Del Mar Park

Allegation investigated: Staff yelled at resident

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced complaint investigation visit on July 10, 2026, to deliver findings regarding the above allegation. LPA was greeted by Denise Sutton, Administrator, and facility staff. LPA explained the purpose of the visit. During the investigation, LPA reviewed and obtained copies of the Resident Roster, Staff Roster, R1's Face Sheet, Physician's Report, and S2's acknowledgment of the facility's client abuse policy. LPA also conducted a tour of the facility and interviewed six (6) staff members (S1–S6) and nine (9) residents (R1–R9). (continued on 9099C) Unsubstantiated Allegation: Staff yelled at resident It is alleged that S2 yelled at R1 on or about June 29, 2026. During the investigation, R1 stated S2 was "rude and nasty" and that the interaction made them feel upset and uncomfortable; however, R1 was unable to recall the specific words that were used. S2 denied yelling at R1 and stated they were joking with R1 before becoming more direct to encourage them] to prepare for there dialysis appointment. S1 stated they conducted an internal investigation after learning of the allegation, during which no evidence was found to substantiate the concern. S1 further reported there have been no prior concerns, complaints, or disciplinary actions involving S2 related to the treatment of residents. Staff interviews were consistent in that no staff reported witnessing S2 yell at or speak inappropriately to residents. While S3 and S4 stated R1 had told them S2 was "mean," neither witnessed the alleged incident. Residents R2 through R9 stated they feel safe living at the facility, reported that staff treat them with dignity and respect, and expressed no concerns regarding S2. Based on the investigation conducted, which included interviews with staff and residents as well as a review of relevant records, there was insufficient evidence to support the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 10, 2026 · control 28-AS-20260707132840

Allegation investigated: Staff did not ensure that resident's hygiene needs are being met.

Licensing Program Analyst (LPA) Tao conducted an unannounced 10-day complaint visit to this facility. Upon arriving at the facility, LPA met with Administrator Denise Sutton. LPA explained the purpose of today’s visit and discussed the allegation mentioned above to Administrator Sutton. The investigation consisted of resident interviews, staff interviews, facility tours, and review of facility records. LPA obtained resident roster, staff roster and residents’ facility files. The investigation revealed that, in regards of facility staff did not ensure that resident's hygiene needs are being met, it was alleged that a resident’s clothes were not changed and showers were not provided for residents who need bathing assistance. Per the resident interviews, nine (9) out of nine (9) residents interviewed could not corroborate the allegation. It revealed residents who need bathing assistance were bathed as scheduled twice or three times a week. Clean clothes were changed after shower and as needed. ( - continued on LIC 9099C-) Unsubstantiated Per staff interviews, four (4) out of four (4) staff interviewed could not corroborate the allegation which indicated staff would provide bathing assistance to those residents who need it and dressed residents with clean clothes after showers or as needed. During the facility tour, LPA observed staff delivered clean clothes to residents from room to room. Residents were observed to be clean and neat. No foul odor was noted. Per record review, facility had a shower schedule for staff to follow and provide bathing assistance to residents. Residents had their own Service Plan charts and staff would check off the log as cares were provided. Therefore, staff provided bathing assistance and dressed residents with clean clothes after showers or as needed. Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegations mentioned above. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator Denise Sutton. The findings were discussed and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 15, 2026 · control 28-AS-20260512090501

Allegation investigated: Staff hit a resident.

Licensing Program Analyst (LPA) Elena Mallett conducted an unannounced subsequent complaint visit to investigate the above allegation. LPA was met by Arineh Vartanian Community Liasion and explained the purpose of the visit. Administrator Denise Sutton was contacted by phone and joined the visit shortly after. During today’s visit, LPA requested and obtained resident and staff rosters and toured the physical plant. No immediate health and safety concerns were observed. The initial visit was conducted on 03/09/26. During the initial visit, the investigation consisted of interviews with Staff #1-#6 (S1-S6) and with Residents #2-#9(R2-R9). LPA toured the physical plant. LPA requested and obtained the following documents: Staff Roster and Resident Roster for February and March 2025 , Resident ADL Master List, Personal Rights Training for S1-S6. LPA obtained the following documents from R1's file: Physician's report, Preplacement Appraisal Information and all SIRs. Unsubstantiated Regarding allegation Staff hit a resident: It is alleged that an unknown staff member hit resident #1 (R1) in the rib area. LPA made several attempts to interview R1, however, all attempts were unsuccessful. LPA interviewed residents R2-R9 and none were able to corroborate this allegation. Eight (8) out of eight (8) residents reported not being aware of staff hitting residents in the ribs and residents stated staff did not hit R2-R-R9 in the ribs or near the ribs. Eight (8) out of eight (8) residents stated they felt safe at the facility. Administrator stated that staff never hit R1 or any other resident. Administrator stated APS and Law Enforcement had come to the facility regarding the incident and had not opened an investigation. Staff 1 -6 (S1-S6) were interviewed and six (6) out six (6) staff were not able to corroborate that a staff member hit R1 or any residents in the rib area. Six (6) out of six (6) staff interviewed deny ever hitting any resident in care. Six (6) out of Six (6) staff interviewed state that staff are trained on resident rights upon hire. LPA reviewed six staff records which revealed that staff had been trained in residents’ rights. During 03/09/26 visit, when LPA toured the facility, LPA observed staff and resident interactions which LPA observed to be professional. The investigation did not reveal that staff hit residents in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. LPA Mallett conducted an exit interviews with Administrator Denise Sutton and a copy of this Licensing report was provided.the state’s words, verbatim · CDSS document, May 12, 2026 · control 28-AS-20260302100048

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Elena Mallett conducted an unannounced Case Management visit to the facility. LPA met with Administrator Denise Sutton and discussed the purpose of the visit which is to reissue a citation from a 03/09/26 Case Management visit to the facility. The reason the citation is being reissued is to clarify language on the Licensing Report and on the LIC 809-D. On today’s visit LPA requested and obtained and staff and resident roster and a copy of S1’s government ID. LPA toured the physical plant and did not observe any immediate health and safety concerns. On 03/09/26 LPA reviewed the LIC 500 Personnel Report and found that Staff 1 (S1) had been working as an Administrative Assistant at the facility since 06/17/2025. S1 was cleared, however, S1 was not associated to the facility at the time of the 03/09/26 visit. The facility did not transfer S1's Criminal Record Clearance to the facility. A Type A deficiency was cited on 03/09/26 along with immediate Civil Penalties, which have been dismissed by the department. The Type A deficiency along with Immediate Civil Penalties are being reissued on today’s visit in the amount of $500. Refer to LIC 809-D. An exit interview was conducted with Administrator Denise Sutton and copy of this Licensing Report was provided along with Appeal Rights.the state’s words, verbatim · CDSS document, May 12, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: May 13, 2026

Criminal Record Clearance 87355 (e) All individuals subject to a criminal record... (b) shall prior to working,residing or volunteering in a licensed facility: (3) request a transfer of a criminal record clearance The above requirement was not met as evidenced by the facility did not transfer S1's Criminal Record Clearance to the facility. S1 was not associated to facility on LIS during LPA's 03/09/26 visit to the facility. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: By POC due date Administrator will give a signed statement of understanding of the regulation. Administrator will assoicate S1 on Guardian before S1 resumes working at the facility.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Elena Mallett conducted an unannounced Case Management visit to the facility. LPA met with Administrator Denise Sutton and discussed the purpose of the visit. Upon review of the LIC 500 Personnel Summary LPA found that Staff 1 (S1) was not associated to the facility. S1's criminal transfer was not completed A deficiency was cited. See 809-D. A Civil Penalty was issued today for the maximum amount of five days in the amount of $500. An exit interview was conducted with Administrator Denise Sutton and copy of this Licensing Report along with a copy of Appeal Rights was provided.the state’s words, verbatim · CDSS document, Mar 9, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Mar 10, 2026

(e) All individuals subject to a criminal record ...(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearancethe state’s words, verbatim · CDSS document, Mar 9, 2026

Plan of correction: By POC due date facility will associate Staff 1 in Guardian.

Allegation investigated: Facility staff handled the resident in a rough manner.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint visit on 02/28/2026, regarding the above allegation to deliver findings. On 01/21/2026, LPA Ramirez conducted an unannounced initial visit and a need further investigation was documented. During today’s visit, LPA Ramirez was greeted by Denise Sutton and explained the purpose of the visit The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster, Resident Roster, Staff interviews#1- 5 (S1-S5) Resident interviews #1-5 (R1-R5), copies of R1's: physician's report, Preplacement Appraisal Information, R1’s Unusual Incident Report/Special Incident Reports, and physical plant tour. See 9099-C for continued report Unsubstantiated The investigation revealed the following: regarding the allegation “Facility staff handled the resident in a rough manner.” It is alleged staff handled R1 in a rough manner. One (1) out of five (5) residents interviewed corroborated this allegation. Five (5) out of five (5) staff interviewed denied this allegation. Four (4) out of the five (5) residents interviewed corroborated that they felt staff treat them well and are happy with their care. Staff interviews revealed that R1 has a history of falls, aggressive behaviors and refusal to comply with grooming and toileting assistance. Staff interviews revealed staff try to redirect R1 when they become aggressive and give R1 space before attempting to assist R1 again. During record review, LPA Ramirez reviewed R1’s Unusual Incident Report/Special Incident Reports from 01/2026 through 02/2026. These records revealed R1 had several unwitnessed falls which resulted in some minor injuries that were assessed and treated by staff. None of these records revealed that R1 received an injury due to staff handling R1 in a rough manner. These records revealed that staff contacted R1’s physician and R1’s family regarding these falls. During facility tour, LPA Ramirez over heard resident#6 (R6) and their family expressing their satisfaction with facility staff and the care R6 was receiving. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited during this visit. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 28, 2026 · control 28-AS-20260115143117

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with Denise Sutton, Supervisor. LPA discussed the purpose of the visit. The facility is licensed to serve 124 non-ambulatory residents over the age of 60, with a hospice waiver for 16 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting each shift for high touched surface area. Facility has sufficient PPE supplies and and an Infection Control Plan. 2. Physical Plant and Environmental: The facility is in a residential area and consists of a multi-level building with a dining room, library area, a commercial kitchen, resident rooms, a medication room, two (2) courtyards, a patio, a smoking area in the first floor. The second floor has a seating area, a TV room, an activity area, and several resident rooms. There is a total of three (3) stairwells. The baseman consists of staff offices, a therapy room, a laundry room, a beauty parlor, and staff break rooms. Each resident' room has a private bathroom. LPA inspected the carbon monoxide/smoke detectors in random rooms and are working probably. Facility tested the general fire alarm during the visit. LPA tested the hot water temperature, and tested between 109.9 –117.3 degrees F. which are within the Title 22 regulation of 105.0 – 120.0 degrees F..All the cleaning supplies and chemicals are locked and inaccessible to residents. The facility has sufficient personal hygiene products for clients to use. All clients rooms are completely furnished with chairs and have required beddings. All the bathrooms are clean, sanitized, and operational. The exit and passageway are safe and free of obstruction. One of the eaves by the stairway #3 leading outside needs to be repaired (continued on 809C) (continued from 809) 3. Operational Requirements: The facility maintains a fire clearance approved by the fire department. Currently the facility is licensed for 124 non-ambulatory and has hospice waiver for 16. The facility has shaded area with table and chairs for residents to utilize for outdoor activity. The last fire/disaster drill was conducted on 12/09/2025 LPA reviewed and verified facility liability insurance which expires on 01/01/2027 4. Staffing: The facility has sufficient staff, and the night supervision staff did receive planned emergency training. 5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The administrator Rabie Bnafshesha certificate will be expired on 11/02/2025. All the direct care staff received Medication Management Training. The first aid training certificates for staff are current. 6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. 7. Resident Rights-Information: The Complaint, ombudsman and Residents personal rights are posted by the main entry. Visiting hours are posted at facility. 8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. 9. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents. (Continued on 809C) (continued from 809C) 10. Incidental Medical & Dental: The medications are centrally stored in original containers. During the visit today, LPA reviewed five (5) residents' medication files, and all medications are administered according to Doctor’s orders. Two (2) of one residents PRNs were missing labels. 11. Disaster Preparedness: The facility has an Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, The facility conducts emergency drill on a quarterly basis for all staff. Facility needs to update emergency disaster plan to include two (2) relocation locations. 12. Residents with Special Health Needs: No residents have prohibited health conditions. No deficiencies observed during today’s visit. Technical Violations issued. An exit interview was held. A copy of this report, technical violations, and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 9, 2026

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff do not ensure resident has privacy in their room. Staff interacts with residents in an inappropriate manner.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit to investigate the above allegations and deliver findings. LPA met with Supervisor, Denise Sutton and explained the purpose of the visit. The investigation consisted of the following: On 11/03/2025, LPA toured the facility, inspected Resident #1 (R1) - Resident #2 (R2) rooms, obtained copies of the following files: staff & resident rosters, in-service training regarding residents rights and privacy (09/18/2024), Resident handbook, 30-day notice of room change provided to R1 (dated 10/20/2025), R1's notes (dated 08/28/2025, 08/29/2025 & 10/27/2025 ), email correspondence (dated 10/15/2025), and (R1)'s files relevant to the investigation. LPA interviewed Staff #1 (S1) - Staff #4 (S4) and Resident #1 (R1) - Resident #6 (R6). During today’s visit, LPA obtained staff & resident rosters and delivered findings. *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation revealed the following: Allegation: Staff do not ensure resident is being accommodated concerning room and roommate choices. It is alleged that R1 has not been asked about preference for accommodation and being moved to a different room for the 2nd time. During the interview, R1 stated that on 08/28/2025, R1 was moved to a different room and on 10/26/2025, R1 received written notice of another relocation. R1 stated that staff did not ask for their preference regarding room and roommate during the transfer and the notice did not provide important details about the new accommodation. R1 also stated that staff did not follow R1’s care plan to accommodate an adjustable bed that was prescribed to R1 for medical reasons. S1 admitted to not informing R1 about the transfer details and stated that the transfer was necessary because R1 is currently in a private room while R1’s rate is for a shared room. S1 stated that there are no documents to confirm that the private room arrangement was temporary, only verbally. (5) out of (6) residents interviewed stated that they have not requested nor been asked to be transferred to a different room. Documents reviewed showed that R1’s rental agreement (signed and dated on 7/31/2025) included “reasonable accommodations with respect to R1’s preferences concerning apartment and roommate choices.” Additional records reviewed also revealed that R1 was not given information about the right to appeal when R1 did not agree with the room change. Documentation reviewed and interviews conducted corroborate this allegation. Allegation: Staff did not provide a 30 day advance notice of room change. It is alleged that R1 received a 30 day notice that R1 will be moving to a larger shared apartment on 10/26/25, but was dated 10/20/25. (3) out of (4) staff interviewed confirmed that despite the 30-day notice of room change date of October 20, 2025, the notice was not delivered to R1 until October 26, 2025, along with other correspondence. R1 confirmed during the interview that the 30-day room change notice and other correspondence were left under their door on October 26, 2025. (5) out of (6) residents interviewed stated that they have not been given 30-day notice of room change because they have not been asked to be transferred to a different room. Documents reviewed showed that in addition to failing to provide the 30 day notice to R1 30 days in advance as specified in the rental agreement, the notice is also missing important information and requirements. Interviews conducted as well as reviewed files and documentation corroborate this allegation. Based on interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to the Supervisor, Denise Sutton along with the appeal rights. The investigation revealed the following: Allegation: Staff do not ensure resident has privacy in their room. It is alleged that R1 did not have privacy because R1 was told by S1 to always keep their apartment door open even during their sleep. All (4) staff interviewed denied the allegation. S1 stated that they respect the residents' privacy and accord them safe and comfortable accommodations. (5) out of (6) residents interviewed denied the allegation. Interviewed residents indicated that no one has told them to always keep their door open, and they are free to open or close their door whenever they choose. During the facility tour, LPA observed some of the residents’ doors were open while others were closed. LPA’s observation and interviews conducted do not corroborate this allegation. Allegation: Staff interacts with residents in an inappropriate manner. It is alleged that S1 told everyone that R1 was being investigated for an accusation of stealing that was not true. Additionally, staff would wake up R1 very early even if R1 told them not to. All (4) staff interviewed denied the allegation and stated they receive regular training on respecting residents' rights. S1 stated they keep confidential information in order to protect the residents. Staff interviewed stated that they treat the residents with respect and dignity and follow their orders or requests. Some staff interviewed denied knowing any of the residents who were under investigation. R1 stated that they wanted to withdraw this allegation since R1 is planning to leave the facility. (5) out of (6) residents interviewed denied the allegation. Some residents interviewed stated that staff interact with them appropriately and unaware of any resident being investigated. Based on the information obtained, the allegation is unsubstantiated. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Denise Sutton, Supervisor.the state’s words, verbatim · CDSS document, Nov 10, 2025 · control 28-AS-20251028080701

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(15) · Plan of correction due date: Nov 17, 2025

87468.2 Additional Personal Rights of Residents....(a) In addition to the rights listed in Section 87468.1, Personal Rights...in privately operated residential care facilities for the elderly shall have all of the following personal rights: (15) To reasonable accommodation of their preferences concerning room and roommate choices. This requirement is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which the staff failed to follow R1’s care plan to accommodate a prescribed adjustable bed for medical reasons, and did not provide important details about the new accommodation including room and roommate choices which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 10, 2025

Plan of correction: Licensee/Administrator shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 87468.2(a)(15) and train all staff on the same regulation. Administrator to submit written POC and in service training log to CCL/LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(16) · Plan of correction due date: Nov 17, 2025

87468.2 Additional Personal Rights of Residents...(a) In addition to the rights listed in Section 87468.1, Personal Rights of..residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (16) To written notice of any room changes...30 days in advance unless a room change is agreed to by the resident...... This requirement is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which the staff did not provide R1 of the room change notice 30 days in advance which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 10, 2025

Plan of correction: Licensee/Administrator shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 87468.2(a)(16) and train staff on the same regulation. Administrator to submit written POC and in service training log to CCL/LPA by POC due date.

Allegation investigated: Staff did not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Nune margaryan conducted an unannounced initial complaint investigation visit regarding the above allegation. LPA met with Denise Sutton, Supervisor and explained the reason for the visit. The investigation consisted of the following: LPA Margaryan obtained a copies of the Staff roster, Residents roster, reviewed Resident 1(R1) and Resident 2 (R2) files and obtained copies of relevant documents. Interviews conducted with Supervisor, Staff 1 and Staff 4 (S1 and S4), Resident 1(R1) to Resident 6 (R6). Continue 9099C Unsubstantiated The investigation revealed the following: Regarding allegation: Staff did not safeguard resident's personal belongings. It was alleged that R2 stole R1's personal belongings, personal documents and attempted to add an additional cable TV receiver in R2's room. Interviewed Supervisor and S1 mentioned that they were aware of the incident that happened about 2 months ago, R2 stole R1's personal documents. R1 and R2 were roommates before the incident. Interviewed Supervisor stated that the best option for both residents was to move R2 to another room to avoid further issues. They chose the better option at that time. Supervisor and S1 stated that they didn't hear any complaints from staff or residents that any resident stole another resident personal belongings, personal documents before. This incident was first one that they heard, and they have done and will do everything to avoid such cases in the future. Interviewed S2 and S3 stated that they didn't hear any complaints about stealing of residents personal belongings. Interviewed S4 stated that they heard that R2 tried to use R1's documents / information to get extra Spectrum box in R2's room. Interviewed R1 stated that R2 was R1's roommate before. R1 indicated that R2 is nice person but he/she likes to go thought to R1's personal belongings. Facility staff move R2 from R1's room. Interviewed R2 - R6 stated that they are not missing anything, and no one took / stole their personal belongings or personal information. They didn't hear that any resident stole another resident personal belonging, personal information. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 24, 2025 · control 28-AS-20251016205205

Allegation investigated: Resident does not have a call signal button in the room Resident is not being provided assistance per care and needs plan Staff entered resident's room without permission resulting in broken furniture

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced complaint investigation visit regarding above allegations. LPA met with Denise Sutton Medical Coordinator and explained the reason for the visit. The investigation consisted of the following: LPA requested a copy of resident/staff roster, conducted a tour of the facility and observed 5 resident bedrooms. LPA interviewed five (5) residents and six (6) staff and requested a copy of admission agreement, physician’s report, preplacement appraisal, and apparel needs and service plan for resident #1(R1). SEE LIC 9099C Unsubstantiated In regard to the allegation “Resident does not have a call signal button in the room”, it is alleged that there is no call button in residents’ room and residents must call facility phone number to request assistance with care. During interviews with staff six (6) out of six (6) stated that all bedrooms are provided with a pull cord in bathrooms. S1 stated that residents are assessed and if determined that a resident is frail and in need of additional assistance a call pendent is provided. Staff stated residents call on their cell phones or room phones if assistance is needed. LPA observed five pull cords in residents’ bathrooms. During interviews with residents four (4) out of five (5) residents stated that they all have pull cords in restrooms and if needed they use their phones for assistance. LPA was not allowed entry in R1’s bedroom and a request for an interview was denied. In regard to the allegation “Resident is not being provided assistance per care and needs plan”, it is alleged that resident is not being provided adequate assistance with transfers from bed to wheelchair due to R1 being tall and caregivers being too small for his/her weight. During interviews with staff six (6) out of six (6) stated that there is enough staff to properly transfer all clients, and facility even has Hoyer lifts if needed. All staff stated that residents care and needs plans are being followed. During interviews with residents five (5) out of six (6) residents stated that all of there care and needs are being met by staff. LPA attempted to interview R1 but was denied. In regard to the allegation “Staff entered resident's room without permission resulting in broken furniture”, it is alleged that staff broke a residents table when cleaning room. During interviews with staff five (5) out of six (6) staff stated that to their knowledge nothing has been broken in resident’s bedroom. S1 stated that he/she did hear of an allegation of a broken table, but no proof was ever submitted. During interviews with residents three (3) out of six (6) residents stated that they have never had anything broken due to a staff entering their room. Two (2) residents stated that a small Christmas decoration and a bidet was accidentally broken when housekeeping was cleaning but not on purpose. LPA attempted to interview R1 but was denied. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 11, 2025 · control 28-AS-20250910102233

Allegation investigated: Staff are not following admissions agreement. Staff are unable to communicate with resident due to language barrier.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding above allegations. LPA met with Denise Sutton Medical Coordinator and Dana Perez Resident Service Coordinator and explained the reason for the visit. The investigation consisted of the following: LPA requested a copy of resident/staff roster, conducted a tour of the facility and observed 3 resident room and dining area. LPA interviewed 6 residents and 6 staff and requested a copy of admission agreement, physician’s report, preplacement appraisal, pharmacy invoice, and letter dated 8/25/25 for resident #1(R1). Regarding allegation: Staff are not following admission agreement. It is alleged resident is not being allowed to stay in assigned room per admission agreement. Interviews with residents revealed 5 out of 6 residents have not had issues with their room accommodations. 1 out of 6 residents stated they were asked to move out of their room and they did not wish to switch rooms, and it was done the same day the resident was notified. (CONTINUED ON LIC 9099C) Substantiated Interviews with staff revealed resident was notified in writing on 8/25/25 that they will be switching R1 from rooms due to the need of the room to accommodate another resident with greater needs. On 8/29/25, Medical Coordinator went to R1’s room and notified R1 that they will be assisting R1 to move rooms that day and was moved within the hour. Per Document review dated 8/25/25 R1 was notified that they will be moved to another room on the first floor due to the need of space in current room and the move will take place on 9/6/25. Admission agreement signed 7/31/25 notes assigned room for R1 and notes transfer will be based on health and safety concerns of either resident. However, it does not note the transfer will take place on the same day. Based on the information provided, the notice, and the admission agreement reviewed, R1 was moved out of the room prior to the date on the notice. Therefore, this allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Regarding allegation: Staff are unable to communicate with resident due to language barrier. It is alleged resident cannot communicate with staff as they do not speak English. Interviews with residents revealed 6 out of 6 residents stated that a few staff are not able to communicate with them when providing care due to the language barrier. However, they provide good care for them. Interviews with staff revealed there are a few staff, mostly the newer staff that cannot communicate in English and require assistance from other staff to communicate with the residents. LPA conducted interviews with staff in English during this visit. Per management team they do have a few staff that use their phone or other means to communicate with the residents. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with staff and a copy of this report, LIC 9099D, and appeal rights were provided. Interviews conducted with residents revealed 4 out of 6 residents stated staff speak to them respectfully and do not yell. 2 out of 6 residents stated a staff member has been disrespectful to them when speaking to them, not yelling but disrespectful. Interviews with staff revealed that staff are respectful when speaking to the residents and have not witness staff yelling or being disrespectful to the residents in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Regarding allegation: Staff are denying resident's request to share a room. Interviews conducted with residents revealed 4 out of 6 residents have a private room and have no concerns or requested to have a shared room. 2 out of 6 residents have or had a shared room, 1 resident stated that they are aware they will be sharing a room with a roommate and had a roommate until recently. Another resident stated that they are concern that they won’t be able to fit their belongings in a different room when needing to share the room as the previous room was large enough to accommodate their belongings. Interviews with staff revealed currently the rooms at the facility are shareable and accommodation is provided to ensure both residents are comfortable when sharing. Per Medical Coordinator and Resident Coordinator, R1 was temporarily moved into a room without a roommate due to accommodation for a resident with greater needs needed to be made. However, once there is a need for R1’s current room to have a roommate, R1 will have a roommate. Per notice provide to R1 on 8/25/25 it notes that for a “short period of time … would be the only occupant.” Although R1 was moved alone to a room, R1 could have a roommate eventually. Therefore, this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Regarding allegation: Staff are not providing adequate food service. It is alleged resident is not provided with a place to sit in the dining room to eat their meals. Interviews conducted with residents revealed 5 out of 6 residents stated there is sufficient space and a space for them to always seat during their meals. 1 out of 6 residents stated that on an occasion they found their usual/assigned dining space occupied and they decided to walk out of the dining room. Interviews with staff revealed there is sufficient seating area for the residents to have their meals. Per Resident Service Coordinator, assignment of seats during meals had been rearranged due to residents not getting along. However, there is always open space for residents to have their meals during mealtimes. During facility’s tour LPA observed a large dining room with tables and chairs available for meals. (CONTINUED ON LIC 9099C) Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Regarding allegation: Staff do not accord resident with privacy. It is alleged staff walk into residents’ room without knocking. Interviews conducted with 5 out of 6 residents revealed staff knocks before entering their rooms. 1 out of 6 residents stated there is one staff member who does knock. However, this staff enters the room without waiting for the residents to respond. Interviews with staff revealed staff knock at residents’ door prior entering their room. LPA observed 1 staff knocking at a resident’s room before entering the room and observed a staff calling out to the resident prior entering the resident room as the resident’s door was open. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Regarding allegation: Staff are withholding resident’s assigned keys. It is alleged facility staff has not provided resident with a key to the room. Interviews conducted with 4 out of 6 residents revealed residents have been provided with a key to their rooms and mailbox. 2 out of 6 residents stated not to have a key to their rooms. However, 1 of the 2 stated that they didn’t need a key as they are not able to use it. 1 out of the 2 residents stated that they were recently provided with a mailbox key but no room key. Interviews with staff revealed that residents are provided with a key upon admission. Per medical coordinator, R1 was provided a key to the mailbox on 9/2/25 and a key to the room on 9/4/25 for the new room that R1 was moved to on 8/29/25 due to the long weekend accommodations to obtain a key sooner was not available. Also, a key to the previous room would have been provided by the marketing employee, who is no longer employed at the facility. Although a key was provided a few days after the resident moved into a new room. There is no evidence that a key was not provided for the previous room or documents that note a key was provided. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. (CONTINUED ON LIC 9099C) Regarding allegation: Staff are overcharging resident. It is alleged resident is being charged for prescription fees. Interviews with residents revealed 5 out of 6 residents stated to not have had additional charges or pharmacy charges from the facility. 1 out of 6 residents stated to have received a statement dated 8/14/25 from the facility’s contracted pharmacy for $4.80. Per resident they use their own pharmacy and do not use the services of the pharmacy that sent the invoice. Interviews with staff revealed R1 had made them aware of the invoice, and they contacted their contracted pharmacy. Resident Service Coordinator stated to have requested a profile only from the pharmacy. However, they did not request medications and pharmacy processed them. After the Resident Service Coordinator contacted the pharmacy, they corrected the error and provide an invoice with no balance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with staff and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 28-AS-20250828081551

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87568.1(a)(6) · Plan of correction due date: Sep 5, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facility (a) In addition...shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility. This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure admission agreement for R1 was followed and was moved before notice day which poses an immediate risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Administrator will certify that they will ensure admission agreement and notices are followed by staff by POC due date 9/5/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Sep 18, 2025

87411 Personnel Requirements - General (d) All personnel shall be given ... shall provide knowledge of and skill in the following, ..: (3) Skill and knowledge required to provide,... including the ability to communicate with residents. This requirement is not met as evidence by: Based on interviews conducted licensee did not ensure staff are able to communicate wtih residents in care which poses a potential risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Administrator will submit a plan to ensure hiring and all staff are able to communicate with residents in care by POC due date 9/18/25.

Allegation investigated: Facility is in violation of their fire clearance

Licensing Program Analysts (LPA) Luis De Leon conducted an unannounced complaint investigation visit for the allegation listed above. LPA met with the Assistant Administrator Denise Sutton and explained the reason for the visit. The investigation consisted of the following: On today’s visit, LPA De Leon toured the physical plant with Assistant Administrator Denise Sutton. LPA obtained the current client and staff roster, physician reports, list of residents in hospice care, and hospice assessment. Regarding allegation: Facility is in violation of their fire clearance. It is alleged that the facility is retaining bedridden residents in violation of their fire clearance which was only approved for non-ambulatory residents. The fire clearance for bedridden was denied on 11/21/2024. The current fire clearance was approved for 124 non-ambulatory residents only. The investigation revealed that seven (7) out of seven (7) residents denied knowing anyone at facility being bedridden or needing help repositioning on bed. Report continues on page 9099C... Unsubstantiated One resident confirmed to need assistance for all activities of daily living, but review of physician reports show identifies resident as non-ambulatory. In addition, a record review of physicians reports for hospice residents revealed that nine (9) out of nine (9) hospice residents’ physicians reports identified residents as non-ambulatory. During facility tour, LPA observed resident R10 to be in bed with half bed rails which physician report identified resident as non-ambulatory. Seven (7) out of seven (7) staff interviews revealed that the facility has no bedridden residents. Some residents were identified as needing repositioning, but record reviews identified residents as being bedbound. Services provided were for transferring, feeding, dressing or showers. Based upon the investigation, client and staff interviews, document review, and LPA observations, the facility is not in violation with their fire clearance. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview was held with Assistant Administrator Denise Sutton. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 24, 2025 · control 28-AS-20250716133904

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Luis De Leon conducted a Case Management- Incident visit to follow up on an incident report submitted to the Regional Office on 2/17/2025. LPA met with Assistant Administrator Denise Sutton. The purpose of today's visit is to check on the health & safety of residents in care. On 7/13/2025, smoke was observed coming out from the breakout room in the basement. Pasadena Fire Department (PFD) arrived to facility and it was reported that source of smoke had been put out upon fire department arrival. Prior to leaving the facility, PFD toured the facility. PFD and Facility were not able to clear alarm on facility’s fire panel. As a result, PFD placed the facility on fire watch. Assistant Administrator Denis Sutton stated that she was present during the smoke alarm incident and stated that Pasadena Fire regulation does not require smoke detectors in the basement, only sprinkler systems. Since there was no fire, the fire sprinklers did not activate. The smoke was discovered when the elevator smoke detector was triggered. PFD cleared all floors but, before leaving, the facility was unable to reset the facility’s fire panel. Therefore, the facility was placed on fire watch until fire system company came on site to service the fire panel system at the facility. Assistant Administrator Denis Sutton confirmed that the facility was out of fire watch the following day on 7/14/2025. LPA toured the basement and observed there was no structural damage and no residents were injured. No health and safety issues were observed. No deficiencies were observed. An exit interview was with Assistant Administrator Denise Sutton. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jul 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Dana Perez and explained the reason for the visit. The facility is licensed to serve 124 non-ambulatory residents over the age of 60, with a hospice waiver for 9 residents. The facility is located in a residential area and consist of a multi level building with a dining room, library area, a commercial kitchen, resident rooms, a medication room, two (2) courtyards, a patio, a smoking area in the first floor. The second floor has a seating area, a TV room, an activity area, several resident rooms. There are a total of three (3) stairwells. The baseman consist of staff offices, a therapy room, a laundry room, a beauty parlor, and staff break rooms. Each resident' room has a private bathroom. LPA conducted a tour of the facility with Dana Perez and observed the following: Facility is clean and in good repair indoor and outdoor. All common areas are in good repair and furnished. Required posters were observed in the hallway across the library. Commercial kitchen was observed clean, and stores sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. A list of special diets is kept in the kitchen. A total of (6) bedrooms were observed each have the required furniture, and bedding supplies, and sufficient lighting. Each resident's bathroom was observed in good repair, with skid strips, and grab bars. Shower's ceiling in room #106 was observed with a crack of about 4in. Water temperature was tested as follow; room #103, tested at 131.0 degrees F., #106 tested at 135.5 degrees F., #207 tested at 132.6 degrees F., #219 tested at 131.3 degrees F., and #226 tested at 135.1 degrees F., which is not within the required 105-120 degrees F. Half bed rails were observed in all (6) bedrooms. Oxygen signs were posted on room #123, oxygen was observed property stored. Courtyards/smoking areas are cleared, a patio with shaded seating area was observed. No large bodies of water were observed. Fire sprinkler system and fire extinguishers were observed throughout the facility. Evacuation chairs were observed in each stairwell. Emergency food supplies and water were observed. Facility maintains a generator in the basement. (CONTINUED ON LIC 809C) LPA reviewed medication and files for 5 residents. Resident #5 did not have a bed rail request on file. Five staff files and training were reviewed. Resident #2 and #4's physician's report note residents have dementia. Per file review residents are not wander risk or non-ambulatory. A change of Administrator has taken place as of 11/4/24. Per current designee documents were mailed to the department. LPA requested that change of administrator documents are submitted to the department by 12/17/24. Infection control plan and emergency disaster plan were reviewed. Last fire drill was conducted on 2/8/24. Deficiencies were noted per Title 22 Regulations. Exit interview was conducted an a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 10, 2024

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit to follow up on items needed to be fixed on the physical plant to continue with capacity increase application. LPA met with Denise Sutton and explained the reason for the visit. On 8/8/24 LPA observed the following: Room #230 was observed currently as a storage, with the closet doors removed, bathroom needs a sink cabinet door, and a toilet seat. Room #208 has a wall with a passageway which will be use for one resident to get to the bathroom and for the other resident to get to the room. On 10/15/24 LPA observed Room #230 had been cleared, doors have been replaced, and a cabinet door in the bathroom was placed and #208's wall has been reduced and allows both privacy and an open path to the bathroom and closet. Facility's physical plant meets Title 22 Regulations. Exit interview was conducted with Denise Sutton and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 15, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit at the facility to follow up on capacity increase request submitted to the department on 2/9/24. LPA met with Denise Sutton and explained the reason for the visit. The facility is currently licensed to serve 60 non-ambulatory residents over the age of 60, of which 5 residents may be bedridden and has a hospice waiver for 9 residents. The facility is located in a residential area and consist of a multi level building with a dining room, library area, a commercial kitchen, courtyard, activity area, several rooms, and patio. No changes have been done to the building. The capacity increase will take place by changing current bedrooms into shared resident bedrooms. The Fire Clearance was granted for 124 non-ambulatory residents over the age of 60 on 7/25/24. The facility does not serve dementia residents and does not have a memory care unit. LPA toured the facility with Denise Sutton and observed common areas and the following resident rooms: #101,116,123,230, 229, 208 randomly chosen. Room #230 was observed currently as a storage, with the closet doors removed, bathroom needs a sink cabinet door, and a toilet seat. Room #208 has a wall with a passageway which will be use for one resident to get to the bathroom and for the other resident to get to the room. Administrator will remove the items, place closet doors back and fix items in bathroom for room #230 and will remove the wall fully or half way in room #208 to avoid confusion on privacy or passageway regulations within 10 days and will submit pictures to the department. Plan of operation will be updated to provide information on meal times and changes due to the capacity in the dining room. LPA will return at a different time to follow up on the items above. Exit interview was conducted and a copy of this review was provided.the state’s words, verbatim · CDSS document, Aug 8, 2024

Allegation investigated: Staff handled resident in a rough manner

Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Administrator Denise Sutton and explained the reason for the visit. The investigation consisted of the following: LPA conducted interviews with Administrator Denise Sutton, Staff 1-5 (S1-5) and Residents 1-5 (R1-5). LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1's facility file. LPA collected copies of documents pertinent to the complaint investigation. LPA conducted a tour of the facility inside and out which consisted of inspection and observations of the lobby, and (5) five resident rooms. LPA conducted a phone call with R1's Family Member (C1 FM). (See LIC9099C for continuation) Unsubstantiated Investigation revealed the following: Regarding allegation, Staff handled resident in a rough manner, it is alleged that on 03/15/24, a facility staff (S1) handled a facility resident (R1) in a rough manner. R1 was allegedly having Physical Therapy when S1 poked them in the chest as a form of motivation. Interview with facility administrator revealed that R1 called the police department and reported that S1 handled them in a rough manner. Administrator stated that R1 does not have physical therapy and stated that S1 or any other staff have not handled R1 or any other resident in a rough manner. Administrator stated that R1 has some confusion. She stated that R1 does require assistance with their Activities of Daily Living (ADLs) and has not previously reported any concerns about any staff handling them in a rough manner before reporting this alleged incident. Interviews conducted with 5 out of 6 staff revealed that facility staff do not handle R1 or any other resident in a rough manner. They stated that they provide care to residents which includes assistance with their ADLs. 1 staff stated that they have heard that a staff at the facility (S5) handles residents roughly and is aggressive with some residents when turning them. S5 denied ever handling any resident in a rough manner and denied ever treating any resident aggressively. Interviews with facility staff revealed that facility residents are always treated with dignity and respect. Interviews conducted with 4 out of 5 residents revealed that facility staff have never handled them in a rough manner, they are satisfied with the services and do not have any concerns. 1 resident stated that a staff at the facility poked them in the chest area but it did not cause any bruising. They stated that they do not remember if it was a male staff or a female staff. They stated that it has not happened again. C1 FM stated that they are satisfied with the services R1 is getting at the facility and does not have any concerns. C1 FM stated that R1 did report to them that an incident had occurred on 03/15/24 but was not able to provide details to them about the incident. C1 FM stated that R1 does have some confusion. LPA reviewed of R1's Physician's Report for Residential Care Facilities for the Elderly (RCFE) dated 12/01/23 which revealed that R1 is diagnosed with Major Neurocognitive Disorder and has conditions and behaviors in relation to that diagnosis. R1 requires assistance with their ADLs. LPA observed interactions between staff and residents and did not observe anything of concern. LPA additionally did not observe any bruising on any resident. Based on statements gathered from interviews conducted with staff, residents, C1 FM and LPA record review and observations there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview held. A copy of the report was provided to Administrator Denise Sutton.the state’s words, verbatim · CDSS document, Mar 28, 2024 · control 28-AS-20240319134029

Allegation investigated: Facility mismanaged resident's medications.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation regarding the above allegation. LPA met with Denisse Sutton and explained the reason for the visit. The investigation consisted of the following: LPA requested staff and resident roster, reviewed medication for 7 residents, interview 7 residents and 5 staff, reviewed resident #1(R1)’s and resident #2(R2) medication and requested copies of medication sheet for January and February 2024 for both residents, resident’s notes, medication error report form dated 1/30/24, incident report dated 2/2/24,physician’s report for R1, face sheet, and staff #1(S1)’ medication training. The investigation revealed the following: Regarding allegation: Facility mismanaged resident's medications. It is alleged that resident took someone else medication and resident is now hospitalize. (CONTINUED ON LIC 9099C) Substantiated Interviews conducted with residents revealed there have not been incidents in which medication was provided by mistake. Interviews with staff revealed there was a medication error on 1/30/24 in which night shift med tech provide someone else’s medication to R1. Per med-tech (S1), staff picked up the cup at 6:00am in the morning and took the medication to R1. Upon returning to the medication room, nurse ask if the medication was provided and realized that the medication taken was not R1’s medication but R2’s medication, once S1 looked at the label in the cup. R2’s medication was a missed dosed and needed to be disposed in the morning. Per S1 it was a mistake. Facility contacted R1’s physician and responsible party. Per physician’s recommendations facility staff monitored R1 throughout the day for side effects which were reported to physician. On 2/2/24 R1 went to an office doctor visit during the visit R1 reported to have hit R1’s right shin and went out to the hospital due to the hematoma to the right shin and unrelated to the medication error. LPA observed prepared medication for residents and each cup is label with residents’ name and time. Document review revealed facility documented medication error on resident’s note and medication error report form, as well as in the medication sheet. S1 last medication training was provided on 9/25/23, 12/28/23, and 12/30/23. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Denise Sutton and a copy of this report, LIC 9099D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Feb 13, 2024 · control 28-AS-20240207115418

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 14, 2024

87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidence by: Based on interviews conducted and document review licensee did not ensure that R1 received the correct medication by giving R1 medication that belong to R2 which poses an immediate risk to the health, safety, or personal rights to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Administrator will provide medication training for S1 which will include shadowing and will submit a copy of training log, topic, description of training, and duration of training by POC due date 2/14/24.

Type of visit: POC

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction (POC) visit to follow up on deficiencies noted during annual visit conducted on 1/4/24. On 1/4/24 LPA Flores conducted an annual visit and noted the following deficiencies: Type A - Section 87303(e)(2) Maintenance and Operation: Water temperature tested as follow in RB #222 water temperature tested at 124.0 degrees F., RB#233 tested at 123.4 degrees F., RB 231 tested at 98.8 degrees F., and RB#206 tested at 100.9 degrees F. On 1/5/24 administrator certify in writing that temperature had been adjusted. On 2/1/24 LPA Flores tested water temperate in room #222,233,231, and 206 tested between 107.7- 109.5 degrees F., which is within the required 105-120 degrees F. Deficiency cleared as of 2/1/24. Type B - Section 87307(d)(2) Personal Accommodations and Services: Courtyard patios were observed with three uneven cracks on the ground of about 1.5 - 2ft in length. On 2/1/24 LPA observed the courtyard and the repairs done to cover the holes. Deficiency cleared as of 2/1/24. Technical Violations noted: 1) Passage way on the side of the kitchen was observed with a mop bucket, several crates, and a box. On 1/23/24 LPA Flores received pictures of cleared passageways. 2) An evacuation chair at each stairwell. On 2/1/24 LPA observed an evacuation chair in both stairwells. Exit interview was conducted with Denise Sutton and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 1, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Denise Sutton and explained the reason for the visit. During this visit LPA Flores concluded the inspection and reviewed the following domains from the CARE inspection tool: Infection Control, Staffing, Incidental Medical and Dental, and Disaster Plan. LPA reviewed medication for 5 residents, infection control plan last reviewed on 6/4/23, First Aid/CPR certificates for 5 staff, and Disaster Plan last reviewed 12/17/23. Last fire drill was conducted on 11/28/23. Evacuation chair was order by the administrator invoice was observed. LPA interview 2 staff and 2 residents. No deficiencies were noted during this visit. Exit interview was conducted with Denise Sutton and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 9, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Denise Sutton and explained the reason for the visit. The facility is licensed to serve 60 non-ambulatory residents over the age of 60, of which 5 residents may be bedridden and has a hospice waiver for 9 residents. The facility is located in a residential area and consist of a multi level building with a dining room, library area, a commercial kitchen, courtyard, and patio. LPA conducted a tour of the facility with Denise Sutton and observed the following: Lobby, library, activity room, dining room, and other areas were observed furnished and in good repair. Fireplace in the library was observed covered. Chemical solutions and other harmful liquids were observed locked and inaccessible to residents. Resident's bedrooms (RB) were observed (7 rooms) randomly and each had sufficient lighting, the required furniture and bedding supplies. Each resident's has a personal bathroom which were observed in working condition. Water temperature was tested in each resident's bathroom and measured between 98.8 - 124.0 degrees F., which is not within the required 105-120 degrees F. In RB #222 water temperature tested at 124.0 degrees F., RB#233 tested at 123.4 degrees F., RB 231 tested at 98.8 degrees F., and RB#206 tested at 100.9 degrees F. Carbon Monoxide/Smoke detectors were tested in each room and are in working condition. Fire Extinguishers were observed throughout the building and were last checked on 4/25/23. No large bodies of water were observed. Facility has two courtyards, a smoking patio, and a smaller patio on the side of the building. The courtyard patios were observed with uneven cracks (3) on the ground of about 1.5 - 2ft in length. An emergency evacuation chair was observed on top of the front stairwell. The back stairwell did not have an emergency evacuation chair. LPA reviewed files for 5 residents and 5 staff. Administrator certificate was observed for Denise Sutton #6009562740 exp. date: 3/5/25. LPA will return at a different time to finish the annual visit. Deficiencies noted on LIC 809D per Title 22 Regulations. Exit interview was conducted and a copy of report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 4, 2024

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Questionable death. Staff did not reposition resident resulting in resident sustaining a stage 4 pressure injury. Staff did not change resident's diaper in a timely manner.

Licensing Program Analyst (LPA) Elizabeth Irra conducted an investigation for the above allegations. LPA met with Denise Sutton (Administrator) and discussed the purpose of today's visit. LPA conducted a tour of the building and grounds and did not observe any signs of neglect, abuse or other immediate health and safety threats. During this visit, LPA obtained a copy of the staff and resident rosters, LPA reviewed and obtained copies of the Resident Daily Census reports for March 2023 through June 2023 and interviewed Denise Sutton (Administrator) and Dana Perez (Resident Service Coordinator). Refer to LIC 9099C for the continuation of this report. Unfounded It was alleged that R-1 had a questionable death, staff did not reposition R-1 resulting in R-1 sustaining a stage 4 pressure injury and staff did not change R-1's diaper in a timely manner. Per interviews, Resident#1 (R-1) has not resided at this facility. Resident Daily Census reports (noted above) do not reflect that R-1 was a resident at this facility. Staff interviews and reviewed documentation do not corroborate the above allegations. This agency has investigated the complaint alleging R-1 had a questionable death, staff did not reposition R-1 resulting in R-1 sustaining a stage 4 pressure injury and staff did not change R-1's diaper in a timely manner. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. Exit interview conducted, a copy of the appeals rights and this report was provided to Denise Sutton.the state’s words, verbatim · CDSS document, Dec 14, 2023 · control 28-AS-20231212155347

Allegation investigated: Facility meals do not meet the needs of the resident(s). Resident's bathroom is in disrepair.

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to investigate the above allegations. The purpose of the visit was discussed with Denise Sutton. The investigation consisted of the following: On 4/27/2023, LPA conducted a physical plant tour of the facility with focus on room #202 and the kitchen. Staff (S1- S3) were interviewed. LPA reviewed resident (R1's) file and obtained copies of file documents [Face Sheet, Physician Report, Admission Agreement, Resident Appraisal, hospital discharge documents, resident notes, Medication Administration Record (MAR), physician orders, weekly [ Sun. April 19- April15] food menu, special diet menu, alternate food menu, resident service plan, and staff and resident rosters. On 4/28/2023, resident (R1) was interviewed at their new place of residence. During today's visit, a physical plant tour was conducted with focus on 7 resident room bathrooms and kitchen food service. Residents (R2 - R8) and staff (S4) were interviewed. Copies of 3 three incident reports 4/15/23 and two (2) dated 4/24/23 were reviewed and obtained. Substantiated Allegation: Facility meals do not meet the needs of the resident(s). It is alleged that resident (R1's) physician ordered restricted diet is not meeting the resident's nutritional needs because residents are served very small meal portions, the food is of low quality with no vegetables, and all the food appears processed. According to information obtained, resident (R1) has physician orders for a diabetic diet. A total of eight (8) residents were interviewed, of which one (1) resident stated the food served is not meeting their needs. The facility serves open breakfast meal. Lunch and dinner are set menus. There is an alternate menu as well. Snacks are served and health shakes are served four (4) times a day in addition to their meals for residents that are low weight. A total of four (4) staff were interviewed, it was acknowledged that resident (R1's) Physician's Report stated the resident requires a Diabetic diet, but the resident was not placed on the restricted diabetic diet due to an oversight. Per record review, the findings indicate that resident (R1) has not added to the Specialized Diet list during the time the resident resided at the facility. Allegation: Resident's bathroom is in disrepair. It is alleged that the screws of the stainless steel grab bar in resident (R1's) the bathroom tub area were loose. The resident tried to stabilize their self upon exiting the shower chair and the resident fell back and almost hit their head, but no injuries were sustained. According to reporting party, Administrator was informed of the hazard, but it was not fixed for at least 3 days. Staff interviews revealed that when resident (R1) moved in the room was checked. It is unknown if the grab bar became loose after resident use, or whether it was a staff oversight when they completed the Apartment Safety and Cleanliness inspection. According to Administrator, preventative maintenance on resident rooms is done on a quarterly basis. LPA inspected eight (8) rooms, none had loose bathroom grab bars. A total of eight (8) residents were interviewed, only resident (R1) reported loose grab bars. Based on observation and interviews conducted, the findings indicate that resident (R1's) bathroom had loose grab bars likely due to staff oversight during the move-in activity, but staff reported it was not intentional. The grab bar was repaired on 4/25/2023. Based on record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited. See LIC 9099D. An exit interview was conducted and a copy of this report and appeal rights was provided to Administrator Denise Sutton. Allegation: Facility staff did not dispense resident's medications as prescribed. It is alleged that on 4/18/2023, resident (R1's) PRN "Hydrocodone-Acetamin 5-325 mg medication was not administered per physician order i.e. every six (6) hours as needed because the medication was brought to the resident at 3:00 AM instead of 2:00 AM, which resulted in "suffering". According to information provided, the resident was being given the PRN medication, but on at least two (2) other occasions it was late as well. Resident (R1) stated that the medication was to be administered routinely every 6 hours. A total of eight (8) residents were interviewed, of which one (1) stated that their medications are not dispensed as prescribed. Per staff interviews, the PRN medication was to be administered every 6 hours. The medication order was not changed by Dr. Chen until 4/20/2023. The new physician's order was changed to every four (4) hours routinely, "hold if pt is asleep". Per record review of Narcotic Drug Record and Medication Administration Records, it was noted that the PRN "Hydrocodone-Acetamin 5-325 mg medications was not always administered every 6 hours. However, based on record review of physician's orders the medication was changed to every 4 hours routinely until 4/20/2023. Therefore, facility staff followed physician's orders. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Denise Sutton. A copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 28-AS-20230418110249

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Nov 3, 2023

General Food Service Requirements. Modified diets prescribed by a resident’s physician as a medical necessity shall be provided. This requirement was not met evidenced by: Based on record review, resident (R1's) Physician's Report states the resident requires a diabetic diet. However, R1 was not being served a diabetic diet, and had not been added to the restricted diet list; which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 20, 2023

Plan of correction: Administrator shall ensure all resident files with special diet physician orders are communicated with kitchen and LVN staff. Submit a written plan of correction by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 3, 2023

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met evidenced by: Based on interviews conducted, resident (R1's) bathroom grab bars were loose and not fixed in a timely manner, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 20, 2023

Plan of correction: Administrator shall submit a written plan of correction by POC due date.