility is licensed to operate for (250) non-ambulatory, of which (10) may be bedridden elderly adults ages 60 and above. The facility is approved for (20) hospice residents. Currently the facility has (164) assisted living residents, (30) residents in memory care, and (11) hospice residents. Delayed egress doors for memory care only. This facility consists of two main areas. The assisted living and the memory care unit which are protected by delayed egress exits. The facility is a three-story structure located in a commercial neighborhood. It consists of the following: (211) resident bedrooms, (211) resident bathrooms, med rooms, a conference room, dining rooms, a laundry room, a mailroom, business offices, a commercial kitchen, a movie theater, (3) multi-purpose rooms, (8) storage rooms, (13) public restrooms, courtyard patio area, a salon, an exterior pool (under maintenance at time of visit), an employee lounge, and rooftop with art & crafts room, sun room area and lounge. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including Activities Calendar and Food Menu. LPA Martinez along with the Interim Executive Director toured the physical plant of both the assisted living and the memory care unit. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at Continued on LIC809-C time of visit. Maintenance records were observed in the main kitchen. LPA observed a bistro adjacent to the main dining room where residents can obtain different snacks and beverages selections than in the main dining area. The bistro offers snacks all day so residents may dine when convenient. LPA observed menus and the food offered is varied and healthful. Kitchen was inspected. During the tour LPA observed residents involved in an activity as well as a posted activity schedule including games, exercise, and outings at the facility. LPA inspected that medication is centrally stored in a safe locked location; facility has a medication room on the first floor where med carts are stored when not used. Med carts are used through the floors to pass out medication to residents. LPA observed and inspected medication carts that are used to dispense meds to residents and observed medication was labeled and stored inaccessible to residents in care. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. LPA inspected bedrooms for residents in the memory care unit and in floors 1-3. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Several resident bathrooms on each floor were tested for water temperature and water temperature measured between 105.6 to 109.4 Fahrenheit degrees in tested bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPA pushed the restroom call button in various resident rooms and response times were within 10 minutes. LPA observed several residents who appeared clean, and happy. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked in a locked in storage closets throughout the facility. LPA toured the memory care unit and observed a kitchen/ dining room as well as posted activity schedule for memory care residents. LPA observed residents in the memory care unit with care staff present. LPA observed the delayed egress exits to be functioning. Carbon monoxide detectors tested and noted to be operational. Fire extinguishers are fully charged and had a service date of September 18. 2025. Smoke detectors and sprinkler system are tested yearly by an outside agency, and LPA was provided with testing documentation, last testing was done February 24-28, 2025. Emergency drills are being conducted monthly on every shift with the last drill conducted on November 19, 2025. LPA observed stairwells have an emergency evacuation chair. Outside grounds have ample shaded seating for residents. LPA observed several courtyards with shaded seating areas for residents’ enjoyment. LPA observed a swimming pool in the outside perimeters of the assisted living side with a fence around it which is under maintenance and it not being used by residents Continued on LIC809-C until repairs are completed. LPA observed the pool gate that has a self-latching and has a key card pad for access at the gate door for inaccessibility. LPA measured the pool fence was observed to enclose the entire pool area. LPA reviewed 15 resident files and 15 staff files. All resident files contained required documentation including updated physician reports and care plans. Staff files contained required documentation including health screens, first aid, and fingerprint clearance. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Executive Director, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Dec 15, 2025

Allegation investigated: Staff did not ensure food served to residents was free from contamination.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Executive Director Myra Aragones and explained the reason for the visit. LPA and the Executive Director toured the facility including the kitchen. The investigation revealed the following. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA inspected the perishable food supply. LPA inspected the 7 day non-perishable food supply. No deficiencies observed in the food supply. LPA observed the facility serving lunch during the visit. LPA interviewed 5 staff members. 5 out of 5 staff members interviewed reported they had not observed any contaminates or foreign objects in any of the food served to residents. LPA interviewed 7 residents. 6 out of 7 residents reported they had no issues with the food and have never had any contaminants or foreign objects in the food. 1 out of 7 residents reported that one time they were served food that had worms in it. LPA did not observe any foreign objects or contaminants during the lunch service. Unsubstantiated LPA did not observe any insects, rodents or worms anywhere in the facility. Based on the evidence gathered the allegation is deemed unsubstantiated, Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 22-AS-20250923163448

Allegation investigated: Staff did not get timely medical care for resident

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Hospitality Services Director Paolla Carrillo and Assisted Living Director Deserie Rodillo. LPA explained the reason for the visit. LPA toured the facility. LPA interviewed staff and residents. LPA requested documents such as admission agreements, physician reports, needs and care plans, medication administration records, resident progress notes, resident roster, staff roster and staff schedule. The investigation into the allegation, staff did not get timely medical care for resident revealed the following. It was reported that Resident 1 (R1) sustained an injury that required medical attention. On August 3, 2025 in the afternoon, R1 was noted to have an injury on each forearm. Resident 2 (R2) noticed the injuries and took R1 to the Wellness office. The Resident Care Coordinator (RCC) assessed R1 and determined that the only injuries were 2 skin tears, one on each forearm. The RCC administered first aid. The RCC reported that R1 reported no pain and could not remember how the injuries occurred.. Unfounded The RCC contacted R1's responsible party and primary care physician (PCP). The PCP arranged for a Home Health visit which took place on August 12, 2025. The Home Health notes show both wounds are closed with no sign of infection. The Home Health notes describe the injuries as skin tears. The RCC reported that the injuries were cleaned daily and bandaged daily. LPA interviewed R1, R1 did not recall the incident and reported they did not fall recently. LPA interviewed R2 who reported there was no blood on R1's clothing and there minimal blood on the skin tears. The RCC reported that R1 only required first aid and because no pain was reported and no other injuries were noted it wasn't necessary to call 911. The RCC reported that R1 was not nervous or displaying any signs of distress. Based on the evidence gathered the allegation, staff did not get trimly medical care for resident is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of the report provided. No evidence was gathered to support the allegation. Therefore the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. a written report to the responsible party concerning R1's injuries. California Code of Regulation (CCR) Title 22, Division 6, 87211(a)(1) states, "A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below." R1 received first aid for their injuries on their forearms so this incident qualifies under CCR Title 22, Division 6 87211(a)(1)(D) which states, "Any incident which threatens the welfare, safety or health of any resident". The incident involving R1 took place on August 3, 2025 and the facility did not report the incident in writing until August 12, 2025, 9 days later. A record review of incidents reports submitted to the Agency from the facility for the month of August 2025 show the facility did not report the incident to the Agency. Based on the evidence gathered, the preponderance of evidence standard has been met, therefore the allegation is substantiated. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations (CCR). An exit interview was conducted and a copy of the report provided along with appeal rights.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 22-AS-20250826093143

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 8, 2025

87211(a)Each licensee shall furnish to the licensing agency ...(1)A written report shall be submitted to the licensing agency and to the person responsible within seven days... (D)Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: The Licensee did not submit a written report for R1's incident that took place on August 3, 2025, to the responsible party and the Licensing Agency within seven days, which poses a potential health, safety and personal rights risk to residents.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: Licensee agrees to train staff who submit incident reports to the Agency on CCR 87211 and to provide proof of training to LPA by POC due date.

Allegation investigated: Resident was not allowed to use the telephone. Facility did not respect residents visitation wishes. Facility did not allow resident to have their mail.

This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Edward Kim for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPAs met with Memory Care Director (MCD) Norma Martinez and explained the reason for today’s inspection. Administrator (AD) Myra Aragones was not present during the inspection. The investigation into the allegations that a resident was not allowed to use the telephone, the facility did not respect residents visitation wishes, and the facility did not allow resident to have their mail revealed the following: During the course of the investigation, LPAs inspected the facility, interviewed AD, Memory Care Director (MCD) Norma Martinez, residents, and witnesses, and obtained and reviewed copies of the resident roster, staff roster, an Unusual Incident Report dated October 10, 2024, Resident #1’s (R1) Care Notes dated September 9, 2024, R1’s Letter dated February 9, 2024, R1’s Visitation Log for 2024, and R1’s Care Notes dated April 6, 2024. Unsubstantiated Regarding the allegation that a resident was not allowed to use the telephone: it was alleged that on October 9, 2024, R1 requested to use a telephone, facility staff told R1 “we don’t have the legal authority to let you use the phone”, R1 protested, and R1 was eventually allowed to use a telephone two hours later. LPA interviewed AD and MCD who denied the allegation, stating that R1 was allowed to use the telephone whenever they wanted and would use it often to call a family member. Regarding the alleged two-hour delay on October 9, 2024, AD and MCD stated that immediately after R1 requested to use a telephone, another resident had a serious fall in the garden which required 911, R1 was advised that once the emergency was resolved staff would be available to assist R1 to use a telephone and R1 agreed without complaint, and once the emergency was resolved and staff were available to assist, R1 was immediately assisted to use a telephone less than forty minutes after R1 had originally requested to use a telephone. LPA reviewed an Unusual Incident Report dated October 10, 2024, which corroborated that a serious fall occurred on October 9, 2024, which required 911 at the same time R1 requested to use a telephone. LPA requested the facility’s telephone logs, but was advised by MCD that the facility does not log phone calls made by residents. LPA reviewed R1’s Care Notes dated September 9, 2024, which documents another recent call between R1 and a family member and per AD the facility does not document all calls residents make and R1 makes calls to their family member frequently. LPA interviewed R1 who stated that this is the only incident involving access to a telephone and that R1 was provided access to a telephone shortly after requesting it. LPAs interviewed 20 residents who did not provide information corroborating that the facility is not providing residents access to a telephone when requested. The information obtained did not corroborate that the facility denied R1 use of a telephone or intentionally delayed assisting R1 to use a telephone. Regarding the allegation that the facility did not respect residents visitation wishes: it was alleged that on October 9, 2024, the facility allowed two family members to visit R1 at the facility, R1 reacted violently and did not want to see these family members, and R1 had previously made their wishes known to the facility that they did not want these family members to visit R1 at the facility. LPA interviewed R1, who has cognitive and mental health diagnoses, who stated that they told the facility from the very beginning that they did not want any visitors except one specific individual and that their visitation wishes were violated on October 9, 2024, but could not remember any other violations of their visitation wishes. LPA interviewed one witness, R1’s family member, who corroborated R1’s statement and stated that the facility allowed visitors against R1’s wishes multiple times. LPA interviewed AD and MCD who denied the allegation, stating that R1 never voluntarily communicated that they wanted the facility to deny visitors without being coached to do so by their family member and that when R1 did communicate their wishes regarding visitation, the facility followed them. Specifically, AD stated that during meetings with R1 and their family member, R1’s family member would coach R1 to tell AD that they did not want other family members visiting them by making that statement and having R1 repeat it, but AD did not take these statements as R1’s voluntary wishes. The facility provided R1’s Letter dated February 9, 2024, which was not directed to the facility itself, but states that R1 only wishes to see one family member. However, per MCD, R1 gave them the letter and stated it had nothing to do with the facility and was for an outside purpose and only requested that MCD hold the letter for R1. Interviews with R1’s conservator, R1’s family member, AD, and MCD revealed allegations of undue influence against multiple family members of R1. The information obtained was conflicting regarding whether R1’s visitation wishes were freely communicated to the facility. Per AD and MCD, the facility does not exclude individuals from the premises unless there is a restraining order and with regards to visitation, the facility’s policy is to ask residents each time whether they would like to meet with a visitor and to follow the resident’s decision during each visitation. When interviewed, R1’s conservator stated there are no restraining orders in place. Regarding R1’s family members being present at the facility on October 9, 2024, AD and R1’s conservator stated that this was not a visit and these family members were present at the request of R1’s conservator to facilitate R1 being moved out of the facility. LPA reviewed R1’s Visitation Log for 2024 which documents that, other than on October 9, 2024, the only other visit by R1’s other family members occurred on April 5, 2024. Per R1’s Care Notes dated April 6, 2024, during the April 5, 2024, visit, a family member visited R1, R1 communicated their wish not to see this family member, and facility staff followed R1’s request and escorted the family member out of the facility. LPAs interviewed 20 residents who did not corroborate that the facility is not respecting their visitation wishes. The information obtained did not corroborate the allegation because the facility took reasonable measures to follow R1’s visitation wishes by asking R1 if they would like to see each visitor that requested to see R1 and followed R1’s communicated wishes. Regarding the allegation that the facility did not allow resident to have their mail: it was alleged that R1 has been receiving mail and legal service at the facility, but the facility has not been giving these documents to R1 and R1 has not received their mail for two years. One witness interviewed stated that they, along with R1, had a meeting with MCD during which they requested R1’s mail, but MCD called R1’s conservator and did not provide R1 their mail. LPA interviewed AD and MCD who denied the allegation, stating that R1 does not receive mail at the facility so the facility does not have any mail to give to R1 and that all of R1’s mail goes directly to R1’s conservator. Per MCD, R1 did receive legal service at the facility, the facility does not get involved with legal service but MCD did escort the process server to R1’s room, R1 received their legal papers and asked the facility to keep them for R1, and MCD provided these legal papers back to R1 when requested. LPA interviewed R1 who did not provide information corroborating the allegation. LPA interviewed R1’s conservator who stated they receive R1’s mail on R1’s behalf when appropriate and they do not know of any mail R1 should be receiving that they are not receiving. LPAs interviewed 20 residents who did not corroborate that the facility is withholding residents’ mail. The information obtained is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are 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 and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Dec 24, 2024 · control 22-AS-20241015084244

Type of visit: Required - 1 Year

On 12/14/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Hospitality Director Paola Carrillo who contacted the Executive Director Myra Aragones by telephone. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (250) non-ambulatory, of which (10) may be bedridden elderly adults ages 60 and above. The facility is approved for (20) hospice residents. Currently the facility has (164) assisted living residents, (30) residents in memory care, and (6) hospice residents. The facility is a three-story structure located in a commercial neighborhood. It consists of the following: (211) resident bedrooms, (211) resident bathrooms, med rooms, a conference room, dining rooms, a laundry room, a mailroom, business offices, a commercial kitchen, a movie theater, (3) multi-purpose rooms, (8) storage rooms, (13) public restrooms, courtyard patio area, a salon, an exterior pool, an employee lounge, and rooftop with art & crafts room, sun room area and lounge. LPA Dabuet and Maintenance Director David Deger toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #106, #112, #127, #132, #250, #274, #373 and #381. Emergency call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.2 – 110.1 degrees F. A comfortable temperature was maintained in the facility at 70 - 74 degrees F. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. (Evaluation Report continues LIC 809-C) Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. Disaster Drill/Evacuation Drill/Fire Drill are conducted with records of 10/17/24 being the last drill. Facility fire cleared approved for delayed egress exits. Facility has delayed egress exit doors in memory care all operable condition. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including Activities Calendar and Food Menu. LPA conducted an audit of resident #1-#7 (R1-R7) out of (194) service files, and staff #1-#7 (S1-S7) out of (142) personnel files were complete. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. The facility is current in CCLD annual fees. The administrator certificate for Myra Aragones #7008607740 effective 10/01/2023 - 09/30/2025. The facility has a Liability Insurance Certificate valid with policy # NSC1000498 effective 06/01/24 – 06/01/25. DEFICIENCIES: Criminal Clearance Transfer Association for staff #8. No Criminal Clearance Transfer Request LIC 9162 on file or included on CDSS Guardian Background System as being associated. Staff #7 did not have current CPR/First Aid Certificate on file last CPR expired 10/2024. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 809-D). An exit interview conducted with the Myra Aragones, and a copy of the report is provided. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *the state’s words, verbatim · CDSS document, Dec 14, 2024

Type of visit: Collateral

Licensing Program Analyst (LPA) Joseph Alejandre conducted an unannounced collateral visit in conjunction with complaint investigation 22-AS-20231004114033 at another licensed facility. LPA was greeted and granted entry into the facility. LPA met with General Manager Myra Aragones and explained the reason for the visit. During the visit, LPA met with Resident 1 (R1) to gather information pertaining to complaint #22-AS-20231004114033. Resident agreed to speak with LPA. Exit interview conducted with the General Manager and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 6, 2023