Divine Life Guest Home

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

On July 30, 2026, the Department conducted a subsequent visit to deliver an updated version of the investigation report regarding the allegation listed above. This investigation report supersedes the reports delivered on 11/19/2025, The purpose of this report is to provide an updated investigation report for “allegation “Staff did not get timely medical care for resident” the finding has changed to Substantiated. CCLD staff met with Rodrigo Rosaldo and the purpose of the visit was explained. The investigation consisted of the following: On 11/19/2025 The Department interviewed Staff S1-S4, resident R2-R5, witness (W1). The Department obtained the following records: Incident report (dated 11/07/2025), Needs and Service Plan (dated 07/27/2025), Physician Report (dated 05/27/2024), 911 training (dated 01/06/2025), Termination letter (dated 11/14/2025) On 05/28/2026 The Department interviewed witnesses (W1). On 07/02/2026 The Department reviewed 3 incident reports for R1. On 07/03/2026 The Department interviewed S2 and S3. Page 1 of Substantiated The investigation revealed the following: Regarding the Allegation: Staff did not get timely medical care for residents. It is being alleged that staff do not provide timely medical care for residents when residents fall. Observations revealed the following: During the investigation the Department noted staff giving morning medications to residents and observed staff moving residents with no issues and there were no negative interactions. Records reviews revealed the following: The incident report (dated 11/07/2025), indicates that on 11/07/2025, R1 had fallen from bed and sustained bruises on both hands and a laceration on the forehead around 6:30 AM. The report states that on 11/07/2025 caregivers did not call 911 or advise facility owner until 7:00 PM. The Department reviewed S1’s termination letter dated 11/14/2025, which indicated that S1 was terminated for not calling 911 and not making S2 aware of incident. Interviews revealed the following: 3 out of 3 staff (S2, S3 and S4) agree that S1 did not provide timely medical care for R1. S2 indicates that R1 fell out of bed and had injuries. S2 indicates that the incident happened at 6:30am and 911 was S2 not called until 6pm. S2 indicates that this was not normal process, that S1 did not call 911 and did not generate an incident report. Resident R1 could not be interviewed as R1 was in the hospital. The Department could not interview residents R2 out of R4 residents due to their medical conditions. Residents R3 and R5 denied the allegation. The Department interviewed W1 who indicates that R1 medical care was not provided timely. Page 2 of 3 Based on observations and interviews conducted by CCLD staff, as well as the records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation that “Staff did not seek medical care for resident” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 are cited on the attached LIC 9099D. An immediate civil penalty of $500.00 is being assessed, please see LIC421IM. At this time, an additional civil penalty determination is pending in reference to The Welfare and Institutions Code Section 15610.67 which defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” An exit interview was conducted, and plans of corrections were developed and a copy of this report, a copy of the amended Investigation Report (LIC9099D) and appeals rights were provided to Administrator Rodrigo Rosaldo (S1). Page 3 of 3 The investigation revealed the following Regarding the Allegation: Staff are not properly trained in how to deal with medical personnel and residents’ medical information. It is being alleged that the facility staff are not trained to work with medical personnel and provide residents with medical information during medical emergencies. On 11/19/2025 the Department observed staff giving morning medications to residents and staff moving residents with no issues and there were no negative interactions. Records indicate the following: The Department reviewed check list (dated 01/06/2025) for staff to follow during emergencies. The following 6 steps were noted on S1-S4 records: 1) check patient, 2) call 911, 3) get a copy of patient ID & insurance card, 4) Get a copy of medication list, 5) call family, 6) generate incident report. Interviews indicate the following: S2 indicates that staff work with medical personnel every week and provide resident medical information when needed. 3 out of 3 staff deny the allegation. R1 cannot be interviewed as R1 was in the hospital. 2 out of 4 residents could not answer any questions due to cognitive issues. R3 and R5 denied the allegation. W1 denied the allegation and indicates seing facility staff work with medical personnel on a weekly basis. Based on interviews and supporting documentation, the preponderance of evidence standard has been met therefore, the allegation of “staff are not properly trained on how to deal with medical personnel and residents’ medical information” is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Rodrigo Rosaldo (S1). Page 2 of 2the state’s words, verbatim · CDSS document, Jul 30, 2026 · control 11-AS-20251110091722

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(5) · Plan of correction due date: Jul 31, 2026

87411 Personnel Requirements – General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement was not met as evidenced by: Based on records review and interviews S1 did not immediately report R1 fall or call 911 for R1 injury. R1 was transported to the hospital which posed an immediate health, safety and personal risk to residents in care.the state’s words, verbatim · CDSS document, Jul 30, 2026

Plan of correction: Licensee agreed to train staff on how to report incident reports and when to call 911. Proof of corrections will be provided by licensee by 07/31/2026

Allegation investigated: Staff holds resident down resulting in injuries. Staff do not change residents timely.

On June 5, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted an initial unannounced complaint visit. Rodrigo Rosaldo Administrator, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegations mentioned above. The investigation included interviews, inspection of the facility, and a collection of documents. The Department reviewed (R1’s) Physician’s Report LIC (dated 05/29/25), Identification and Emergency Information LIC 601 (dated 05/29/25) Medication Profile (dated 12/01/25), Appraisal/Needs and Services Plan LIC 625 (dated 05/29/25) Admissions Agreement (dated 0729/25), Unusual Incident Report LIC 624 (dated 05/30/26) Facility Progress Notes (dated 05/02/26 – 05/30/26) and Torrance Memorial Medical Assessment (dated 05/31/26). Interviews conducted with Resident#1 through #5 (R1-R5) and Staff #1 through Staff #3 (S1-S3). (Evaluation Report continues on LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff holds resident down resulting in injuries. It is alleged that the staff physically restrained Resident #1 (R1), resulting in injuries. Reports indicate that the facility staff used physical restraint on (R1), leading to cuts on (R1's) arms. No additional information about the incident has been provided. On June 5, 2026, between 09:30 AM and 01:25 PM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) out of the three (3) staff members could not support this claim. Resident #1 (R1) was feeling unwell, impacting (R1’s) mood and mental clarity associated with the behaviors from the infecton. Staff (S1) contacted (R1's) responsible party, and (R1) was admitted to Torrance Memorial Hospital on May 30, 2026, for medical evaluation. The Torrance Memorial Medical Assessment (dated 05/31/26), indicated that (R1) is being treated for a urinary tract infection. (S1-S3) firmly denied any use of restraining (R1) in their caregiving or supervision. They disputed (R1) ever sustaining injuries resulting from manual or physical restraint. On June 5, 2026, between 9:45 AM and 10:25 AM, the Department interviewed resident members identified as Resident #2 through Resident #5 (R1-R5). Five (5) out of the (5) five residents cannot support this claim. All reported feeling well-treated by the staff and stated that they have not undergone any physical restraint or sustained any injuries while in care. On June 5, 2026, between 10:40 AM and 11:23 AM, the Department interviewed resident member identified as Resident #1 (R1) at Torrance Memorial Hospital. (R1) confirmed was admitted for medical care due to Urinary Tract Infection. Resident (R1) reported that a staff member at the facility would hold (R1) in a way that caused cuts on (R1’s) right wrist and arm. (R1) could not remember when the incident occurred or name the staff member involved, but (R1) indicated that this behavior is ongoing. However, (R1) clarified that it was not physical abuse and did not wish to provide further details. Overall, (R1) stated that (R1) have been treated well by the facility's staff and feel safe living there. During the interview with (R1), the Department observed that there were no fresh cuts, scrapes, or bruises on (R1’s) arms. (Evaluation Report continues LIC 9099-C) On June 5, 2026, between 11:32 AM and 12:32 PM, the Department interviewed witness members identified as Witness #1 and Witness #2 (W1-W2). Two (2) out of the (2) witness members could not corroborate this claim. (W1) believes that (R1's) urinary tract infection (UTI) contributes to (R1's) inaccurate reporting of the incident. (W1) stated that there has been no neglect or abuse in the care provided, and that the facility is delivering standard care. (W2) noted that (R1) showed no signs of cuts or injuries during the medical intake assessment. Based on the information gathered, there is enough evidence to support the allegation mentioned above. Allegation #2: Staff do not change residents timely. The complaint alleges that the staff failed to change Resident #1 (R1) in a timely manner. It reported there is a delay in care for diaper changes and cleaning for (R1). No additional information about the incident has been provided. On June 5, 2026, between 09:30 AM and 01:25 PM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) out of the three (3) staff members could not validate this claim. (S1-S3) stated that (R1) receives proper assistance with toileting and bathing. (S1-S2) explained that (R1's) diapers are changed three to four times daily or as needed. Additionally, (S1-S2) mentioned that the facility maintains progress notes listing the services provided daily by the time spent with (R1). These notes also document instances where (R1) has refused diaper changes and medications. On June 5, 2026, between 9:45 AM and 10:25 AM, the Department interviewed resident members identified as Resident #2 through Resident #5 (R2-R5). Five (5) out of the (5) five residents cannot validate this claim. All reported satisfaction with the care and supervision provided by the staff, stating that it is adequate and that the staff is responsive. On June 5, 2026, between 10:40 AM and 11:23 AM, the Department interviewed resident member identified as Resident #1 (R1) at Torrance Memorial Hospital. (R1) stated this claim is false. (R1) reported no issues with the timeliness of staff services. In fact, (R1) admitted to refusing diaper changes at night to avoid disrupting sleep, even if it meant dealing with soiled diapers. (R1) also stated to have no concerns with bathing as (R1) prefers sponge bathing. (Evaluation Report continues LIC 9099-C) On June 5, 2026, between 11:32 AM and 12:32 PM, the Department interviewed witness members identified as Witness #1 (W1). (W1) believes the staff is providing appropriate care and confirms that there is no neglect. The Department reviewed the following records for this complaint: (R1’s) Physician’s Report LIC 602A (dated 05/29/25), Identification and Emergency Information LIC 601 (dated 05/29/25) Medication Profile (dated 12/01/25), Appraisal/Needs and Services Plan LIC 625 (dated 05/29/25), Admissions Agreement (dated 07/29/25), Unusual Incident Report LIC 624 (dated 05/30/26) Facility Progress Notes (dated 05/02/26 – 05/30/26), Torrance Memorial Medical Assessment (dated 05/31/26), Personnel Report LIC 500 (dated 04/25/23) and Register of Facility Residents LIC 9020 (dated 07/22/25). Based on the information gathered, there is enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. No deficiencies were cited. An exit interview was conducted with RODRIGO ROSALDO, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Jun 5, 2026 · control 11-AS-20260601151344

Allegation investigated: Staff hit resident

On 01/21/2026 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Divine Life Guest Home and was greeted by Administrator Rodrigo Rosaldo (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S3, residents R1-R4. LPA Calderon obtained the following records: Admission Agreement (dated 07/29/2025). Incident report (dated 07/20/2025), Physician report (dated 05/27/2025), Needs and Service Plan (dated The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff hit resident’. This complaint alleged that the facility staff struck R1 left cheek. LPA Calderon noted staff giving morning medications to residents. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions between staff and residents. Records review indicate the following: Physician report (dated 05/27/2025) indicates that R1 has health issues and cognitive issues. Interviews indicate the following: S1 indicates that R1 was aggressive with other staff and residents. S1 indicates that R1 refused to take a shower or take R1 medication. 4 out of 4 staff deny the allegation. R1 indicates that unknown male staff member struck R1 right cheek a grabbed R1 right wrist and injured the wrist. R1 indicates that R1 did not call the police and R1 cannot id the attacker. 3 out of 4 residents deny the allegation. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff hit resident” is found to be UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 11-AS-20260114161425

Type of visit: Required - 1 Year

On 12/02/2025 at 11:30 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Divine Life Guest Home Facility. LPA Calderon was allowed entry into the facility by Administrator Rodrigo Rosaldo. Facility is to operate a Residential Care Facility for 6 Elderly residents 60 years or older. Currently, there are five (5) residents residing in the facility, 60 and older. LPA Calderon explained to Administrator Rosaldo the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Five (5) client service records, five (5) client medication records (MAR), four (4) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 10/04/2025. The one-story residential home consists of five (5) client bedrooms, three (3) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored on the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage and kitchen area. On 12/02/2025 at 11:30 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Divine Life Guest Home Facility. LPA Calderon was allowed entry into the facility by Administrator Rodrigo Rosaldo. Facility is to operate a Residential Care Facility for 6 Elderly residents 60 years or older. Currently, there are five (5) residents residing in the facility, 60 and older. LPA Calderon explained to Administrator Rosaldo the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Five (5) client service records, five (5) client medication records (MAR), four (4) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 10/04/2025. The one-story residential home consists of five (5) client bedrooms, three (3) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored on the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage and kitchen area.the state’s words, verbatim · CDSS document, Dec 2, 2025

Allegation investigated: Staff did not get timely medical care for resident Staff are not properly trained on how to deal with medical personnel and resident's medical information

On 11/19/2025 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Divine Life Guest Home and was greeted by Administrator Rodrigo Rosaldo (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: LPA Calderon interviewed Staff S1-S3, resident R1-R5, witness (W1). LPA Calderon obtained the following records: Incident report (dated 11/07/2025), Physician Report (dated 05/27/2024), Needs and Service Plan (dated 07/27/2025), check list for staff to call 911. The investigation revealed the following: Unsubstantiated Regarding the Allegation: Staff did not get timely medical care for residents. This complaint alleged that the facility staff did not provide timely medical care for R1. LPA Calderon noted staff giving morning medications to residents. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions. Reviewed incident report (dated11/07/2025), report indicates that R1 had fallen from R1 bed and sustained minor injuries. The report does state that caregiver did not call 911 or advise facility owner timely. Incident report written up (dated 11/07/2025) indicates that staff called 911 and facility owner fired caregiver who did not call 911 timely. Reviewed notice to staff check list for an emergency. Check list indicates 6 steps for staff to follow. Check patient, call 911, get a copy of patient ID & insurance card, copy of medication list, call family, generate incident report. Interviews indicate the following: S1 indicates that R1 fell out of bed and had minor injuries. S1 indicates that the incident happened at 6:30am and 911 was not called until 6pm. S1 indicates that this was not normal process and the staff that did not call 911 was fired. 3 out of 3 staff deny the allegation. R1 cannot be interviewed as R1 was in the hospital. 2 out of 3 residents could not answer any questions due to cognitive issues. 3 out of 5 residents deny the allegation. W1 indicates that R2 medical care is provided timely. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not get timely medical care for resident” is found to be UNSUBSTANTIATED. Regarding the Allegation: Staff are not properly trained in how to deal with medical personnel and residents’ medical information. This complaint alleged that the facility staff are not trained to work with medical personnel and provide residents with medical information. LPA Calderon noted staff giving morning medications to residents. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions. Records indicate the following: Check list for staff to follow for an emergency. 6 steps, check patient, call 911, get a copy of patient ID & insurance card, copy of medication list, call family, generate incident report. Interviews indicate the following: S1 indicates that R1 fell out of bed and had minor injuries. S1 indicates that the incident happened at 6:30am and 911 was not called until 6pm. S1 indicates that this was not normal process and the staff that did not call 911 was fired. S1 indicates that staff work with medical personnel every week and provide resident medical information when needed. 3 out of 3 staff deny the allegation. R1 cannot be interviewed as R1 was in the hospital. 2 out of 3 residents could not answer any questions due to cognitive issues. 3 out of 5 residents deny the allegation. W1 indicates that W1 has seen facility staff work with medical personnel on a weekly basis. Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff are not properly trained on how to deal with medical personnel and residents’ medical information” is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Rodrigo Rosaldo (S1).the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 11-AS-20251110091722

Type of visit: Required - 1 Year

On December 5, 2024, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced required annual visit using the CARE Inspection Tools. LPAs met with staff Alvin Geniza and explained the purpose of this visit. Rodrigo Rosaldo subsequently arrived to assist with visit. The facility is license to serve (6) elderly residents ages 59 and older. The fire clearance is approved for (5) non-ambulatory and (1) bedridden resident in room #4. Approved Hospice waiver for (6). Currently there are 4 residents over the age of 60. Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: (5) residents' rooms, (2) bathrooms, (1) staff room (1) staff bathroom, a living area, a dining area, a kitchen, an outside seating area and a garage Back Yard, Ramps and Outside table with shade. Physical Plant LPA and Staff Alvin Geniza toured the facility inside and outside. LPA observed There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available. Bathrooms were operational with water temperature measured at 111.2 F. A comfortable temperature of 75 degrees F. was maintained in the facility. Page 1 of 3 Bedrooms LPA inspected all (5) bedrooms. All bedrooms were observed to have the required furniture including beds, dressers, night stands with lamps, chairs, and ample storage space for personal belongings. All bedrooms were observed to be clean, in good repair, and have ample lighting. Bathrooms LPA inspected the facility bathrooms. In the resident’s bathroom the toilet, faucets, and shower were fully operational. All safety handrails were securely fastened. LPA observed the showers to be clean and free of mold or mildew. The shower had a nonskid material in bottom and shower chair. The water temperature measured 111.2-degrees Fahrenheit. The Staff bathroom was observed to be clean. The toilet and faucets are operational. Both bathrooms were observed to be clean, in good repair and within Title 22 regulations. Linens & Hygiene LPA observed all beds to have the required linens including mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens, towels, and blankets in the hall closets. Kitchen/Laundry Room LPA inspected the kitchen and observed all appliances to be in good working repair, including stove/oven, microwave, dishwasher, washer, dryer, refrigerator, LPA observed an ample supply of pots, pans, and bowls to be in good repair. LPA observed knives and additional sharps to be secured in locked drawers in the kitchen and are inaccessible to residents. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. Washer and dryer located back hall of the facility. page 2 of 3 Common Rooms In the living room, LPA observed, ample seating for all residents. In the dining room, LPA observed a rectangle table and chairs to accommodate all residents. The facility is maintained at a comfortable temperature. Safety LPA observed and tested smoke/carbon monoxide detectors to be fully operable. LPA observed an addition Carbon Monoxide detector in the hallway. LPA observed 2 fully charged fire extinguisher mounted on the wall, last serviced on 6/29/24. LPA inspected the First Aid kit and found it contained an ample supply of required items. LPA observed the required posting in the facility. LPA observed all exits to be clear and easily accessible. There are no firearms or ammunition stored on the premises. Medications LPA observed all centrally stored medications in their original packaging and are secured in a locked cabinet near kitchen area. Files/postings LPA reviewed four (4) resident files and found that 4 out of 4 contained all the necessary documentation. LPA reviewed four (4) staff files and found that 2 out of 4 contained the required documentation, certification, and training. LPA observed all required posting. Infection Control During the visit, LPA observed the facility’s infection control practices. There were 2 deficiencies issued during this visit. Deficiencies are documented on the 809D. Exit interview conducted with Administrator Rodrigo Rosaldo and copy of report and appeals right provide. page 3 of 3the state’s words, verbatim · CDSS document, Dec 5, 2024

Allegation investigated: Staff restrained resident in care. Staff yelled at resident in care.

On 11/15/2024, Licensing Program Analyst (LPA) Troy Watson conducted an unannounced complaint visit at this facility and was greeted by the Administrator Rosaldo Rodrigo. LPA explained the purpose of the visit is to deliver findings for the allegations listed above and was allowed entrance into the facility. The investigation consisted of the following: On 11/01/2024 LPA Watson toured the facility, reviewed records and interviewed staff and residents. LPA interviewed staff #1-#6 (S1-S6) and interviewed residents #1-#4 (R1-R4). LPA Watson requested, received, and reviewed Physician's Reports, Appraisal Needs and Services, Staff schedule for staff (S1-S6) and Residents Roster, for residents (R1-R4). The department toured the buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. CONTINUED ON LIC9099C Unsubstantiated The investigation revealed the following: Allegation: Staff restrained resident in care On 11/01/2024 LPA Troy Watson interviewed staff #1-#6 (S1-S6). The question asked of the staff was, have you ever restrained any of the residents that live at the facility? 6 out of 6 staff interviewed answered no. On 11/01/2024 LPA interviewed residents #1-#4 (R1-R4). Of those interviewed 4 out of 4 residents were asked if they had been put in restraints? 4 out 4 residents replied to no. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. 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 allegations are Unsubstantiated. Allegation: Staff yelled at resident in care On 11/01/2024 LPA Troy Watson interviewed staff #1-#6 (S1-S6). The question asked of the staff was, have you yelled at anyone of the residents in this facility? 6 out of 6 staff interviewed answered no. On 11/01/2024 LPA interviewed residents #1-#4 (R1-R4)4 out of 4 residents were interviewed and asked if anyone has yelled at them? 4 out of 4 residents replied to no. Based on the information gathered, interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. 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 allegations are Unsubstantiated. An exit interview was conducted with Administrator Rosaldo Rodrigo, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 15, 2024 · control 11-AS-20241024194808

Type of visit: Case Management - Other

On 11/9/2023 at 8:50 AM LPA Alfonso Iniguez conducted an announced Pre-license correction visit at this facility. LPA met with licensee Rodrigo Rosaldo who assisted with this visit. During this visit, LPA together with licensee toured the facility. LPA observed more board games in the living room and the new facility sketch form CAB was updated. LPA conducted the Component III Orientation with the Licensee and copy of this report was provided. A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review.the state’s words, verbatim · CDSS document, Nov 9, 2023

Type of visit: Prelicensing

On 10/26/23 Licensing Program Analysts (LPA) Alfonso Iniguez conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with authorized licensee: Rodrigo Rosaldo. The licensee has applied for a license to serve (6) elderly residents ages 59 and older. The fire clearance is approved for (5) non-ambulatory and (1) bedridden resident in room #4. Approved Hospice waiver for (6). The licensee plans to advertise for Special Care Programs for Dementia Residents. A tour of the Kitchen, Dining Room, Living Room, (5) Bedrooms, (1) Staff Room, (2) Bathrooms, Garage, Storage for all supplies, Back Yard, Ramps and Outside table with shade. The following was observed during this visit: MEDICATIONS There is a locked centralized storage area for Resident medications. PHYSICAL PLANT Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 73°F. degrees. Open porches, and areas of potential hazard are well-lit. Smoke alarms operate properly. Carbon monoxide detectors operate properly. Report continues on LIC 809 C... BEDROOMS There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair. Mattresses and pillows are flame-retardant. There is dresser and closet space for each client that includes at least two (2) drawers or eight (8) cubic feet of dresser space per client. There is a chair and lamp for each client and at least one (1) night stand per two (2) clients. BATHROOMS There is at least one (2) toilet and washbasin per six (6) clients, family, and personnel. There is at least one (2) shower or bathtub per ten (10) clients, family, and personnel. Hot water temperature is 113° Fahrenheit. Bathroom is located near client bedrooms. There are night-lights in the hallways outside non-private bathrooms. SUPPLIES There are client personal hygiene supplies to include soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths. FOOD SERVICE Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least two (2) days of perishable foods. Freezer is 0° Fahrenheit. Refrigerator is a maximum of 45° Fahrenheit. A seven (7) day supply of non-perishable food is present. There are enough tableware, tables, dishes, and utensils. There is enough equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. Report continues on LIC 809 C... RECORDS There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility. ADMINISTRATION The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. ACTIVITIES There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. Report continues on LIC 809 C... MISCELLANEOUS There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. PRE-LICENSING CHECKLIST N/A During today’s inspection LPA found the following correction(s) are required: -Currently room #1 and #2 are connected through a door, this layout does not reflect the facility sketch submitted to CAB. -LPA did not see enough board games for residents. Correction(S) needed: Licensee will ensure to submit a new facility sketch to CAB. Licensee will ensure a variety of board games are available at the facility. Exit interview conducted with Rodrigo Rosaldo/Administrator-Licensee.the state’s words, verbatim · CDSS document, Oct 26, 2023