Discovery Commons Whittier

Allegation investigated: Staff does not ensure resident's care needs are being met due to lack of staff.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 05/22/2026 regarding the above allegation. On 03/12/2026, LPA Ramirez conducted an initial complaint investigation visit and a need for further investigation was documented. During today’s visit LPA Ramirez was greeted by Administrator George Gonzalez and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster, Staff#1 - 10 interviews (S1 – S10), Resident#1-8 interviews (R1- R8), Interview of Witness#1 (W1), staffing schedules from March 2026 through May 2026, and physical plant tour. SEE 9099-C Unsubstantiated The investigation revealed the following: regarding the allegation “Staff does not ensure resident's care needs are being met due to lack of staff.” It is alleged that staff are not meeting resident’s care needs due to lack of staff. Ten (10) out of the ten (10) staff interviewed denied this allegation. Staff interviews revealed that additional staff have been hired due to additional admission of residents. Staff interviews revealed that residents who require more assistance due to their care plan receive additional assistance in a timely manner. Staff interviews revealed that residents who require use of a Hoyer lift always have two (2) staff to assist. Staff interviews revealed that on average days there are three (3) to four (4) caregivers and one (1) medication technician to assist residents in the assisted living section and memory care section. Eight (8) out of the eight (8) residents interviewed denied this allegation. Resident interviews revealed that there is sufficient staff to assist residents with their needs. Resident interviews revealed that staff meet all of the residents’ needs majority of the time. Interview with W1 did not corroborate this allegation. Review of facility staffing schedules from March 2026 to May 2026 revealed additional staff were hired. During facility tour, LPA observed several staff providing care and supervision to residents. LPA observed residents to be well groomed and observed residents’ rooms to be well maintained. 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 complaint investigation. Exit interview was conducted with Administrator George Gonzalez. A copy of this report was provided.the state’s words, verbatim · CDSS document, May 22, 2026 · control 28-AS-20260309193845

Allegation investigated: Staff neglect resulted in resident sustaining an injury due to a fall. Staff did not ensure resident was adequately hydrated.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 01/29/2026 regarding the above allegations. On 01/22/2026, LPA Ramirez conducted an unannounced initial complaint investigation, and a need further investigation was documented. During today’s visit LPA Ramirez was greeted by Administrator George Gonzalez and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster (LIC 500), Staff#1 - 5 interviews (S1 – S5), Attempted Interview of Staff#6-7 (S6-S7), Attempted Interview of Resident#1-5 interviews (R1-R5), Attempted Interview with R1’s responsible party, Copies of Resident#1 (R1): Admissions Agreement, Change in Condition Assessment, Observations Notes on R1, Physician Report and Admissions Orders, Unusual Incident Reports, Hospice Care Orders and Notes and physical plant tour. SEE 9099-C Unsubstantiated The investigation revealed the following: regarding the allegation “Staff neglect resulted in resident sustaining an injury due to a fall.” It is alleged that staff neglect resulted in a resident sustaining an injury due to a fall. Five (5) out of five (5) staff interviewed denied this allegation. Staff interviews revealed that R1 was considered a high fall risk and staff took interventions to prevent R1’s falls. Staff interviews revealed that R1 was placed on 30-to-45-minute room checks, a fall mat was placed in their room, a wheelchair was used to assist R1, and staff attempted to keep R1 in common areas so that R1 was always in line of sight of staff. Records reviewed revealed that R1 was admitted into the facility on 11/27/2024. On 12/03/2024, R1 was moved into the facility memory care due to a change in condition. Review of Unusual Incident Reports revealed the following: on 06/01/2025, R1 had a witnessed fall and was observed with discoloration to their eye and nose and R1’s responsible party was notified and took to urgent care the same day. On 11/30/2025, R1 had a witnessed fall. R1 was assessed by staff and did not see any visible injuries. Staff contacted R1’s responsible party and R1’s physician regarding the fall. On 12/25/2025, R1 was observed laying on the hallway floor with discoloration to their forehead. Staff called 911 and R1 was sent to a local hospital for further evaluation. R1 was released later that day with no new orders but staff documented R1 was placed on frequent checks as a result of this fall. On 01/15/2026, staff conducted a room check on R1 and discovered R1 on the floor with a minor cut to their forehead. Staff called 911 and R1 was taken to a local hospital for evaluation. R1’s responsible party and physician were notified of R1’s fall. R1 was admitted to the hospital and released back to the facility on 01/16/2026 with hospice care services. Review of R1’s change of condition assessment conducted on 10/26/2025, revealed that R1 was assessed as a high fall risk. LPA Ramirez attempted to interview R1’s responsible party but all attempts were unsuccessful. LPA Ramirez attempted to interview R1 but all attempts were unsuccessful. LPA Ramirez attempted to interview R2-R5 but due to cognitive impairment, responses were unreliable. Record review of R1’s observation notes documented room checks conducted by staff, R1’s falls and notification to R1’s responsible party and physician about the falls. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. SEE 9099-C for continued narrative Staff did not ensure resident was adequately hydrated.” It is alleged staff did not ensure R1 was adequately hydrated. Five (5) out of five (5) staff interviewed denied this allegation. Staff interviews revealed that R1 was always provided with water, however, R1 would at times refuse to eat or drink water. Staff interviews revealed that staff would encourage R1 to eat or drink water when R1 would initially refuse but R1 would get agitated if staff persisted. Review of staff observations notes revealed that staff documented R1’s refusal to eat or drink and staff notified R1’s responsible party and physician. LPA Ramirez did observe staffing notes that indicated R1 ate and drank water without resistance. LPA Ramirez attempted to interview R1’s responsible party but all attempts were unsuccessful. LPA Ramirez attempted to interview R1, but all attempts were unsuccessful. LPA Ramirez attempted to interview R2-R5 but due to cognitive impairment, responses were unreliable. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 28-AS-20260117135300

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual inspection visit on 11/14/2025 and was greeted by Administrator Joshua Castillo. LPA Ramirez identified herself and explained the purpose of the visit. The facility is located on a main street and is a two-story dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be accessible in resident room#207 (R2’s room). Administrator Castillo immediately removed upon LPA Ramirez’s observation. LPA Ramirez observed R5’s bathroom cabinet was unlocked and R5 had direct access to personal grooming and hygiene items. Per R5's recent physician's report, R5 may not have direct access to personal grooming and hygiene items. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected six (6) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed no-slip coating in showers. See 809-C Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Residents Rights-Information: LPA Ramirez did not observe Complaint Poster (PUB 475) in main entrance of facility. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 10/23/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in kitchen pantry. LPA Ramirez observed one (1) evac-chair in each stairwell of the facility. Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication closet and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services. Staffing: Administrator Certificate for Joshua Castillo 05/03/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. see 809-C Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for two (2) out of the two (2) direct care personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel record reviewed. Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for one hundred twenty-five (125) non-ambulatory residents of which twenty (20) may be bedridden. This facility may retain no more than twenty (20) hospice residents. Resident Records/Incident Reports: LPA reviewed resident records for six (6) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. Two (2) deficiencies were identified, and plan of corrective action was issued. Exit interview conducted. A copy of this report, 809-D and appeals rights were provided.the state’s words, verbatim · CDSS document, Nov 14, 2025

Allegation investigated: Due to neglect, resident sustained wounds Staff are not ensuring residents hygiene needs are met Staff did not provide timely medical care for resident

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Frances Reyes and explained the reason for the visit. The purpose of the visit is to deliver findings from the original complaint dated 12/18/2024. The initial visit was a Health and Safety Check conducted on 12/19/2024 and included the following: LPA conducted a tour of the facility, including food supply, resident rooms, bathrooms, and common areas. The kitchen had sufficient perishable and non-perishable food. Resident rooms and common areas were properly furnished. LPA did not observe any immediate health and safety risks on today's visit. LPA observed the water temperature measured between 105* F - 120* F, the facility temperature was comfortable for the residents, and electricity was operational. LPA requested and obtained copies of staff and resident roster along with additional pertinent documentation. Investigation was conducted by the Investigations Branch (IB) and completed 03/18/2025 for allegations Due to neglect, resident sustained wounds, Staff are not ensuring residents hygiene needs are met and Staff did not provide timely medical care for resident. Investigation consisted of interviews with facility staff, resident, review of medical documentation and interviews with staff at Hospice Agency and Home Health Agency. I Unsubstantiated In regards to the allegation Due to neglect, resident sustained wounds, based on file reviews, and interviews conducted, there was insufficient evidence to prove that the facility was responsible for Neglect/ Lack of Care, leading to the Resident R1 to sustain wounds while in care. Per the progress notes, on 12/14/2024, the Staff S1 documented that R1 sustained a red spot and scabbing on her right foot. On 12/15/2024, the staff S2 documented that the right dorsal surface (on R1's foot) had redness with open sores and skin lesions. She notified R1's family and her Primary Care Physician (PCP). On 12/16/2024, R1 was taken to the hospital for an evaluation and treatment by her sister. Per interview with the Nurse Practitioner at St. Jude Medical Center, she stated that R1 was diagnosed with cellulitis of her right foot. She added that the wounds would be consistent with this timeline; however, it could take longer for a wound like this to advance to cellulitis. She added that this could occur from hours to days. All the staff interviewed, stated that R1 would have her socks changed daily and she would have showers twice a week. Per the Hospice Nurse and the Home Health Nurse , they both stated that the facility appeared to not be neglectful of R1. They did not believe the facility was neglectful with R1's level of care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated. In regards to the allegation Staff did not provide timely medical care for resident, Based on file reviews, and interviews conducted, there was insufficient evidence to prove that the facility was responsible for Neglect/ Lack of Care, due to Staff not providing timely medical care for the Resident R1 while in care. Per the progress notes, on 12/14/2024, the Staff S1 documented that R1 sustained a red spot and scabbing on her right foot. On 12/15/2024, the Staff S1 documented that the right dorsal surface (on R1's foot) had redness with open sores and skin lesions. She notified R1's family and her Primary Care Physician (PCP). On 12/16/2024, R1 was taken to the hospital for an evaluation and treatment by her sister. Per interview with the Nurse Practitioner at St. Jude Medical Center, she stated that R1 was diagnosed with cellulitis of her right foot. She added that the wounds would be consistent with this timeline; however, it could take longer for a wound like this to advance to cellulitis. She added that this could occur from hours to days. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated. In regards to the allegation Staff are not ensuring residents hygiene needs are met, based on interviews conducted and information gathered Resident R1 revealed that she felt happy and safe at the facility. R1 added that she enjoyed playing games with the staff and other residents, and there was nothing she disliked. R1 added that she would receive two showers weekly. R1 stated that staff would change her socks daily. R1 stated that she has a lot of nurses who would tend to her weekly. Interview with Hospice Agency Representative who stated that “I’m a patient care advocate and I don’t hesitate to call APS, but I don’t think they (the facility) was being neglectful.” Stated that R1's foot issue was addressed by a home health agency, and she believed that the home health agency would be responsible for caring for R1's foot. Interview with Home Health Agency representative who stated that she did not recall any foot issues with R1 as she appeared well cared for and well dressed. Her room was cleaned, and it seemed as she was showered regularly .Could not recall seeing R1 in socks as she would typically wear sandals barefoot. Interview with Staff who stated that R1 was cared for very well by the facility and other agencies. Stated she took 2 showers each week and did not go without socks. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.the state’s words, verbatim · CDSS document, Apr 17, 2025 · control 28-AS-20241218082122

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management visit to investigate a self reported incident received by CCLD on 10/18/2024 of suspected elder abuse by staff on Resident #1. LPA met with Joshua Castillo, Executive Director and explained the purpose of the visit. The report stated that on 10/18/24 at approximately 9:15am, Witness #1 (W1) called Staff #1 (S1) to report an inappropriate conversation at a family dinner involving Resident #1 (R1) and Staff #2 (S2). W1 mentioned hearing about R1 "smooching someone," and R1 mentioned S2’s name. Other family members of R1 also thought the conversation was inappropriate. Staff spoke to R1 and S2 to investigate the allegation. R1 confirmed the dinner and conversation but denied any relationship with S2. S2 stated that he only assists with maintenance requests in R1’s apartment and denied any relationship or physical contact with R1. During today's visit, LPA interviewed (6) staff members, Resident #1 (R1) and obtained copies of the staff/resident rosters and R1's files such as Emergency and Identification Information, Admission Agreement and latest Physician's report. According to S1, he received a call at approximately 9:15am on 10/18/2024 from W1 who reported the inappropriate conversation he had with R1 during a family dinner. On the same day, S1 along with other staff members conducted an immediate investigation and spoke with R1 and S2. R1 mentioned that she finds S2 good-looking but stated that nothing has or will happen between them because of her age and denied any communication or physical contact with S2. Afterward, S1 sent SOC 341 incident report to CCL and LTC Ombudsman. According to S1, there was no credible evidence found on his investigation to substantiate it. S4 stated R1 never complained about pain in any parts of her body and no noticeable injuries found on her. All staff concluded that there is no relationship between R1 and S2. R1’s gestures and comments were perceived as light-hearted and not indicating any actual romantic interest or relationship between them. LPA reviewed R1's Physician's report which showed that R1 is ambulatory and independent. LPA spoke with R1 and S2 in person during the visit, and both denied having any type of relationship between them. There was no additional evidence of inappropriate behavior to suggest a sexual relationship between R1 and S2. Moreover, LPA was unable to find anyone to corroborate that the alleged incident or sexual abuse occurred at this time. Based on the information gathered, there is no signs of neglect or lack of supervision found. No deficiency was issued. An exit interview was held, and a copy of this report was provided to the Executive Director, Joshua Castillo.the state’s words, verbatim · CDSS document, Dec 5, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Joshua Castillo, Executive Director. LPA explained the purpose of the visit. The facility was licensed to serve elderly, ages 60 years old and older. Its capacity was 125 including 125 non- ambulatory and twenty (20) bedridden. The facility had dementia program in place and twenty (20) approved hospice waiver. Annual fees were current. Administrator certificate is current with expiration date on 5/3/26. The inspection consisted of using CARE tool, conducting physical plant, review of food supply, interviews staff/residents, reviews of staff/residents records and medications. The facility is a two-story building. On the first floor, it consisted of a TV room, dining room, kitchen, administrative offices, a locked medication room, the Memory Care Unit, some assisted living rooms, common bathroom, and activity room. On the second floor, it consisted of assisted living residents’ rooms, TV room, resident laundry room, and locked housekeeping storage rooms. Residents' bedrooms were furnished with required furniture and in compliance. Bathrooms, kitchen, common areas were inspected and in compliance. Smoke and carbon monoxide detectors were operable. Fire extinguishers were fully charged with last service on 4/5/24. Auditory devices were operable. Delayed egress exits were operable. Medication was centrally stored in med rooms. Resident records were stored in a locked storage room and inaccessible to residents. Two (2) days perishable and seven (7) days non-perishable were observed. Physical plant was conducted on each floor. Hot water temperature was in a range of 107.5 - 114.2 degrees Fahrenheit which was within Title 22 Regulation guidelines. Signal system was operable and staff arrived to provide assistance within 10 minutes. No deficiency is cited per California Code of Regulations, Title 22. An exit interview was conducted and this report was provided to Joshua.the state’s words, verbatim · CDSS document, Nov 21, 2024

Allegation investigated: Resident developed pressure wounds while in care. Facility is neglecting resident's care. Facility failed to provide timely medical attention to resident in care.

***The licensing report created on 07/26/2024 is being superseded by this licensing report dated 10/01/2024. The licensing report is being superseded due to missing required information relating to the LIC 9099.*** On 10/1/2024 Licensing Program Analyst (LPA) Jewel Baptiste conducted and unannounced visit to interview additional residents. The findings will remain the same and the citations issued during the visit dated 7/26/2024 is still valid. LPA met with Executive Director Joshua Castillo and explained the reason for the visit. During todays visit LPA Baptiste obtained a copy of the staff and resident roster and conducted interviews for residents #4 through Residents #7 (R4-R7). During the prior visit dated 7/26/2024 Licensing Program Analyst (LPA) Angelica Rea made another visit to issue the final results of the investigation. LPA met with Mr. Castillo, who assisted with today's visit. Report Continued on 9099c Substantiated During the prior visit dated 7/26/2024 Licensing Program Analyst (LPA) Angelica Rea made another visit to issue the final results of the investigation. LPA met with Joshua Castillo, who assisted with today's visit. Regarding the allegation that: Facility does not have sufficient staff which has resulted in resident leaving the facility unattended. The investigation was conducted by the department, and consisted of of interviews, review of facility documentation, and review of resident #1 medical records. Interviews conducted were unable to corroborate that resident #1 left the facility unattended. Attempts were made to interview resident #1's family member, however LPA was unable to interview resident #1's family member to obtain additional information. Resident #1 was no longer living at the facility when LPA conducted initial visit and was not interviewed. 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 the report was provided. Regarding the allegation that: Resident developed pressure wounds while in care. The investigation was conducted by the department, and consisted of interviews, review of facility documentation, and review of resident #1 medical records. Hospital records show that resident #1 was admitted to the hospital on 12/5/22 due to a fall and did not have any pressure injuries. Resident #1 was re-admitted to the hospital on 1/16/23 and was diagnosed with an unstageable pressure injury on his right hip, a deep tissue injury on his right hip, and an unstageable pressure injury on his right foot. Per facility documentation provided, on 1/10/23, the pressure injuries on resident #1 were noted. Resident #1's family member stated that they were permitted and relied upon to perform wound care from 1/11/23-1/15/23 at the facility. The investigation found sufficient evidence to show that resident #1 developed pressure wounds while in care of the facility. Regarding the allegation that: Facility is neglecting resident's care. The investigation was conducted by the department, and consisted of interviews, review of facility documentation, and review of resident #1 medical records. Per hospital records, upon admittance resident #1 had "oral cavity dryness, crusting, and debris" due to "poor oral intake and poor oral care at the facility". Resident #1 was diagnosed with a staphylococcus (staph) infection in his mouth. Additionally, hospital records show that staff neglect of resident #1, resulted in a weight loss of sixteen pounds within approximately six weeks. On 12/5/22, resident #1 was admitted to the hospital weighing 150 lbs. On 1/16/23, resident #1 was admitted to the hospital weighing 134 lbs. Per reports provided by the facility, dated 1/11/23, 1/12/23, 1/14/23, and 1/15/23, it was noted that resident #1 was unable to eat, chew, or swallow his food. Resident #1 was diagnosed with severe malnutrition upon admittance to hospital on 1/16/23. The investigation found sufficient evidence to show that the facility was neglecting resident #1's care. Regarding the allegation that: Facility failed to provide timely medical attention to resident in care. The investigation was conducted by the department, and consisted of of interviews, review of facility documentation, and review of resident #1 medical records. Upon being admitted to the hospital on 1/16/23, resident #1 was diagnosed with severe sepsis with acute organ dysfunction, pneumonia, hypernatremia, due to dehydration, severe protein calorie malnutrition, in addition to the unstageable pressure injury on his right hip, a deep tissue injury on his right hip, and an unstageable pressure injury on his right foot. The investigation found sufficient evidence to show that the facility failed to provide timely medical attention to resident #1. Based on interviews which were conducted with staff and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited on the attached LIC 9099D. Immediate Civil Penalty will be issued in the amount of $500.00. The licensee was informed that a civil penalty might be assessed based on health and safety code 1569.49 (e) or (f). Exit interview conducted and copy of report and appeal rights were provided on 7/26/2024.the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 28-AS-20230120113757

Allegation investigated: Resident developed pressure wounds while in care. Facility is neglecting resident's care. Facility failed to provide timely medical attention to resident in care.

Licensing Program Analyst (LPA) Angelica Rea made another visit to issue the final results of the investigation. LPA met with Mr. Castillo, who assisted with today's visit. Regarding the allegation that : Resident developed pressure wounds while in care. The investigation was conducted by the department, and consisted of of interviews, review of facility documentation, and review of resident #1 medical records. Hospital records show that resident #1 was admitted to the hospital on 12/5/22 due to a fall, and did not have any pressure injuries. Resident #1 was re-admitted to the hospital on 1/16/23 and was diagnosed with an unstageable pressure injury on his right hip, a deep tissue injury on his right hip, and an unstageable pressure injury on his right foot. Per facility documentation provided, on 1/10/23, the pressure injuries on resident #1 were noted. Resident #1's family member stated that they were permitted and relied upon to perform wound care from 1/11/23-1/15/23 at the facility. The investigation found sufficient evidence to show that resident #1 developed pressure wounds while in care of the facility. Substantiated Regarding the allegation that : Facility is neglecting resident's care. The investigation was conducted by the department, and consisted of of interviews, review of facility documentation, and review of resident #1 medical records. Per hospital records, upon admittance resident #1 had "oral cavity dryness, crusting, and debris" due to "poor oral intake and poor oral care at the facility". Resident #1 was diagnosed with a staphylococcus (staph) infection in his mouth. Additionally, hospital records show that staff neglect of resident #1, resulted in a weight loss of sixteen pounds within approximately six weeks. On 12/5/22, resident #1 was admitted to the hospital weighing 150 lbs. On 1/16/23, resident #1 was admitted to the hospital weighing 134 lbs. Per reports provided by the facility, dated 1/11/23, 1/12/23, 1/14/23, and 1/15/23, it was noted that resident #1 was unable to eat, chew, or swallow his food. Resident #1 was diagnosed with severe malnutrition upon admittance to hospital on 1/16/23. The investigation found sufficient evidence to show that the facility was neglecting resident #1's care. Regarding the allegation that : Facility failed to provide timely medical attention to resident in care. The investigation was conducted by the department, and consisted of of interviews, review of facility documentation, and review of resident #1 medical records. Upon being admitted to the hospital on 1/16/23, resident #1 was diagnosed with severe sepsis with acute organ dysfunction, pneumonia, hypernatremia, due to dehydration, severe protein calorie malnutrition, in addition to the unstageable pressure injury on his right hip, a deep tissue injury on his right hip, and an unstageable pressure injury on his right foot. The investigation found sufficient evidence to show that the facility failed to provide timely medical attention to resident #1. Based on interviews which were conducted with staff and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited on the attached LIC 9099D. Immediate Civil Penalty will be issued in the amount of $500.00 The licensee was informed that a civil penalty might be assessed based on health and safety code 1569.49 (e) or (f). Exit interview conducted, and copy of report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 26, 2024 · control 28-AS-20230120113757

From the deficiency page — Deficiency type: Type A · Section cited: CCR 876615(a)(1) · Plan of correction due date: Aug 2, 2024

(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not being met as evidenced by : Resident #1 was admitted to the hospital on 1/16/23 with an unstageable pressure injury on his right hip, a deep tissue injury on his right hip, and an unstageable pressure injury on his right foot. This poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 26, 2024

Plan of correction: Licensee will ensure that the facility abides by Title 22 regulations, and does not retain resident(s) with prohibited health conditions. LIcensee will ensure that an in service training with staff is provided, on Section 876615, and will provide LPA with proof of training by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Aug 2, 2024

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not being met as evidenced by : Resident #1 was diagnosed with a staphylococcus (staph) infection in his mouth, upon hospital admittance on 1/16/23. This poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 26, 2024

Plan of correction: Licensee will ensure that the facility abides by Title 22 regulations. Licensee will ensure that an in service training is provided with staff on Section 87465, and will provide LPA with proof of training by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Aug 2, 2024

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not being met as evidenced by : resident #1 was admitted to hospital on 1/16/23, and diagnosed with severe malnutrion. It is documented that resident #1 lost sixteen lbs between 12/5/22, and 1/16/23. This poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 26, 2024

Plan of correction: Licensee will ensure that the facility abides by Title 22 regulations. Licensee will ensure that staff are provided with an in service training on Section 87466, and will provide LPA with proof of training by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Aug 2, 2024

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs This requirement was not being met as evidenced by : resident #1 was admitted to hospital on 1/16/23, with severe sepsis with acute organ dysfunction, pneumonia, hypernatremia, severe protein calorie malnutrition. and several pressure injuries. This poses a an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 26, 2024

Plan of correction: Licensee will ensure that the facility abides by Title 22 regulations. Licensee will ensure that staff are provided with an in service training on Section 87468.2, and will provide LPA with proof of training by POC due date.

Allegation investigated: Uncleared staff caring for residents in care. Staff do not meet required qualifications. Staff do not address pest infestation. Staff do not address rodent infestation. Staff do not ensure facility is free of disturbances.

Licensing Program Analyst (LPA) Angelica Rea conducted another visit in response to the above allegations. LPA met with Administrator, Joshua Castillo who assisted with the visit. Regarding the allegation that there are : Uncleared staff caring for residents in care. The investigation consisted of interviews with Administrator, staff #1 - staff #7, resident #1 - resident #6, and review of staff files, facility staff roster and facility staff clearance documents. Administrator and staff interviewed were unable to corroborate the allegation. Eight out of eight staff interviewed stated that there are no uncleared staff caring for residents in care. Residents interviewed were unable to corroborate the allegation. SIx out of six residents interviewed stated that they do not know if there are uncleared staff caring for residents in care. LPA review of staff clearance documents, indicate that there are no uncleared staff caring for residents in care. Regarding the allegation that : Staff do not meet required qualifications, specifically that the medication technicians are not certified, and the kitchen staff are not certified. Unsubstantiated The investigation consisted of interviews with Administrator, staff #1 - staff #7, resident #1 - resident #6, and review of staff files, including medication certification(s), and kitchen staff certification(s). Administrator, and staff interviewed were unable to corroborate the allegation. Eight out of eight staff interviewed stated that the medication and kitchen staff are certified and meet the required qualifications. Residents interviewed were unable to corroborate the allegation. SIx out of six residents interviewed stated that the facility staff meet the required qualifications to their knowledge. LPA reviewed staff files, and observed that the medication technicians and kitchen staff meet the required qualifications. Regarding the allegation(s) that : Staff do not address pest infestation, and staff do not address rodent infestation. The investigation consisted of interviews with Administrator, staff #1 - staff #7, resident #1 - resident #6, tour of facility, and review of recent pest control invoices. Administrator and staff interviewed denied the allegation. Administrator stated that the facility has a contract with a pest control company as a preventative measure. Eight out of eight staff interviewed stated that they have not observed any pests or rodents at the facility. Residents interviewed were unable to corroborate the allegation. Six out of six residents interviewed stated that they have not observed any pests or rodents at the facility. LPA did not observe any pests or rodents during the facility tour. Facility pest control receipts do not indicate that the facility has an infestation of pests or rodents at this time. Regarding the allegation that : Staff do not ensure facility is free of disturbances. The investigation consisted of interviews with Administrator, staff #1 - staff #7, resident #1 - resident #6, and tour of facility. Administrator and staff interviewed were unable to corroborate the allegation. Eight out of eight staff interviewed stated that the staff do ensure that the facility is free of disturbances. Residents interviewed were unable to corroborate the allegation. Six out of six residents interviewed stated that staff do ensure that the facility is free of disturbances. 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 the report was provided to Mr. Castillo.the state’s words, verbatim · CDSS document, May 6, 2024 · control 28-AS-20230321160829

Allegation investigated: Lack of staff resulting in residents not being administered their medication(s) as prescribed.

Licensing Program Analyst (LPA) Angelica Rea conducted another visit to deliver the final results of the investigation. LPA met with Administrator, Joshua Castillo, who assisted with today's visit. **The purpose of the visit is to remove confidential information listed on the report dated 3/22/24, however, the finding will remain the same** Regarding the allegation that : Lack of staff resulting in residents not being administered their medication(s) as prescribed. The investigation consisted of interviews with Administrator, staff #1 - staff #4, and resident #1- resident #5. LPA also reviewed resident #6's medication administration record. The investigation revealed the following : Administrator stated that a medication technician from a staffing agency was due to come in to work on 1/14/24. However, the medication technician dropped the shift, and did not come to the facility. Administrator stated that resident #6 did receive their medication on 1/14/24, however it was given late. Substantiated Staff interviewed corroborated the allegation. Four out of five staff interviewed stated that resident #6's medication was administered late, and not as prescribed. Residents interviewed were unable to corroborate the allegation. Five out of five residents interviewed stated either that they handle their own medication, or that their medication is administered as prescribed. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Mr. Castillo. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 6, 2024 · control 28-AS-20240117100508

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 8, 2024

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not being met as evidenced : LPA Rea learned that Resident #6 prescribed medication OLANZAPINE F/C 2.5MG TABLET which is to be administered every day at 4:00pm was not given as prescribed. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2024

Plan of correction: Administrator will ensure that residents receive medications as prescribed. Administrator will send LPA a written plan detailing what the facility plan is to ensure that there is sufficient staff to administer medications as prescribed.

Allegation investigated: Resident sustained multiple unexplained bruises and scratches while in care.

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint investigation regarding the above allegation. LPA met with Administrator, Joshua Castillo who assisted with the visit. Regarding the allegation that : Resident #1 sustained multiple unexplained bruises and scratches while in care. The investigation consisted of interviews with Administrator, Staff #1 - Staff #2, resident #1 - resident #4, and review of resident #1's file. LPA also obtained copies of specific documents from resident #1's file. The investigation revealed the following : Administrator and staff interviewed stated that on 4/14/24, staff #3 observed that resident #1 had a bruise on her left arm during a safety check. Staff interviewed stated that the family was notified and a special incident report was submitted to community care licensing as required. Staff interviewed were unable to corroborate the allegation. Three out of three staff interviewed stated that they have not observed anything that may have caused resident #1 to sustain any bruises or scratches. Unsubstantiated Residents interviewed were unable to corroborated the allegation. Four out of four residents interviewed stated that they have not had any incidents which would cause them any bruising or scratches. Based on staff and resident interviews, although resident #1 sustained bruising to her left arm, there is nothing to support that this occurred due to staff negligence. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, and a copy of the report was provided to Mr. Castillo.the state’s words, verbatim · CDSS document, Apr 23, 2024 · control 28-AS-20240417102216

Allegation investigated: Staff do not respond to requests for communication regarding resident in a timely manner. Administrator is not on the facility premises a sufficient number of hours as required.

Licensing Program Analyst (LPA) Angelica Rea conducted another visit to deliver the final results of the investigation. LPA met with Administrator, Joshua Castillo who assisted with today's visit. Regarding the allegation that : Staff do not respond to requests for communication regarding resident in a timely manner. The investigation consisted of interviews with Administrator, staff #1 - staff #4, and resident #1- resident #5. Staff interviewed denied the allegation. Five out of five staff interviewed stated that staff do respond to requests for communication in a timely manner. Residents interviewed were unable to corroborate the allegation. Five out of five residents interviewed stated that the staff do respond to requests for communication in a timely manner, and that they have not had any problems with communication. Regarding the allegation that : Administrator is not on the facility premises a sufficient number of hours as required. The investigation consisted of interviews with Administrator, staff #1 - staff #4, and resident #1- resident #5. LPA also reviewed a copy of the staff schedule. Staff interviewed denied the allegation. Unsubstantiated Residents interviewed were unable to corroborate the allegation. Five out of five residents interviewed stated either that they handle their own medication, or that their medication is administered as prescribed. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Mr. Castillo. A copy of the report and appeal rights were provided. Five out of five staff interviewed stated that the administrator is on the facility premises a sufficient number of hours, as required. Residents interviewed were unable to corroborate the allegation. Five out of five residents interviewed stated that the administrator is at the facility a sufficient number of hours. Review of staff schedule, indicates that the administrator is on the facility premises a sufficient number of hours. 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 the report was provided.the state’s words, verbatim · CDSS document, Mar 22, 2024 · control 28-AS-20240117100508

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 2, 2024

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not being met as evidenced : LPA Rea learned that Resident #6 prescribed medication OLANZAPINE F/C 2.5MG TABLET which is to be administered every day at 4:00pm was not given as prescribed. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 22, 2024

Plan of correction: Administrator will ensure that residents receive medications as prescribed. Administrator will send LPA a written plan detailing what the facility plan is to ensure that there is sufficient staff to administer medications as prescribed.

Allegation investigated: Facility has scabies outbreak

Licensing Program Analyst (LPA) Angelica Rea conducted another visit to deliver the final results of the investigation. LPA met with Administrator, Joshua Castillo, who assisted with today's visit. Regarding the allegation that: the facility has a scabies outbreak. The investigation consisted of interviews with Administrator, Hospice Nurse Director, and Los Angeles County Department of Public Health (LACDPH) Nurse. LPA also reviewed resident #1- resident #4 files, including Medication Administration Records. Administrator stated that there were some residents in memory care that had complaints of itching. He stated that the residents were not diagnosed with scabies, however they were prescribed with medication to treat their skin condition(s). LPA reviewed 4 resident files, and observed that 4 memory care residents were being treated for a skin condition, consistent with scabies. Interview with Hospice Nurse Director indicated that sometimes they do not do skin scraping on hospice resident(s) to determine if a resident has scabies. LPA observed that resident #1 - resident #4's skin condition(s) were being treated as scabies and medication was prescribed. Substantiated LPA spoke to LACDPH nurse who stated that they conducted an investigation into an outbreak of Rash/Scabies at the facility. LPA obtained information that there were a total of 10 cases reported, the first onset was in August 2023, and the last onset was in November 2023. LPA obtained a copy of the outbreak site clearance notification dated 12/19/23, which was provided to the facility. The facility failed to report the scabies outbreak to community care licensing as required. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted with Mr. Castillo. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 23, 2024 · control 28-AS-20231011155531

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(2) · Plan of correction due date: Jan 24, 2024

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not being met as evidenced by: Administrator did not submit a special incident report to Community Care Licensing indicating the facility had a scabies outbreak.the state’s words, verbatim · CDSS document, Jan 23, 2024

Plan of correction: Administrator will ensure that Title 22 regulations are being followed. Administrator will review Section 87211, and will send LPA a written statement indicating that the section has been read, and is understood.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Executive Director Joshua Castillo and explained the reason for the visit. Physical Plant was toured, medications were reviewed, resident and staff files were reviewed, and food supply was inspected. LPA and Mr. Castillo toured the facility including common areas and a random sample of resident rooms. There are multiple shaded seating areas for the residents throughout the facility patio area. Passageways and exits are free of obstruction. The water temperature was tested in a random selection of resident bedrooms and measured between 116 degrees F - 120 degrees F which is within the required 105 F - 120 F degrees. Grab bars and non-skid mats were observed in resident bathrooms. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors and carbon monoxide detectors were observed in resident rooms and were tested and operable during the visit. Facility common areas have a smoke alarm that is hard wired, tested and operational during the visit. There are multiple fire extinguishers located throughout the facility. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked and are inaccessible to residents. Cleaning supplies and disinfectants are locked and are inaccessible to the residents. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed. 6 resident medications were reviewed at random. Medications are centrally stored in carts in the medication room. Medications are given as prescribed. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit. Exit interview held and a copy of the report, and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 22, 2023

Allegation investigated: Resident sustained unexplained injuries while in care and supervision of the facility Staff failed to maintain facility clean and sanitary for resident in care Facility has insufficient staffing to meet residents needs. Facility did not conduct reappraisal for resident as needed

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit to deliver the final results of the investigation. LPA met with Administrator, Joshua Castillo who assisted with today's visit. Regarding the allegation that : Resident #1 sustained unexplained injuries while in care and supervision of the facility. The investigation consisted of review of resident #1's file, interviews with Administrator, and staff #1 - staff #4. The investigation revealed : Resident #1 lived at the facility from 2/25/23 to 3/22/23. Administrator and staff interviewed were not aware of any unexplained injuries sustained by resident #1. Review of resident #1's flie, indicates that resident #1 was taking medication that can cause bruising. Regarding the allegation that : Staff failed to maintain facility clean and sanitary for resident in care. The investigation consisted of tour of facility, including common areas, and resident rooms in assisted living and in memory care, and interviews with Administrator and staff #1 - staff #4. Unsubstantiated The investigation revealed : LPA toured facility on initial visit, and on subsequent visit. LPA observed that the facility was clean and sanitary on both visits. Administrator and Staff interviewed stated that the facility is cleaned daily, and resident rooms are cleaned once per week, and more often, if needed. They stated that the housekeeping department has a cleaning schedule to ensure that all resident rooms are cleaned. Regarding the allegation that : Facility has insufficient staffing to meet residents needs. The investigation consisted of review of resident and staff roster(s), and interviews with Administrator and staff #1 - staff #4. The investigation revealed : Administrator and staff interviewed stated that the facility has sufficient staff to meet resident needs. Administrator and staff stated that both the assisted living and memory care have sufficient staff. LPA observed that the facility staff roster(s), and it appears that the facility has sufficient staffing to meet resident needs. Regarding the allegation that : Facility did not conduct reappraisal for resident as needed. The investigation consisted of review of resident #1's file, and interview with Administrator. The investigation revealed : Resident #1 lived at the facility from 2/25/23 to 3/22/23. Review of resident #1's file indicated that resident #1's pre-placement appraisal was completed. Administrator stated that the facility conducts a reappraisal after 30 days of admission, and then 6 months thereafter, or as needed. However, resident #1 did not live at the facility long enough to have a reappraisal conducted. 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 was conducted with Mr. Castillo, and copy of report was provided.the state’s words, verbatim · CDSS document, Nov 27, 2023 · control 28-AS-20230511155149