Evergreen Retirement

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced continuation of the Required One (1) year visit, conducted previously on 08/10/2026. LPA met with Tanya Quezada - Executive Director and explained the reason for the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools. The Residential Care For the Elderly (RCFE) facility is for residents of ages 60 and above. Fire clearance is for 99 ambulatory residents, of which 50 may be non-ambulatory. A hospice waiver for 6 residents is in place with currently only 2 residents are in hospice care. LPA had previously toured the kitchen, multiple bedrooms/bathrooms in both floors, and common areas. During today’s visit, at approximately 2:05pm, LPA also conducted a tour of the facility. No immediate health or safety issues were observed. During today’s visit LPA interviewed staff and residents. LPA had previously reviewed Medication Administration Records (MAR)s and counted the medications for eight (8) residents. During today’s visit LPA conducted a file review of nine (9) resident records, including but not limited to: Admission records, current physician/appraisal and needs plans, resident rights. All resident records reviewed were current. Staff records for nine (9) staff were also reviewed, including training records. All records were in order. LPA reviewed the Fire and Disaster/Earthquake drills, which is usually conducted quarterly. The last drill was conducted on 05/25/2026. A fire inspection visit by K.O. Fire is scheduled for 09/03/2026. LPA obtained a copy of the Infection Control Plan and the Emergency and Disaster Plan. Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit Interview Conducted / A Copy of the Report provided to Administrator.the state’s words, verbatim · CDSS document, Aug 18, 2026

Allegation investigated: Staff does not prevent the spread of bed bugs.

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced 10 day complaint investigation visit to the facility regarding above allegation. LPA met with Tanya Quezada-Executive Director and explained purpose of the visit. LPA requested copies of the staff roster, resident roster, training records, pest control records and other documents relevant to the investigation. From 1:35pm to 2:00pm, LPA conducted a physical tour, including common areas, kitchen, dining room, hallways and ten (10) rooms on both floors in random. LPA also toured the walkways outside of the facility. No health or safety issues or infestations were observed. Continued on 9099-C Unsubstantiated Regarding the allegation that Staff does not prevent the spread of bed bugs. It was alleged that there are bed bugs in a room on the second floor and two rooms on the third floor but facility are not treating the other two nearby rooms where residents may also have bed bugs. To investigate the allegation, from 2:05pm to 3:45pm, LPA interviewed the Administrator, seven (7) staff members and nine (9) residents. Seven (7) residents stated that the rooms and bathrooms are clean and they have not noticed insects or bedbugs. Two (2) residents stated that they were aware of the bed bugs in one room but facility has contacted a pest control company to address the issue. Of the seven (7) staff interviewed, four (4) stated they were informed of only one room on the third floor, which had bed bugs. LPA interviewed the Executive Director who stated last week on Thursday 08/06/26, they became aware of bed bugs in a shared room on the third floor and immediately called a pest control company the facility uses on a regular basis. The pest control company came the same day and found bed bugs in the bed of one resident, in the shared room. Both residents were moved to another room. Executive Director stated the mattress and bed of the room were destroyed and the room was treated with heat treatment and a new bed/mattress was ordered. In addition, some of the chairs in the activity room were replaced, even though there was no infestation discovered. The pest control company visited rooms in both floors but did not find any infestation in other rooms and they will return to ensure facility is free of pests and bed bugs. During LPA’s visit, all rooms, bedding, furniture inspected were observed to be clean, without infestation; all bedding were clean and mattresses were encased in protector sheets. Based on interviews and records from the professional exterminating company, it was revealed that the facility uses the pest control company on a monthly or bi-monthly basis as general maintenance and they have taken all measures to ensure there is no pest infestation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted. Copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 10, 2026 · control 31-AS-20260806153517

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced Required One (1) year at this facility today. LPA met with Tanya Quezada - Executive Director and explained the reason for the visit. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools. The Residential Care For the Elderly (RCFE) facility is for residents of ages 60 and above. Fire clearance is for 99 ambulatory residents, of which 50 may be non-ambulatory. A hospice waiver for 6 residents is in place with currently only 2 residents in hospice care. Facility is a three story building consisting of 72 resident rooms, living room, activity room, dining room, kitchen, beauty salon, 2 laundry rooms, attached parking and a courtyard patio. All required posters were posted at the entrance and the hallways throughout. At approximately 10:40am LPA conduted a tour of the physical plant with the assistance of the Executive Director. The following was noted: COMMON AREAS: These included the living room, activity room and dining room. All areas were observed to be clean and furnished with tables and chairs, appropriate for number of residents. Facility has recently purchased brand new chairs for the activity room. LAUNDRY ROOM: There are two laundry rooms on the second and third floors. There are (2) washers, (2) dryers on the second floor and (1) dryer, (1) washer in the third floor. All chemicals were observed to be locked in the laundry rooms. Continued on 809-C KITCHEN: Facility has an industrial kitchen and the door was observed to be locked and inaccessible to residents. Kitchen floors, counters and work areas were clean and sanitary. LPA observed an adequate supply of perishable foods for two (2) days, and non-perishable food supply for seven (7) days stored in the walk-in refrigerator, walk-in freezer, and pantry. Food was properly labeled and stored. Emergency food is kept in a separate locked area, outside of the kitchen. Knives and sharp utensils are stored in the kitchen; inaccessible to residents. Detergents and chemicals were locked in a storage room outside of the kitchen. SURROUNDING GROUNDS: The parking and passageways were clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. There is no swimming pool but there is a raised decorative water fountain in the patio. There are two sets of furniture, underneath two pergolas in the patio. BEDROOMS: LPA toured multiple resident bedrooms on both floors for health and safety. The bedrooms were inspected and observed to maintain required furnishings and sufficient lightings, bed linens, closets/dresser drawers. All bedrooms were observed to be clean and clear of obstructions. LPA pulled the assistance cord in three rooms on both floors and staff responded within one minutes. BATHROOMS There are several bathrooms in the hallway on each floor for staff and residents use. There are private bathrooms in each resident room; all bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, non-slip mats). Hot water temperature was measured in two hallway bathrooms and three resident bathrooms, between 108.3-110.7°F. MEDICATIONS: Facility has a Wellness Room on the second floor, in which all medications are securely locked, inaccessible to residents. Multiple First Aid kits and the First Aid Manual were observed in the Wellness Room. LPA counted the medications for eight (8) residents and compared them to Medication Administration Records (MAR)s and observed that medication records were consistent. During today's visit LPA was unable to review resident and staff records. LPA was unable to complete the visit today and will return at a different time to complete the visit. Exit interview was conducted. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Aug 10, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Mariana Agban conducted a case management visit to note deficiency found during a complaint visit conducted on 10/16/25. On 10/16/25 LPA Agban conducted an investigation for complaint # 31-AS-20250422083808. During the course of the investigation, it was revealed that Resident #1 (R1) had a behavior which let to hoarding in their bedroom. Per document review there were no records that indicate that facility staff had assisted R1 with obtaining assistance with the behavior. Furthermore, the licensee did not ensure that changes in R1’s mental condition were documented and reported to the resident’s physician and responsible party, as required. Deficiency was noted on LIC809D per Title 22 Regulations. An exit interview was conducted and a copy of this report, LIC809D, and appeal rights were provided to the facility representative.the state’s words, verbatim · CDSS document, Jul 9, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Jul 13, 2026

87466: Observation of the Resident 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 is not met as evidenced by: Based on the interviews conducted and record reviews, Licensee did not document that R1 obtained medical professional assistance for behavior observed which poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 9, 2026

Plan of correction: The administrator agreed to certify in writing that upon observing changes in condition or behaviors in the residents, will provide assistance with obtaining proper medical care and submit a letter to the department by POC date.

Allegation investigated: Resident sustained multiple falls due to lack of supervision Facility staff did not ensure that resident has an appropriate bed Facility staff did not shower resident Facility staff did not maintain resident's room clean

On 07/06/26, at 8:58am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Tannya Quezada, Administrator. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 04/23/25, Licensing Program Analysts (LPA)s Mariana Agban and Nadia Shahbazia conducted the initial complaint visit. On 07/06/26, at 10:30am, LPA Saucedo conducted a physical tour, interviewed additional staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Resident sustained multiple falls due to lack of supervision. It is alleged that resident #1 (R1) had two (2) falls since they moved in. Let it be noted that R1 moved in on 04/04/25 and had only one (1) fall on 07/06/25. R1 had one (1) fall on July 06, 2025 that was confirmed by Staff #1 (S1)’s interview with LPA. LPA reviewed the Unusual Incident/Injury Report that was sent to Community Care Licensing Department on 07/09/25. R1 had fallen on 07/06/25 and was sent to the hospital also notification was sent to R1’s Power of Attorney and doctor. LPA could not interview R1 because R1 no longer resided at the facility. LPA obtained R1's admission agreement, Physician's Report and Service Plan. Furthermore, because of R1's fall on 07/06/25, R1 was put on safety checks four (4) times per shift on 07/08/25 for extra precaution. Therefore, based on the record reviews and interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Facility staff did not ensure that resident has an appropriate bed. It is alleged that that the facility has not provided an appropriate bed for the resident #1 (R1) since they moved in and R1 has been sleeping on a "cot" for 2 weeks. During LPA’s interview with Staff #1 (S1) confirmed that R1 had two (2) beds since their stay at the facility. One (1) was provided by the facility themselves and the other was provided by home health. Let it be noted that R1 was under home health care at the time. LPA could not interview R1 because R1 no longer resided at the facility. During LPA’s physical tour, LPA observed seven (7) random bedrooms that had appropriate beds-beds with bedspreads, mattresses and headboards. LPA interviewed seven (7) residents that confirmed they have always had individual beds and not “cots”. Therefore, based on the record reviews, physical tour and interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Facility staff did not shower resident. It is alleged that Resident #1 (R1) did not shower for two (2) weeks. During LPA’s interview with Staff #1 (S1) and Staff #2 (S2) they confirmed that all residents shower twice a week. LPA could not interview R1 because R1 no longer resided at the facility. LPA interviewed seven (7) residents. Three (3) out of the seven (7) residents that were interviewed need help showering and confirmed they shower twice a week. Therefore, based on the record reviews and interviews conducted, the allegation is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Facility staff did not maintain resident's room clean. It Is alleged that Resident #1 (R1)’s room was not cleaned and there was food and trash on the floor. During LPA’s interview with Staff #1 (S1) and Staff #2 (S2) they confirmed that all resident rooms get cleaned everyday-the trash is taken out daily, basic cleaning and the deep cleaning is done once a week. LPA could not interview R1 because R1 no longer resided at the facility. During LPA’s physical tour, LPA observed seven (7) random rooms and they were clean. LPA interviewed seven (7) residents that confirmed their room is cleaned weekly and the trash is taken out daily. Furthermore, LPA observed one (1) of the housekeepers cleaning the hallway. Therefore, based on the record reviews, physical tour and interviews conducted, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issue, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jul 6, 2026 · control 31-AS-20250423105657

Allegation investigated: Staff does not ensure resident’s room is clean.

**This report supersedes the report dated 08/27/25 to change the finding of allegation “Staff does not ensure resident’s room is clean” from Substantiated to Unsubstantiated and add additional information.** On 06/11/26 Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced subsequent complaint visit and met with Tanya Quezada- Executive Director and explained the reason for the visit. On 10/16/25 LPA Mariana Agban met Tannya Quezada, Executive Director, and delivered findings for the above allegation. On 6/19/25 LPA Agban conducted a physical plan tour to ensure the health and safety of the residents are protected and in compliance with Title 22 Regulations. On 4/23/25 LPA Agban conducted an initial complaint investigation visit. Continued on 9099-C Unsubstantiated Regarding the Allegation: Staff does not ensure resident’s room is clean: It is alleged that facility staff do not clean R1’s room. Interview with R1 revealed that staff come to R1’s room to provide housekeeping services, however, R1 refuses staff to clean the room and provide laundry services. Interview with ten (10) residents revealed their rooms are clean and had no concerns regarding housekeeping services. Interview with the Executive Director revealed that R1 does not allow housekeeping staff in their room. The Executive Director mentioned that they have worked with R1 to declutter R1’s room, however, R1 would bring additional boxes into the room. LPA Agban observed R1’s room filled with storage boxes, recycling bottles, and stacks of paper. LPA also noted that R1’s bed sheets are not clean and have urine stains. LPA visited five (5) random resident rooms and observed the rooms to be clean. Based on information obtained, the allegation is deemed Unsubstantiated as facility staff had provided housekeeping services; however, R1 refused to utilize it. Other allegations remain the same. Exit interview conducted, copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jun 11, 2026 · control 31-AS-20250422083808

Allegation investigated: Resident did not receive necessary medical attention. Staff did not comply with physician’s instructions for medications and care Facility did not ensure appropriate communications with resident’s responsible person Staff did not report observed changes in resident’s condition

Licensing Program Analysts (LPAs) Mariana Agban, Nadia Shahbazian and Licensing Program Manager (LPM) Mary Flores conducted an unannounced subsequent complaint investigation visit for the above allegations. Licensing team arrived and were greeted by the receptionist and met with the Executive Director and explained the reason for the visit. On 3/12/25 LPA Agban conducted an initial complaint visit, conducted a tour of the facility, requested pertaining documents, and delivered findings for 1 allegation. On 3/13/25 LPA conducted a subsequent visit and interviewed 7 residents. On 8/7/25 LPA conducted a subsequent visit and delivered findings for 2 allegations. On 5/7/26 LPAs requested copies of pertinent information, which includes LIC 500 and Resident Roster, interview 7 staff and 6 residents. Regarding the Allegation: Resident did not receive necessary medical attention. It is alleged that Resident#1(R1) was in pain and facility staff did not provide pain medication for R1. (Continue on 9099C) Unsubstantiated Interviews with 6 staff revealed residents are provided assistance promptly. Interviews with 7 residents revealed they are provided with medical attention as needed. Record reviewed indicated that on 2/13/25, 2/15/25, and 2/16/25 R1 was provided with pain medication per R1’s request, as prescribed by the physician. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Regarding the allegation Staff did not comply with physician’s instructions for medications and care. It is alleged that facility staff failed to discontinue R1’s high blood pressure medication due to low blood pressure concerns and that R1’s prescribed back brace was not provided. LPA reviewed facility records and observed documentation indicating that, on 01/30/2025 at 4:46 PM, facility staff received instructions from R1’s physician to hold R1’s blood pressure medication due to R1’s low blood pressure condition. Additionally, the LPA reviewed R1’s medication list, which indicated that Amlodipine Besylate 5 mg was placed on hold effective 02/11/2025. Regarding the use of back braces, records reviewed confirmed that R1 was using the prescribed back brace. Facility notes indicate that a back brace was received on 2/12/25 and that a back brace was observed on R1 on 2/14/25. The Administrator stated that a Home Health nurse provided training to facility staff regarding proper assistance with the brace. Interviews conducted with 7 residents stated they receive assistance with medications or doctor’s recommendations as prescribed. Interviews conducted with 6 staff revealed that they assisted as the physician prescribed. Based on records reviewed and interviews conducted, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Regarding allegation: Facility did not ensure appropriate communication with the resident’s responsible person and Staff did not report observed changes in resident’s condition. It is alleged that facility staff did not communicate with R1's responsible party regarding R1’s needs and that facility staff did not report observation of R1 being lethargic. Interview with 6 staff stated that responsible parties are always notified regarding any changes in the condition of the residents and or any incidents that occurred. Interview with 7 Residents revealed that staff notifies their responsible parties regarding any change in condition or any incidents that occur. Record review indicated that on multiple occasions, R1's responsible party was notified. Facility’s internal notes review indicated that on October 2, 2024, R1 was observed to be lethargic, facility staff had called paramedics and R1's responsible party. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, a copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 7, 2026 · control 31-AS-20250303151829

Allegation investigated: Staff retaliated against resident for making a complaint

Licensing Program Analysts (LPA)s Nadia Shahbazian, Mariana Agban and Licensing Program Manager (LPM) Mary Flores conducted an unannounced subsequent visit to investigate the allegation(s) above. LPAs/LPM met with Rosie Julinek and explained the reason for the visit. Initial complaint investigation was conducted by LPA Shahbazian on 04/07/2026. LPA had requested copies of staff roster, resident roster and relevant documentation regarding the investigation and conducted interviews with the Administrator, (7) seven staff members and (9) nine residents. During today's visit on 05/07/2026 LPA conducted interview with an additional resident. Continued on 9099-C Unsubstantiated Regarding the allegation: Staff retaliated against resident for making a complaint. It was alleged that a violation letter was issued to a resident in retaliation for reporting a dispute. Interviews with all (7) staff revealed that they all treat residents with respect. (2) out of (9) staff mentioned that residents have spoken to them regarding their concerns, without any fear of retaliation. Administrator stated residents are encouraged to speak with management directly or during the Resident Council Meetings to be able to address concerns. Administrator added that they generally try to assist and resolve residents with their issues. Interview with a resident revealed an incident was brought to the attention of the administrator and resulted in relation with a notice. Interviews with (7) out of (9) residents revealed that they don't have any issues speaking with staff regarding issues and they have not been retaliated against. (1) out of (9) residents stated they are not afraid of retaliation. Document review revealed a violation notice was provided to resident # 1 (R1) on 02/27/26 due to health and safety concerns. LPA observed R1’s room and observed the concerns addressed in the notice. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted. Copy of report provided to Administrator.the state’s words, verbatim · CDSS document, May 7, 2026 · control 31-AS-20260403092449

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

On 04/07/2026 Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced initial 10 day visit to investigate the allegation(s) above. LPA met with Tanya Quezada - Executive Director and disclosed the reason for the visit. LPA requested copies of staff roster, resident roster and relevant documentation regarding the investigation, including but not limited to records for Resident 1 (R1). From 11:05am to 3:05pm LPA interviewed the Administrator, (10) Staff members, (10) Residents and (1) Witness. Regarding the allegation: Staff does not safeguard resident's personal belongings. It is alleged that: Over the past six to seven months, an unknown person has entered Resident 1 (R1)'s room and stolen a large number of items. To investigate the allegation above, LPA interviewed Resident 1 (R1) and (9) residents in random. One (1) Resident stated that they had a box of items, including clothing and shoes, taken or perhaps misplaced, when they moved in but they did not notify the Administrator. Continued on 9099-C Unsubstantiated Interview with R1 revealed that throughout last year several smaller items, including postage stamps and gift cards were missing but they did not notify the Administrator. One (1) Resident stated that they are aware of another resident whose items, such as clothing, were missing; the resident informed LPA that none of their items have ever been missing and that they trust the staff members. Interview with the Administrator and (8) Staff members revealed that no residents have notified them of any missing items or are aware of anyone entering residents' rooms without permission. One (1) Staff member mentioned that they were notified by a resident that their purchased item was missing but caregiver was able to locate the item in the room. All staff members stated that facility policy is for staff to notify Administrator of any missing items and generally caregivers will be responsible for searching for resident's missing items. Administrator stated that they prepare LIC 621 Client/Resident Personal Property and Valuable report, as part of the Admission Record but some residents decline to have their belongings itemized and yet they sign the LIC 621. Administrator also stated that they remind residents to notify staff of any items of value, purchased after admission, in order for LIC 621 to be updated. Interview with Witness (W1) revealed that they became aware of R1's possible missing items, such as clothing and personal items but did not know the exact value or exact items, therefore did not notify facility management. Based on interviews it was revealed that facility staff are respectful of residents, resident's rights and their belongings, and if known, they will search for or try to replace any missing items. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 7, 2026 · control 31-AS-20260402102935

Allegation investigated: Unlawful eviction

On 03/23/2026 Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced subsequent complaint visit to investigate the allegation(s) above. LPA met with Tanya Quezada - Executive Director and disclosed the reason for the visit. The initial and subsequent complaint investigations were conducted by LPA Nadia Shahbazian on 01/09/2026 and 03/10/2026 pertinent documents were gathered, including records for Resident 1 (R1). Regarding the allegation: Unlawful eviction. It is alleged that R1 received an eviction notice but there are no reasons why R1 is being evicted. To investigate this allegation LPA conducted interviews with the Administrator, (5) staff members, R1 and (7) residents. Based on interviews with the Administrator and (4) staff, it was revealed that R1 had multiple behavioral outbursts in the past. Several of the outbursts, involved residents and staff. Continued on 9099-C Substantiated Interviews with (3) residents revealed them to be aware of R1’s behavioral issues. Two (2) of the residents stated R1 had disruptive behavior towards them or other residents. LPA interviewed R1 who stated to have been given an eviction notice. However, R1 does not know the reason for the eviction as the notice does not state it. On 12/29/2025, R1 was provided with a 30-day eviction notice with another resident’s name, listed in error. On 01/14/2026, a revised 30-day eviction notice was provided to R1, with correct resident’s name. Based on review of the eviction notice dated 01/14/2026, the reason of the eviction is listed as not following the “Good Neighbor Policy”: To turn down sounds on radios and television after 9:00pm. In addition, residents must treat other residents and staff with respect and must not be disruptive. The 30-day eviction notice does not include details with dates and incidents of R1’s disruptive behavior. Per R1’s Resident Assessment dated 09/15/2025 and Service Plan dated 10/01/2025, no recent behavioral expressions/health status were observed. On five (5) separate occasions, dated 09/26/2024, 08/27/2025, 09/22/2025, 11/05/2025 and 12/18/2025, LIC 624 - Unusual Incident/Injury Reports (UIR)s, were provided to LPA, which list R1's aggressive or disruptive behaviors towards residents and staff. Although R1 had disruptive behaviors, the 30-day eviction notice failed to provide specific information regarding the incidents and facility staff did not ensure to properly re-assess R1 to prevent such behaviors. Administrator stated that a reassessment was requested for R1 and a new eviction notice may be provided to R1 in the future. Based on interviews with facility personnel and record review, there is sufficient evidence to prove the alleged allegation did occur, therefore the allegation is SUBSTANTIATED. LIC9099-D with citation and Appeal Rights were provided. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 23, 2026 · control 31-AS-20260102100122

From the deficiency page — Deficiency type: Type B · Section cited: CCR 03/23/2026 · Plan of correction due date: Mar 23, 2026

Eviction Procedures: 87224 (d) - The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. Based on interviews and record review, facility did not comply with providing R1 with an lawful eviction notice with specific reasons/dates, which poses/posed an immediate health, safety to persons in carethe state’s words, verbatim · CDSS document, Mar 23, 2026

Plan of correction: Administrator has allowed R1 to stay in the facility, since R1 was placed on notice and has not had behavioral outbursts recently. Staff will continue to provide assistance to R1 for behaviors and update the Appraisal/Needs and Care plan. Administrator may submit a new eviction notice, along with behavioral reassessement, in the future. POC cleared during today's visit.

Allegation investigated: Staff gave the wrong medication to resident in care Staff did not ensure that residents' nursing care needs were performed by an appropriately skilled professional

On 03/10/2026 Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced subsequent complaint visit to investigate the allegation(s) above. LPA met with Tanya Quezada - Executive Director and disclosed the reason for the visit. The initial complaint investigation was conducted by LPA Nadia Shahbazian on 02/17/2026 and pertinent documents were gathered, including records for Resident 1 (R1) and (R2). LPA conducted interviews with the Administrator, (5) staff members and (8) residents. Regarding the allegation: Staff gave the wrong medication to resident in care. It is alleged that R1 was given medication intended for another resident because they do not verify the residents information. Interviews with Administrator revealed that R1 was not given medications for another resident. LPA interviewed R2, who revealed that they order their own medication and they keep their medication in a locked box in their room. Per physician’s report dated 06/23/2025: R2 is able to manage and store their medications. R2 informed LPA that staff do not handle R2' medications. Continued on 9099-C Unsubstantiated Interviews with medication technicians revealed that medication for each resident is prepared by reviewing the Medication Administration Record (MAR) and resident’s face sheet in the system. Medication cups are filled based on comparing the MAR to medication list, resident’s name, picture and room # to avoid errors. Interview with staff revealed that every day there is a shift change meeting, in which any changes in residents’ medications or conditions are discussed with all care staff and kitchen staff. Interviews with residents revealed that they have never experienced and/or are aware of any medication errors. During the complaint visit, LPA conducted a medication count/review for (8) residents. Medications were counted and compared to MAR and there were no discrepancies encountered. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding the allegation: Staff did not ensure that residents' nursing care needs were performed by an appropriately skilled professional. It is alleged that staff are performing nursing-related tasks such as; conducting body assessments, making clinical decisions regarding resident medications, and performing other nursing tasks. Based on interviews with the Administrator and care staff, all staff stated they do not make clinical decisions regarding resident’s care or medications. Medication Technicians communicate with resident’s physician and responsible persons, regarding any changes to residents’ condition or medications. In cases of an emergency, staff immediately calls 911 and notifies the responsible party and residents’ physicians. Also, all staff are notified of any changes in residents’ condition. Administrator stated that there are several residents who are receiving home health or hospice care services through licensed companies; these are licensed nurses who provide care to our residents. Administrator added that “our staff are not trained, nor do they provide any “nursing-related care”. LPA’s interviews with Caregivers revealed that some residents take their own showers, but it is the responsibility of the Caregivers to shower residents two times per week. Per caregivers, they always do a visual body check to ensure there are no wounds. Med techs informed LPA that they do perform visual body checks if a resident falls or returned from the hospital. Interviews with (3) residents revealed that they take their own shower. (5) residents stated Caregivers shower them two times a week and they possibly do body checks during showering. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 31-AS-20260211093558

Allegation investigated: Staff did not prevent facility from being in disrepair. Staff are not providing adequate food service to residents in care.

On 02/17/2026 Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced subsequent complaint investigation visit to the facility regarding above allegations. LPA met with Tanya Quezada-Executive Director/Administrator and explained purpose of the visit. On 02/17/2026 LPA Shahbazian requested copies of the Staff Roster, Resident Roster, facility menus and documents regarding Resident 1 (R1). During today’s visit, LPA interviewed residents and staff and conducted a tour of the facility, including kitchen; no immediate health and safety issues were observed. Regarding the allegation: Staff did not prevent facility from being in disrepair. It is being alleged that for last few months the kitchen was shut down during weekends due to the plumbing issues. LPA interviewed eight (8) residents. Interview with two (2) out of eight (8) residents revealed that they remember the kitchen being closed due to repairs for short time but did not remember exact date, additionally they stated facility notified residents of the repairs. Six (6) out of the eight (8) residents stated that they don't remember closure of the kitchen, or were not concerned, since food was always provided to them. Continue on 9099-C Unsubstantiated LPA interviewed Administrator who stated that back in March 2025, a pipe leading from a small part of the kitchen to the street had burst. Administrator provided a copy of a service contract from a contractor to LPA regarding work to be done, including replacing pipes and concrete. Administrator stated repairs were completed within a few days and residents were notified that food will be ordered from a catering company. Residents were not affected since meals were ordered and served in the dining room or residents' rooms. Based on interviews with staff and residents it was revealed that facility notified residents of the kitchen repair efforts and residents stated they were not affected, therefore above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are not providing adequate food service to residents in care. It is being alleged that the food portions are small, and that staff are not meeting R1’s dietary needs. LPA interviewed eight (8) residents. Two (2) out of eight (8) residents revealed that food portions are sometimes small but they can ask for more. Only one (1) out of eight (8) residents stated that their dietary needs are not always provided. Six (6) out of the eight (8) residents stated that food choices are sufficient and there is always fruit, vegetables and alternative choices available daily. Interview with staff revealed that menu is prepared a month in advance and is posted weekly in common areas and in the facility’s newsletter. Staff stated that food quality and portions are good and balanced. Facility provides three meals, which includes vegetables, fruits, salad and dessert with a secondary menu for residents who do not like the meal of the day, as additional options. Residents may ask for more food, which is provided throughout the night. Residents can notify the caregivers or dining room staff of their food preferences, if they don't like the food of the day and the kitchen staff will prepare a different meal for them. During the visit to the kitchen, LPA observed a roster of residents with dietary needs, including R1, for whom meals are prepared based on physician's provided instructions. LPA observed sufficient supply of perishable (2 days) and non-perishable (7 days) food items in the pantries, refrigerators and freezers. LPA obtained copy of menus from September 2025 through December 2025, in which a diet for residents with meat or vegetable preference can be observed. Based on interviews with staff and residents, it was revealed that facility provides adequate meal sizes and choices, therefore the above allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Feb 17, 2026 · control 31-AS-20251222162029

Allegation investigated: Licensee is financially abusing resident in care. Licensee did not ensure appropriate communications with resident’s responsible person.

Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegation. The initial visit was made by LPA Cava and Nadia Shahbazian on 04/15/25. Investigation consisted of interviews with the Executive Director (ED) Tannya Quezada, Staff 1 (S1) and Staff 3 (S3). In addition to interviews, a record review and physical plant inspection to insure the health and safety of the residents was also made. Licensee is financially abusing resident in care: In regards to the allegation, it was reported that an unauthorized withdrawal of $1,420 was made from Resident 1’s (R1) account on March 3, 2025, which was not approved and directly violated the terms agreed upon. R1 moved into the facility in the middle of February 2025. It is thought that R1 will be charged $720 for the month of March, and the full amount of $1420 commencing on March 1, 2025. Unsubstantiated Between (9:00am to 11:00am), interviews were made with the ED and staff. These interviews confirm the following information · R1 moved into the facility 02/17/25 · The amount for $720 is the pro-rated amount for rent due in February 2025, from 02/17/25 to 02/28/25. · The full amount of $1420 for rent due will commence on March 1, 2025 Between (11:00am to 12:00pm) LPA conducted a record review of R1’s files. Review of R1’s Admission Agreement confirm the monthly rate of $1420, and R1 being admitted into facility on 02/17/25. A further review from accounting breaks down the transaction from 02/17/25 to 04/05/25. It is as follows: · 02/17/25 – Amount due $720, prorated rate for twelve (12) days · 03/01/25 – Rent due for $1420.07 · 04/01/25 – Rent due for $1420.07 In addition to the record review, a physical plant inspection was made between (12:00pm to 2:30pm), Based on the information obtained, there was insufficient evidence to prove that the Licensee is financially abusing R1. Therefore, the allegation is deemed Unsubstantiated at this time. Licensee did not ensure appropriate communications with resident’s responsible person. In regards to the allegation, it was reported that from approximately March 19, 2025 to April 7, 2025, R1’s representative has been trying to get a hold of the ED or any staff available at the facility to resolve R1’s admission agreement and rent due, but the out reach has completely been ignored. Between (9:00am to 11:00am), interviews were made with the ED and Staff 1 (S1) and Staff 2 (S2). All three deny the allegation. ED and the staff provided email communication between the facility and R1’s representative, to try and resolve the issue pertaining to R1’s rent and admission agreement. Moreover, interviews with the responsible party confirm that there was communication between them and facility staff. Based on the information obtained, there was insufficient evidence to prove that there was appropriate communication between the Licensee and R1’s Representative. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 31-AS-20250408085610

Allegation investigated: Staff did not dispense medication as prescribed

Licensing Program Analyst (LPA) Nadia Shahbazian conducted a subsequent visit to the facility to address the allegation listed above. Upon arrival at 10:40 a.m., LPA met with Executive Director -Tanya Quezada and explained the reason for the visit. On 08/07/2025 the initial complaint visit was conducted by LPAs Shahbazian and Agban, and pertinent documents were gathered, including records for Resident 1 (R1). During today's visit at approximately 10:50AM a tour of the facility was conducted and no health hazards were noticed. Cont. on 9099C Substantiated Regarding the allegation: Staff did not dispense medication as prescribed. It is alleged that on 07/12/2025, approximately at 10:00AM, med tech (S2) erroneously administered a blood pressure medication to the R1 that was not prescribed to R1. To investigate this allegation LPA conducted record review and interviews with five (5) staff members and R1. The medication error was recognized at approximately 12:30PM. S2 attempted to contact R1's primary care doctor (PCP) but there was no response. S2 was advised to contact the paramedics. Paramedics arrived and transported R1 to hospital due to hypotension. R1 later returned to the facility on 7/18/2025. Facility submitted an LIC 624-Unusual Incident/Injury Report (UIR) to LPA regarding the incident. In addition, S1 revealed that due to the error, said S2 was removed from their duties as a med tech and is currently working as a care giver. S1 mentioned that facility has updated their process of medication administration by adding resident's pictures, name and room number on medication cups. Based on interviews with facility personnel and record review, there is sufficient evidence to prove the alleged allegation did occur, therefore the allegation is SUBSTANTIATED. Citation, Civil Penalty and Appeal Rights were provided. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 31-AS-20250730144554

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Dec 20, 2025

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for ... medication ... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met by: Based on interviews and record review, facility did not comply with physician orders regarding R1's medication, which poses/posed an immediate health, safety to persons in carethe state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: Administrator removed S2 from their role as a Med Tech and assigned S2 to a Caregiver position. In addition Med Staff were retrained in medication administration process. POC cleared on the date of visit.

Allegation investigated: Staff did not safeguard resident's personal items

On 12/15/25 Licensing Program Analyst (LPA) Nadia Shahbazian and Licensing Program Manager (LPM) Troy Agard visited the facility to conduct an initial 10-Day investigation for the allegation(s) listed above. LPA & LPM met with Tanya Quezada-Executive Director/Administrator and explained purpose of the visit. LPA/LPM requested copies of the Staff Roster/LIC 500, Resident roster and copies of pertinent documents for residents. At approximately 9:50AM a tour of the facility was conducted and no health hazards were noticed. From 10:05AM until 11:50AM, LPA and LPM conducted interviews with facility personnel and residents, including Resident 1 (R1) and Resident 2 (R2). Cont on 9099C Unsubstantiated Regarding the allegation: Staff did not safeguard resident's personal items. It is alleged that a resident's personal belongings are suspected to be stolen by their roommate. To investigate this allegation LPA/LPM conducted interviews with six (6) residents. Four (4) out of six (6) residents stated that they had items missing and notified the staff, who looked for the items. Two (2) residents mentioned that even though staff looked for their items, the items were not located. LPA/LPM interviewed R1 who stated they had three items missing, after moving in but does not know what happened to the belongings and is not clear on when, where or who might have taken said items. During an interview with R2, R2 denied taking any items from R1. Interview with the staff revealed that R1 and R2 have been living together and have a tendency to argue and accuse each other of taking each other’s belongings. Executive Director has offered to house R1 and R2 in separate rooms but both R1 and R2 did not want to move. Staff mentioned that R1 has a drawer full of items but has not notified staff of any specific missing items. Executive Director stated that she asked residents to inform her anytime they bring any items that is valuable to their attention, so that the items can be added to their property log, in case items are misplaced or destroyed. Interview with staff indicated that when residents notify the staff of any missing items, staff look for the items and try to find it if possible, and/or try to replace them. Based on interviews, there is not a preponderance of evidence to prove the alleged allegation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Dec 15, 2025 · control 31-AS-20251207212910

Allegation investigated: Staff does not ensure resident’s room is clean.

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced subsequent complaint visit to include additional interviews for the Substantiated complaint report on 08/27/25 and amended the LIC 9099D. LPA arrived and was greeted by the receptionist, and met with the Executive Director, Tanya Quezada, and explained the reason for the visit. LPA requested copies of LIC 500, the Resident Roster, and other pertinent documents. At 9:45 AM, LPA conducted a physical plan tour to ensure the health and safety of the residents are protected and are in compliance with Title 22 Regulations. During today's visit, LPA interviewed an additional 3 residents, 5 staff members, and the Executive Director. Based on information obtained, the allegation remains Substantiated at this time. Exit interview conducted, POC is cleared, a copy of this report signed and delivered Substantiatedthe state’s words, verbatim · CDSS document, Oct 16, 2025 · control 31-AS-20250422083808

Allegation investigated: Staff does not ensure resident’s room is clean.

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced subsequent complaint visit to include additional interviews for the Substantiated complaint report on 08/27/25 and amended the LIC 9099D. LPA arrived and was greeted by the receptionist, and met with the Executive Director, Tanya Quezada, and explained the reason for the visit. LPA requested copies of LIC 500, the Resident Roster, and other pertinent documents. At 9:45 AM, LPA conducted a physical plan tour to ensure the health and safety of the residents are protected and are in compliance with Title 22 Regulations. During today's visit, LPA interviewed an additional 3 residents, 5 staff members, and the Executive Director. Based on information obtained, the allegation remains Substantiated at this time. Exit interview conducted, POC is cleared, a copy of this report signed and delivered Substantiatedthe state’s words, verbatim · CDSS document, Oct 16, 2025 · control 31-AS-20250422083808

Allegation investigated: Staff do not ensure resident rooms are clean and orderly Staff are not properly mitigating a pest infestation

On 10/03/25 Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced subsequent complaint investigation visit to the facility regarding above allegation. LPA met with Tanya Quezada-Executive Director/Administrator and explained purpose of the visit. LPA requested copies of the Staff Roster and Resident Roster. At 10:40 LPA toured the facility; no immediate health and safety issues were observed. It is alleged: Regarding the allegation that rooms are not clean and orderly. LPA visited various resident rooms randomly and interviewed the residents. Majority of the residents stated that housekeepers clean the rooms, including bathrooms, daily and take out the trash. Only in one of the rooms, LPA observed clutter, although the room was clean. Resident stated that staff do not move the items on the floor but they do clean the floor and the room daily. Continued on LIC9099C Unsubstantiated In addition LPA conducted interviews with several housekeepers who stated they are assigned to 4-5 residents' rooms daily. Housekeepers informed LPA that as part of their daily tasks, they pick up the trash, clean rooms daily, with weekly deep cleaning and change the sheets weekly, or more, due to accidents. Based on the LPA's interviews with staff and residents, rooms are cleaned daily. In addition, LPA observed the rooms and bathrooms to be clean; therefore, the above allegation is UNSUBSTANTIATED at this time. It is alleged: Regarding the allegation that there is a pest infestation. LPA visited various resident rooms randomly and interviewed the residents. Majority of the residents stated that the rooms and bathrooms are clean and they have not noticed insects or pests. Only one resident stated that couple of times she noticed “water bugs” in her bathroom, possibly coming from the pipes or opening of the sink. Resident notified the Maintenance Director and mesh coverings were placed in the sink. LPA interviewed the Maintenance Director who showed LPA the purchased mesh covers to install in bathrooms and stated only one resident notified him about the water bug. LPA interviewed the Executive Director who stated there were some “water bugs” in vacant rooms, since they don’t get cleaned as often. Executive Director stated it is facility's policy to fumigate biweekly and provided LPA with invoices from a professional exterminating company, which has been spraying rooms and common areas biweekly. Both the Executive Director and Maintenance Director told LPA that products used for extermination are safe for humans and residents did not get evacuated. Based on the LPA's interviews with staff, facility has taken all measures to ensure there is no pest infestation. In addition, LPA observed the rooms, bathrooms, kitchen and common areas to be clean and without any pests; therefore, the above allegation is UNSUBSTANTIATED at this time. Exit interview conducted and copy of the report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Oct 3, 2025 · control 31-AS-20250819144820

Allegation investigated: Staff do not ensure facility telephones are in working condition Staff do not ensure signal system is in working condition Staff do not provide necessary personal care Staff do not provide necessary basic services

On 10/03/25 Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced subsequent complaint investigation visit to the facility regarding above allegation. LPA met with Tanya Quezada-Executive Director/Administrator and explained purpose of the visit. LPA requested copies of the Staff Roster and Resident Roster. LPA toured the facility; no immediate health and safety issues were observed. It is alleged: The complainant alleged the facility telephones are not in working condition. Based on interviews with residents in various floors, several residents stated they are not concerned since they own their personal cellular telephones. Residents also stated that there are telephones for residents’ use in activity rooms. In addition, LPA observed working telephones in activity room on the first floor and telephones with sitting area, throughout each floor for residents’ use. Therefore, based on the LPA's observations and interviews with residents, the above allegation is UNSUBSTANTIATED at this time. Unsubstantiated It is alleged: Signal system is not in working condition. LPA Shahbazian visited 10 resident rooms on various floors randomly and interviewed the residents. Majority of the residents stated that staff check on them on regular basis and yet, they have the option of calling for assistance by using the signal system. Residents informed LPA that staff come for assistance very quickly. In addition, LPA observed signal systems in each room, next to the beds and in the bathrooms, including bathrooms in common areas. LPA pulled the signal cord in three separate rooms and staff responded within 1-3 minutes. In fact, on one occasion, two separate caregivers arrived within 2 minutes to provide assistance. Therefore, based on the LPA's observations and interviews with residents, the above allegation is UNSUBSTANTIATED at this time. It is alleged: Staff do not provide personal care. LPA conducted interviews with several caregivers who stated they are assigned to 4-5 residents daily, for assistance. Caregivers stated they bathe residents at least twice a week or more, due to accidents, they check on residents every hour or two hours to assist with any needs such as toileting. Caregivers also informed LPA that they work in conjunction with housekeepers to ensure trash is picked up, rooms and bedding are clean. LPA visited various resident rooms randomly and interviewed the residents. Majority of the residents stated that staff check on them on regular basis, shower them twice a week or more, clean the rooms and do their laundry. Only one resident stated that sometimes she does not allow caregivers to shower her since “they don’t properly know how” and sometimes my sheets are not changed regularly. Based on the LPA's interviews with staff, personal care is provided timely. Interviews with majority of residents revealed staff are caring and provide personal care; therefore, the above allegation is UNSUBSTANTIATED at this time. It is alleged: Staff do not provide basic services. LPA conducted interviews with several caregivers and housekeepers who stated are assigned to 4-5 residents daily for assistance. Caregivers stated they bathe residents at least twice a week or more, due to accidents, check on residents every hour or two hours to assist with any needs such as toileting. Housekeepers informed LPA that as part of their daily tasks, they picked up the trash, clean rooms daily and with weekly deep cleaning and change the sheets weekly, or more, due to accidents. LPA visited various resident rooms randomly and interviewed the residents. Majority of the residents stated that staff check on them on regular basis, shower them twice a week or more, clean the rooms and do their laundry. Only one resident stated that she does not allow staff to clean her room because “they don’t know how and they don’t wash my clothes”. While in the room LPA observed a housekeeper to come and clean the room but resident refused. Based on the LPA's interviews with staff, basic services are provided timely. Interviews with majority of residents revealed staff do provide basic services on daily basis; therefore, the above allegation is UNSUBSTANTIATED at this time. Exit interview conducted and copy of the report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Oct 3, 2025 · control 31-AS-20250611130317

Allegation investigated: Staff does not ensure resident’s room is clean.

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced subsequent complaint investigation. LPA met Tannya Quezada, Executive Director, and disclosed the reason for the visit. LPA conducted a physical plan tour to ensure the health and safety of the residents are protected and in compliance with Title 22 Regulations. Allegation: Staff does not ensure resident’s room is clean It was alleged that facility staff do not clean R1’s room. The complainant stated that R1’s room is cluttered. Interview with R1 revealed that staff come to R1’s room to provide housekeeping services; however, R1 refused. An interview with the Executive Director revealed that R1 does not allow housekeeping staff in his or her room. The Executive Director mentioned that she had worked with R1 decluttering R1’s room; however, R1 would bring additional boxes into the room. LPA observed R1’s room filled with storage boxes, recycling bottles, and stacks of papers. LPA also noted that R1’s bed sheets are not clean and have urine stains. Substantiated Allegation: Staff does not assist resident in a timely manner. It was alleged that facility staff do not assist R1 with R1’s dressing and toileting in a timely manner. Interview with the Executive Director denied the allegation. Interview with 4 residents denied the allegation. LPA had tested the emergency call in R1’s room and other residents room, and the staff were answering within a minute. Based on information obtained, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report signed and delivered. Based on interviews and observations, the allegation is deemed substantiated at this time. LPA advised the Executive Director that facility staff must maintain a clean, safe, and sanitary environment for the residents. Exit interview conducted, citation issued, copy of this report delivered.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 31-AS-20250422083808

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 3, 2025

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by Based on interviews and observations, the licensee did not comply with the section cited above. R1's room was not clean and full of clutter which poses/possessed a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Executive director will conducted in service training to all staff regarding the cited section and will provide list of attendees.

Allegation investigated: Staff does not ensure resident’s room is clean.

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced subsequent complaint investigation. LPA met Tannya Quezada, Executive Director, and disclosed the reason for the visit. LPA conducted a physical plan tour to ensure the health and safety of the residents are protected and in compliance with Title 22 Regulations. Allegation: Staff does not ensure resident’s room is clean It was alleged that facility staff do not clean R1’s room. The complainant stated that R1’s room is cluttered. Interview with R1 revealed that staff come to R1’s room to provide housekeeping services; however, R1 refused. An interview with the Executive Director revealed that R1 does not allow housekeeping staff in his or her room. The Executive Director mentioned that she had worked with R1 decluttering R1’s room; however, R1 would bring additional boxes into the room. LPA observed R1’s room filled with storage boxes, recycling bottles, and stacks of papers. LPA also noted that R1’s bed sheets are not clean and have urine stains. Substantiated Allegation: Staff does not assist resident in a timely manner. It was alleged that facility staff do not assist R1 with R1’s dressing and toileting in a timely manner. Interview with the Executive Director denied the allegation. Interview with 4 residents denied the allegation. LPA had tested the emergency call in R1’s room and other residents room, and the staff were answering within a minute. Based on information obtained, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report signed and delivered. Based on interviews and observations, the allegation is deemed substantiated at this time. LPA advised the Executive Director that facility staff must maintain a clean, safe, and sanitary environment for the residents. Exit interview conducted, citation issued, copy of this report delivered.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 31-AS-20250422083808

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 3, 2025

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by Based on interviews and observations, the licensee did not comply with the section cited above. R1's room was not clean and full of clutter which poses/possessed a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Executive director will conducted in service training to all staff regarding the cited section and will provide list of attendees.

Allegation investigated: Facility was not kept at a comfortable temperature Facility did not safeguard resident’s personal property

Licensing Program Analysts (LPAs) Mariana Agban and Nadia Shahbazian conducted an unannounced subsequent complaint visit for the above allegations. LPAs met with Tannya Quezada, Executive Director, and explained the reason for the visit. LPAs conducted a physical plan tour to ensure the health and safety of the residents are protected and in compliance with Title 22 Regulations. Allegation: Facility was not kept at a comfortable temperature It was alleged that R1's room was cold. Interview with 5 out of 72 residents stated that the rooms temperature was not comfortable and that it gets extremely cold. Interview with the Executive Director revealed that the facility has a centralized AC system that can not accommodate every resident. The Executive Director stated that the maintenance director at that time is no longer an employee at the facility. The Executive Director was advised to measure all residents' room temperature and have the AC system adjusted to the appropriate range. The Executive Director was also advised to maintain a daily temperature log in place. Based on the information obtained, the allegation is deemed Substantiated at this time. (Continue on 809C) Substantiated Allegation: Facility was not kept clean and sanitary It was alleged that R1's bedsheet had fecal matter. Interviews with 7 out of 72 residents denied the allegation. LPAs conducted a physical plant tour of random rooms, and rooms were observed to be clean and sanitary. Based on the information obtained, there was insufficient evidence to corroborate the allegation. Therefore, the finding is Unsubstantiated at this time. Exit interview conducted, a copy of this report signed and delivered. Allegation: Facility did not safeguard resident’s personal property. It was alleged that the facility did not safeguard R1's personal property. LPAs reviewed R1's Resident Personal Property and Valuables form (LIC 621), and it was not complete. Executive director stated that R1's incident happened before she was hired. Executive director was advised to complete all current residents LIC 621. Based on the information obtained, the allegation is deemed Substantiated at this time. Exit interview conducted, citations issued, appeal rights given, and a copy of this report delivered.the state’s words, verbatim · CDSS document, Aug 7, 2025 · control 31-AS-20250303151829

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b) · Plan of correction due date: Aug 14, 2025

87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. This requirement was not met. Based on interviews, the licensee did not comply with the section cited above. Interviews with 5 out of 72 residents stated that room temperature is not comfortable and it gets extremely cold which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: Executive Director measure all residents room temperature and have the AC system adjusted to the appropriate range and will maintain daily temperature log. A copy of the log and a picture of adjusted AC system will be sent to LPA by the POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87218(1) · Plan of correction due date: Aug 14, 2025

87218 Theft and Loss (1)The initial personal property inventory shall be completed by the licensee, and the resident, or the resident’s representative. This requirement was not met. Based on record reviews, the licensee did not comply with the section cited above. R1's Resident Personal Property and Valuables form (LIC 621) and it was not complete. which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 7, 2025

Plan of correction: Executive Director will complete Resident Personal Property and Valuables form (LIC 621) for all the current residents by the POC date.

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

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Nadia Shahbazian and Mariana Agban conducted an unannounced Required One (1) year at this facility today. LPAs met with Tanya Quezada - Executive Director and explained the reason for the visit. LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools. The Residential Care For the Elderly (RCFE) facility is for residents of ages 60 and above. Fire clearance is for 99 ambulatory residents, of which 50 may be non-ambulatory. A hospice waiver for 12 residents is in place with currently only 1 resident is in hospice care. Facility is a three story building consisting of 72 resident rooms, living room, activity room, dining room, kitchen, beauty salon, 2 laundry rooms, underground garage and a courtyard patio areas. The smoke/carbon monoxide detectors are interconnected. There are several fire extinguishers located throughout the facility and last fire inspection was conducted on 03/19/2025. The facility is equipped with emergency pull alarm and fire sprinkler system. There is an elevator with an evacuation chair in the stairway. There is only one entrance being utilized at the facility but there are several exits, in case of emergencies. All required posters were posted at the entrance and the hallways. A tour of the physical plant was conducted at 9:40 am and the following was noted: Kitchen: Facility’s kitchen door was observed to be locked and inaccessible to residents. Kitchen floors, counters and work areas were clean and sanitary. LPAs observed an adequate supply of perishable foods for two (2) days, and non-perishable food supply for seven (7) days stored in the walk in refrigerator, walk in freezer, and pantry. Food was properly labeled and stored. Emergency food is kept in a separate locked area, outside of the kitchen. Knives and sharp utensils are stored in the kitchen; inaccessible to residents. Detergents and chemicals were locked in a storage room outside of the kitchen. (Continued on 809-C) Bedrooms: LPA toured multiple resident bedrooms on both floors for health and safety. The bedrooms were inspected and observed to maintain required furnishings and sufficient lightings, bed linens, closets/dresser drawers. All bedrooms were observed to be clean and clear of obstructions. Bathrooms: There are several bathrooms in the hallway on each floor for staff and residents use. Hot water temperature was measured in two hallway bathrooms, both measured at 106°F. There are private bathrooms in each resident room; all bathrooms were observed to be clean and sanitary with necessary supplies and required safety fixtures (grab bars, non-slip mats). Laundry: Facility has two (2) laundry rooms, one (1) in each floor with total of four (4) washers and four (4) dryers. LPAs observed all the machines in functional capacity. Laundry detergents, cleaning agents and other toxins are secured in locked storages outside of the laundry room. Medications: Facility has a Wellness Room on the second floor, in which all medications are securely locked, inaccessible to residents. Medication and medication records were reviewed for proper documentation. LPAs observed that medication records were consistent with medication administration records. Multiple First Aid kits and the First Aid Manual were observed in the Wellness Room. Resident records: All records were observed as locked in administration office. A total of seven (7) resident files were reviewed for current physician reports, Needs and Services plans, admission agreements and appraisals. Resident records appeared to be complete and current. Staff records: All records were observed as locked in administration office. A total of five (5) Staff files were reviewed. Criminal record clearances were present, and staff are associated to this facility. Staff records appear to be complete with current training. There were no immediate health and safety hazards observed at the time of this inspection. Exit interview conducted and a copy of this report was provided to the Executive Director.the state’s words, verbatim · CDSS document, Jul 24, 2025

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility staff did not safeguard resident's confidential information

On 07/02/25 Licensing Program Analyst (LPA) Nadia Shahbazian and Licensing Program Manager (LPM) Eva Miller responded to the facility to conduct an initial 10-Day investigative visit for a complaint received regarding above allegation. LPA & LPM met with Tanya Quezada-Executive Director/Administrator and explained purpose of the visit. At approximately 8:30AM until 11:30AM, LPA and LPM conducted interviews with facility personnel and Resident 1 (R1). LPA/LPM requested copies of the Staff Roster, LIC 500 and copies of the medical documents for R1. Allegation states that facility staff did not safeguard resident's confidential information. The complainant alleged that prior to midnight on 04/26/25, R1 was transported to hospital via ambulance Continued on 9099-C Unsubstantiated due to a medical emergency. Upon return of R1 on 04/27/25, R1 observed resident #2 (R2) in the lobby area at the Concierge desk, reading some paperwork that contained confidential information regarding R1. Complainant did not know who was the person who left confidential documents accessible to other residents in the concierge desk area. The information obtained during the investigation included the following: On 04/26/25, around 10:00 PM, R1 was experiencing a medical emergency and 911 was called. EMS responded to the facility and transported the resident to hospital via ambulance approximately at 10:35PM. On 04/27/25 R1 returned to facility at approximately 2:30AM, transported by family member in a privately owned vehicle. R1 entered the lobby alone and witnessed another resident (R2) at the front concierge area, holding and reading paperwork that was R1's documents prepared for, and provided to the EMS personnel at the time of the 911 call for R1's medical emergency. The documents included the face sheet and medication list for R1. R1 was unable to confirm who left the documents in the area of the concierge desk. There was no facility personnel assigned to the concierge desk or lobby area during the hours between (approximately) 5:00pm and 8:00am. R1 did not observe anyone else in the area at the time of this incident. R1 spoke to a facility staff on duty at the time and alerted the staff of the incident. R1 was unable to recall the identity of the staff and did not know the name of R2. R1 did not report this incident to the Administrator. During the visit, the Administrator advised the LPA & LPM that she only became aware of this incident recently, since R1 had not reported the incident to her. The Administrator was alerted to the incident by a third party. Due to the extend of time between the incident and receiving the information, the Administrator was unable to confirm whether the EMS personnel had knowingly or accidentally left the documents behind, when transporting R1, It is the facility policy to provide EMS with the Face Sheet and Medication List when transporting residents for medical emergencies, and it is the expectation that EMS will take the documents with them to the hospital. At this time there is insufficient evidence to confirm or deny that facility staff left resident's confidential information accessible to unauthorized persons. The allegation is deemed UNSUBSTANTIATED. Exit interview conducted. Copy of report issued.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 31-AS-20250624115431

Allegation investigated: Facility coffee maker is in disrepair and staff are not providing hot water to residents for hot tea or coffee.

On 05/14/2025, at 09:45am, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced initial complaint visit to the facility to investigate the above allegation(s). LPA met with Administrator, Tannya Quezada and explained the reason for the visit. On 05/14/25, LPA asked for the cenus, staff and resident roster. On 05/14/25, at 10:15am, LPA conducted a physical plant tour. LPA interviewed three (3) staff and seven (7) residents and delivered findings. 9099C-continued Unsubstantiated Regarding the allegation: Facility coffee maker is in disrepair and staff are not providing hot water to residents for hot tea or coffee. It is being alleged that the coffee maker was broken and the residents were not being offered other alternatives. LPA interviewed seven (7) residents that were aware that the coffee maker was broken but they also confirmed that there was hot water being provided to them for instant coffee. Three (3) staff confirmed that the coffee maker was broken but repaired as soon as possible and alternatives were being offered to the residents. One (1) staff showed LPA the packets of instant coffee that are given to the residents. During LPA's physical tour, LPA observed a Keurig coffee maker on the second floor that is for resident use. LPA took a picture of the Keurig coffee maker that was properly working and available for resident use. Along side the Keurig coffee maker there was coffee cups, utensils, and non-dairy creamer. LPA also observed another coffee maker and hot water machine for resident use in the Activities Room on the first floor. LPA took a picture of these two (2) machines in the Activities Room. Therefore, based on the LPA's observations, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Exit interview conducted, and copy of the report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, May 14, 2025 · control 31-AS-20250507145734

Allegation investigated: Facility did not enforce house rules regarding no smoking.

Licensing Program Analysts (LPAs) Mariana Agban, Nadia Shahbazian and Licensing Program Manager (LPM) Eva Miller conducted an unannounced initial complaint visit for the above allegation. LPAs arrived and were greeted by the receptionist and met with the Executive Director and explained the reason for the visit. LPAs requested copies of pertinent information, which includes LIC 500 and Resident Roster. LPAs conducted a physical plan tour to ensure the health and safety of the residents are protected and in compliance with Title 22 Regulations. Today's investigation consisted of interviews with 3 out of 70 residents and record review. Allegation: Facility did not enforce house rules regarding no smoking. The Reporting Party (RP) alleged noticing a resident sleeping with a lit cigarette in her/his hands. During the physical plant, LPAs observed R2 smoking in R2's bedroom balcony. Executive Director advised R2 to close the door room and smoke in the designated area. The Resident and Care Agreement on pages 21 and 43 indicates that the community is a no-smoking building. Smoking is prohibited in suites and all common areas, both inside and outside the building, including the apartment patios. (Continue on 9099 C) Substantiated The Executive Director had directed R2 to use the patio as a designated area for smoking. Based on the record review, there's no designated area for smoking. Based on observations and record review, the allegation is deemed Substantiated at this time. Exit interview conducted, citations issued, and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 31-AS-20250303151829

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(2) · Plan of correction due date: Mar 18, 2025

Administrator-Qualifications and Duties: The Administrator shall have the knowledge of the requirements for providing care and supervision..The administrator shall also have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on observations and records review the Administrator did non comply with the section sited above by not following the Addmission Agreement regarding the smoking house rules.the state’s words, verbatim · CDSS document, Mar 12, 2025

Plan of correction: The administrator will issue letters regarding house rules to prohibit smoking in suites and all common areas, both inside and outside the building. A copy of the letters will be emailed to LPA by the POC date.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff are threatening to evict resident

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPA met with Executive Director Tanya Quezada and explained the reason for the visit. LPA conducted physical plant tour at 10:25 AM, requested copies of facility documents relevant to the investigation at 10:58 AM and interviewed staff and residents between 11:10 AM to 12:45 PM. It was alleged that Resident #1 (R1) was being forced to move to another room or leave the facility. LPA's record review on 11/20/24 at around 11:00 AM revealed that R1 was issued an eviction letter on 11/12/24 for violating house rules for verbally abusing R1's roommate or Resident #2 (R2). LPA's interview with the former Administrator on 11/20/24 at about 12:15 PM and the Wellness Director today at (R2) at 11:35 AM, revealed that once they received the report on the altercation between R1 and R2 and as no one witnessed the incident as it happened in their own room, they conducted a meeting in their (R1 & R2)’s room to hear both side of their story but R1 became verbally aggressive and called R2 names during the meeting. Unsubstantiated (continued from LIC 9099) On 11/20/24 interview with R1, R1 denied any wrongdoing nor being verbally abusive to anyone. LPA's interview with R1 today, revealed that R1 is doing okay but maintained any wrongdoing nor verbally abused R2. LPA attempted to interview R2 on 11/20/24 but R2 refused to be interviewed. Further interview with the former Administrator on 11/20/24 also revealed that they will rescind the eviction letter and give R1 another chance with some condition. LPA's observation during today's visit confirmed that R1 was not evicted and interview with the new Administrator also confirmed that they are not evicting R1 at this time. Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jan 14, 2025 · control 31-AS-20241112111644

Allegation investigated: Staff are not adequately trained to meet resident needs Staff do not assist resident's in a timely manner Staff does not ensure that the facility is secure Staff does not ensure residents are provided adequate food service

At 10:30 a.m. on 12/06/24, Licensing Program Analysts (LPAs) Nicholas Reed and Nadia Shahbazian conducted an unannounced subsequent complaint visit. LPAs met with the administrator and disclosed the reason for the visit. To investigate the above allegations, LPA Reed conducted an initial visit on 09/04/24 and toured the facility at 10:45 a.m., interviewed the administrator, staff, and a resident between 11:00 a.m. and 12:00 p.m., and obtained pertinent records at 12:00 p.m. On 09/11/24, LPA toured the facility at 10:40 a.m., reviewed pertinent records at 10:50 a.m. including but not limited to staff and resident lists, service plans, staff training records, and a physician’s report, and interviewed three (03) staff and four (04) residents between 11:00 a.m. and 2:30 p.m. Regarding the allegation “Staff are not adequately trained to meet resident needs” it was alleged Staff #1 (S1) is not trained properly to transfer Resident #1 (R1). Unsubstantiated Upon review of the staff list at 12:00 p.m. on 09/04/24, it was revealed that S1 was never employed at the facility. R1 did not wish to be interviewed for the investigation. LPA and the administrator reviewed training records which revealed all staff were sufficiently trained in transferring care and up to date on all trainings. Interviews with the administrator at 11:20 a.m. on 09/04/24, the Wellness Director at 11:00 a.m. on 09/11/24, and with Staff #2 (S2) at 12:30 p.m. on 09/11/24 revealed staff are trained for and competent in transferring residents. Interviews with five (05) out of five (05) residents revealed they have had no issues with staff transferring them to and from beds and wheelchairs. Based on interviews and record review, all staff are adequately trained to transfer residents. Based on interviews and observations, staff ensure residents are provided adequate food service. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff do not assist residents in a timely manner” it was alleged residents wait up to an hour for incontinence care. Interviews with five (05) out of five (05) residents revealed they have their incontinent needs met in a timely manner. Interviews with the administrator and Wellness Director revealed that resident rooms have pull cords near the bed and emergency pull cords in the bathrooms. Bathrooms emergency pull cords are prioritized higher and staff always respond as soon “within a couple of minutes”. Staff respond to non-emergency pull cord requests based on availability and urgency. LPA tested the facility call system in resident rooms between 12:00 p.m. and 2:00 p.m. on 09/11/24. Four (04) out of four (04) pull cords tested were operable. Staff arrived within five (05) minutes of each request. Based on interviews and observations, staff assist residents in a timely manner. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff does not ensure that the facility is secure” it was alleged residents are not safe because doors are unlocked from the outside. During physical plant tours on 09/04/24 and 09/11/24, LPA observed four (04) out of four (04) exterior side doors to be locked form the outside. The main entrance was unlocked. Interviews with the administrator and Wellness Director revealed that all side doors are locked form the outside at all times and the main door is locked around 5:00 p.m. everyday until about 6:00 a.m. There have been no issues with security or safety. Five (05) out of five (05) residents interviewed confirmed they feel safe and secure in the facility. Based on interviews and observations, staff ensure the facility is secure. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Staff does not ensure residents are provided adequate food service” it was alleged the facility serves food which is not nutritious. LPA observed lunch service at 11:45 a.m. on 09/04/24 and at 12:15 p.m. on 09/11/24 and observed food to be well-prepared and of adequate nutrition. Meals contained vegetables, proteins, and grains. Daily menus were posted in the elevator and on dining room tables. Interview with the head chef at 11:45 a.m. on 09/04/24 revealed some residents prefer alternatives to the food served, so the facility offers an alternate menu. Five (05) out of five (05) residents interviewed revealed they enjoy the facility food form the main and alternate menus. Based on interviews and observations, staff ensure residents are provided adequate food service. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health and safety risks were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Dec 6, 2024 · control 31-AS-20240830120239

Allegation investigated: Staff do not esnure residents are spoken to in an appropriate manner

At 10:00 AM, Licensing Program Analysts (LPAs) Huma Rahimi, and Nadia Shahbazian, conducted an unannounced initial complaint visit. LPAs met with the Administrator and LPAs disclosed the reason for the visit. During course of the investigation, interviews and record review were made. At 10:55 AM, LPAs requested resident and staff roster. At 12:20 PM, LPAs requested copies of pertinent information which include, but not limited to Physician's Report, Appraisal Needs and Services Plan, Admission Agreement, and etc., relevant to the investigation. At approximately 12:25 PM, LPAs conducted a physical plant tour. Between 12:45 PM to 2:00 PM, LPAs conducted an interview with the Administrator, Wellness Director (WD), three (3) Staff, and seven (7) out of ten (10) residents. Continue on LIC 9099C Unsubstantiated Staff do not ensure residents are spoken to in an appropriate manner: Regarding the allegation Staff do not ensure residents are spoken to in an appropriate manner. It was alleged that the Wellness Director (WD) made upsetting comments about health treatments of R1. To investigate this allegation LPAs conducted interviews with the Administrator and (WD) and both parties denied the allegation. Interview with three (3) staff members revealed that they never witnessed nor heard that the (WD) spoke inappropriately or disrespectfully to anyone particularly to R1. Six (6) out of nine (9) residents interviewed expressed no concerns regarding this allegation. Lastly, interview with R1 confirmed that (WD) suggested R1 to go under physical therapy in order to use a walker. R1 also did not express any concerns regarding this all allegation.Based on the information gathered during the visit, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Nov 20, 2024 · control 31-AS-20241118112448

Allegation investigated: Staff did not seek medical attention for resident in a timely manner:

Licensing Program Analyst (LPA) Michael Cava conducted a subsequent visit to the facility to amend the 9099D page that was issued on 03/09/24. The above allegation was investigated by Investigations Branch (IB) Investigator Spindola. IB’s investigation consisted of interviews with the facility administrator, staff, and residents. IB’s investigation also included a review of R1’s medical records from the hospital and the skilled nursing facility (SNF) that R1 was discharged to. Based on the information that IB obtained, the allegation was Substantiated, which remains the same. The purpose of amending this report is to delete the continued citation, that was entered in the Plan of Correction (POC) box, and fit into the citations box. POC has since been corrected, therefore no further corrections will be needed. Office Manager advised and a copy of this report issued. Substantiatedthe state’s words, verbatim · CDSS document, Sep 4, 2024 · control 28-AS-20230104121616

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a)(3) · Plan of correction due date: Sep 4, 2024

Reappraisals- In Part: (a) Pre-admission appraisal shall be updated as necessary…to note significant changes & keep appraisal accurate. Significant changes include: (3) Any illness or change in health care needs of the resident. This requirement was not met as evidenced by: Based on LPA’s review of R1’s medical records which document since 10/22/22 staff had knowledge of R1’s cognitive/physical decline & increased needs for service. This deficiency posed an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Sep 4, 2024

Plan of correction: The licensee has since submitted their POC, which was cleared on 03/18/24. No further corrections required.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Antonia Alvizar-Ettima and Leizl De La Cerra conducted an unannounced Required One (1) year at this facility today. LPAs met with Administrator and explained the reason for the visit. Wellness coordinator, Jasmin Saldivar joined in the inspection. LPAs utilized the Compliance and Regulatory Enforcement (CARE) tools. Resident age range 60 and over. 99 ambulatory, of which 50 may be non-ambulatory. A hospice waiver for 12 residents is in place. The facility does not have a Dementia waiver. Facility is a 3-story building consisting of 72 resident rooms, three (3) common areas, 1 living room/activity room, dining room, kitchen, beauty salon, 2 laundry rooms, underground garage and a courtyard patio areas. The facility maintains a comfortable temperature at 74°F. There are carbon monoxide detector installed in the facility. Fire extinguishers are located all throughout the facility and last inspected on 05/22/24. The facility is equipped with emergency pull alarm and sprinkler system. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located in the lobby. Sign in sheet, hand sanitizer, gloves and masks are available. Some staff were observed to be wearing mask during this visit. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. A tour of the physical plant was conducted at 10:30a.m. and the following was noted: Kitchen: The kitchen appliances and fixtures were functional. Food Service area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food and properly stored. Knives and sharp objects were observed to be locked and inaccessible to residents. Walls, ceiling, and floor is in good repair, ample supply of dishes, cups, glasses and utensils for the current census. Dining area: The dining area was observed to be neat, clean and in proper order. Walls, ceiling, tables, chairs and floor is in good repair. Beauty Salon: The beauty salon was observed to be locked, clean and in proper order. It opens on Sundays only. Laundry rooms: Laundry rooms are located diagonally across from room numbers 208 and 308 on the second and third floor. All toxins such as laundry detergents, cleaning agents were observed to be locked inaccessible to the residents in laundry rooms. Medication Room: Medications were kept in a locked medication carts in the medication room. The medications were observed to be locked and inaccessible to residents. There are multiple complete first aid kits located in the medication room. Medication and Medication Records were properly labeled and review for proper documentation. Bedrooms: Six (6) randomly select rooms were adequately furnished with appropriate beddings and linens with sufficient lighting. Hygiene for residents was observed and hallways/passageways are lit. There were enough clean linen available in the closets. Bathrooms: Six (6) randomly selected bathrooms were properly supplied, checked for cleanliness and had functional fixtures. LPA observed that there are appropriate grab bars in the showers and toilets. The hot water temperature measure range was between 111.2 – 114.3 degrees Fahrenheit. Common Areas: These included the living room and dining area. All furnishings are in good repair, lighting is good, walls, ceiling and floors are also in good repair. Surrounding Grounds: There is no body of water at the facility. Front yard and courtyard patio areas passageways were observed to be clear from obstruction. There are shaded area in the courtyard for residents. Resident Files: LPAs conducted a file review of five (5) randomly selected resident records to ensure compliance of licensing forms. Residents’ files appear to be complete and updated. Staff Files: LPAs also conducted a file review of six (6) randomly selected staff records to ensure forms and training are up to date and compliance with licensing forms. Staff files appear to be complete and updated. Staff and Residents were also interviewed using the CARE Tools questionnaire. Facility emergency disaster plan was reviewed. Facility disaster drill was last conducted on 03/12/24. In addition to the physical plant inspection, residents and staff records were reviewed. Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit interview conducted. A copy of this report issued.the state’s words, verbatim · CDSS document, Jun 12, 2024

Allegation investigated: Resident's personal items were not safeguarded

At 9:50a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver the finding for the above noted allegation. LPA met with the ED and explained the reason for the visit. During initial visit on 07/28/2023 at approximately 9:15a.m., LPA conducted a physical plan walk-through, at 9:40a.m. collected facility records, included but not limited to R1 Identification and Emergency Information, Physician’s Report, Resident Appraisal, Admission Agreement and Resident Personal Property and Valuables. Between 11:20a.m. – 12:30p.m. LPA conducted interviews with three (03) out of three (03) staff and one (1) resident at the time of this visit. During Licensing Visit conducted on 05/17/2024 at 10:10a.m. LPA Alvizar-Ettima and ED conducted a physical plan tour. Between (10:30a.m – 12:30am) LPA interviewed six (6) out of seventy (70) residents. Unsubstantiated Prior to this visit on 05/16/2024 LPA Antonia Alvizar-Ettima reviewed the information and the documents previously obtained. 1. Resident's personal items were not safeguarded. It is alleged that R1 jewelry box was previously “ransacked and picked at” and now gone. Staff revealed that when a resident leaves to the hospital and don’t come back the facility staff locks the resident room. R1’s belongings were locked in their room until R1’s family hired movers to pick them up from the facility. Interviews with seven (07) out of seventy (70) residents confirmed the information that staff provided. Residents have no concerns regarding facility staff not safeguarding personal items. A review of facility Resident Personal Property and Valuables document indicate that R1 did not identify a jewelry box on the personal inventory record. Based on interviews and documents review there is no pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard is noted during this visit. Exit interview is conducted and copy of report was provided to Executive Director.the state’s words, verbatim · CDSS document, May 17, 2024 · control 31-AS-20230727091900

Allegation investigated: Staff are not seeking appropriate medical services for residents Staff force residents to accept emergency transport to the hospital

At 9:50a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver the finding for the above noted allegations. LPA met with the ED and explained the reason for the visit. During initial visit on 07/28/2023 at approximately 9:15a.m., LPA conducted a physical plan walk-through, at 9:40a.m. collected facility records, included but not limited to R1 ,Identification and Emergency Information, Physician’s Report, Resident Appraisal, MAR’s, Unusual Incident/Injury Reports, Progress Notes and Admission Agreement. Between 11:20a.m. – 12:30p.m. LPA conducted interviews with three (03) out of three (03) staff involved with R1 care. LPA also interview one (1) resident at the time of this visit. During Licensing Visit conducted on 05/17/2024 at 10:10a.m. LPA Alvizar-Ettima and ED conducted a physical plan tour. Between (10:30a.m – 12:30am) LPA interviewed five (5) out of seventy (70) residents. Prior to this visit on 05/16/2024 LPA reviewed the information and the documents previously obtained. Unsubstantiated 1. Staff are not seeking appropriate medical services for residents. It is alleged that facility are not helping residents to obtain appropriate medical care and will only call emergency services to transport patients to a local hospital, even for non-emergency issues. Staff interviews reveal that they always seek medical services for all residents as needed. They always communicate with the doctors and call paramedics per doctors request. Recently R1 was having nose bleeding on and off for about 2 weeks. R1’s primary physician was contacted and per doctor order R1 needed to go to the hospital. Staff contacted paramedics twice and R1 refused to go. R1 was not available to be interviewed. Interview with five (5) out of seventy (70) residents revealed that staff do seek appropriate medical services. Residents have no concerns regarding medical services provided by the facility staff. Information revealed from facility records supported the information provided by the staff. 2. Staff force residents to accept emergency transport to the hospital. It is alleged that staff convince R1 to accept emergency transport to the hospital. Staff interviews reveal that resident can not be forced to go to the hospital. Staff contacts emergency medical services based on the orders received from medical professionals. However, resident has a right to refuse to go to the hospital. Once staff calls 911 the decision is up to resident. All residents interviewed verified that staff never forced them to take emergency transportation to go to the hospital. R1 was not available to be interviewed. A review of facility internal incident log verified the information revealed from interviews. Based on interviews and documents review there is an insufficient information to support the allegations. Therefore, the allegations are UNSUBSTANTIATED at this time. No health and safety hazard is noted during this visit. Exit interview is conducted and copy of report was provided to Executive Director.the state’s words, verbatim · CDSS document, May 17, 2024 · control 31-AS-20230721160221

Allegation investigated: Staff do not provide adequate food service to residents Staff do not answer residents' call buttons in a timely manner Staff stole residents' belongings

At 9:50a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver the finding for the above noted allegations. LPA met with the ED and explained the reason for the visit. During initial visit on 04/10/2024 at approximately 10:30a.m., LPA request and collected facility records, included but not limited to Alternative Menu, Alternative Menu Request form, and April 2024 Menu. LPA conducted a physical plan walk-through, at 10:45a.m. Between 11:00a.m. – 1:00p.m. LPA interviewed seven (07) out of sixty-six (66) residents including resident (R1). ED and other staff were interviewed at approximately 1:10p.m. LPA asked questions relevant to the nature of the complaint. The call button was tested from seven (07) randomly selected resident's rooms and interviewed. During Licensing Visit conducted on 05/17/2024 at 10:10a.m. LPA Alvizar-Ettima and ED conducted a Unsubstantiated physical plan tour. Between 1:00p.m -1:30p.m. LPA interview S1 and S2 was not available to be interviewed during this visit. Prior to this visit on 05/16/2024 LPA Antonia Alvizar-Ettima reviewed the information and the documents previously obtained. 1. Staff do not provide adequate food service to residents. It was alleged that facility food is low quality and not nutritious it is sometimes burnt, tough and the veggies and baked potatoes are served undercooked. Staff interviews reveal that they have not received any complaints about inadequate food service. Facility provides an alternative menu if residents do not like what is being server for the day. ED indicated that cooks are always making sure the food menu is created with residents’ favorites and well prepared and they are open for residents suggestions. During interview R1 indicated that staff do not provide adequate food service. Interview with six (6) out of sixty-six (66) residents revealed that sometimes veggies are overcooked. Overall, the food is okay. When residents address their concerns about the food, the cooks resolve the issues. Residents interviews confirm that facility has an alternative menu which is available per residents’ request. A review of facility main menu and alternate options supported the information provided by the staff. Based on observation, interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 2. Staff do not answer residents' call buttons in a timely manner It was alleged that R1 pull they cord four (4) to five (5) times and staff do not answer because there are not enough staff in the facility. During inspection LPA randomly selected seven (07) out of sixty-six (66) residents and the call buttons were tested in their rooms. All call buttons appeared to be functional, and LPA observed staff answering to call between three (3) to five (5) minutes. Staff interviews reveal that they do answer residents’ call button in a timely manner. The medication room has a phone, and the med-techs walk around the facility with a cordless phone answering calls. The other departments have walkie talkies to communicated and respond to the call button calls. ED indicated that they manage calls to audit night shift to see if staff answer calls. Six (06) out of seven (07) residents confirm the information received from the staff. Only one resident (R1) addressed their concerns regarding call button. R1 was unable to provide specific details to clarify when the staff did not respond to the calls. Based on observation and interviews there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 3. Staff stole residents' belongings It was alleged that staff (S1 and S2) stole R1’s sweater and winter pants with Mickey Mouse on them. Staff (S1) interview reveal that R1 has not reported missing a sweater and winter pants with Micky Mouse on them. S2 was not available to be interview at the time of this visit. ED indicated that if residents report missing belongings, first thing staff does is ask questions pertaining to the belongings. They then ask for permission to look through their stuff if not found. All staff members are informed about missing clothing. ED stated that no resident reported a missing sweater and winter pants with Mickey Mouse on them. Six (6) out of seven (07) residents interviewed during investigation had no concern about their personal belongings. R1 indicted that their belongings were missing, but they were unable to specify why it was not reported to the staff. The staff interviewed during investigation, denied stealing residents belongings. LPA reviewed R1’s Resident Personal Property and Valuables document and no personal items were recorded. Based on interviews and record review, there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard is noted during this visit. Exit interview is conducted and copy of report was provided to Executive Director.the state’s words, verbatim · CDSS document, May 17, 2024 · control 31-AS-20240405152252

Allegation investigated: Staff did not prevent a resident from stealing another resident's personal belongings

At 12:00p.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced initial visit and was greeted by Executive Director (ED), Administrator and LPA explained the reason for the visit. During investigation at 12:05p.m. LPA requested and received staff and resident roster. At 12:15p.m. LPA and ED conducted a physical plant tour. At approximately 12:35p.m. LPA requested R1’s Resident Personal Property & Valuables and Staff Notes. Between 12:40p.m. – 1:30p.m. LPA conducted interviews with ED, Wellness Coordinator (WC), three (3) out of sixty-three (63) residents and one (1) staff that provides care to resident #1 (R1). LPA was informed that resident #2 (R2) is no longer residing at the facility therefore unable to be interviewed. Unsubstantiated At approximately 1:30p.m. LPA received and reviewed R1’s Resident Personal Property & Valuables and a Staff Note. Between 1:35p.m. – 2:30p.m. LPA interviewed two (2) out of sixty-three (63) residents including R1 and one (1) staff via-phone that provides care to R1. LPA asked questions relevant to the investigation. 1) Staff did not prevent a resident from stealing another resident's personal belongings. It was alleged that resident R#2 (R2) stole jewelry from resident R#1(R1). Interview with resident R1 reveal that they stole a wedding ring but do not want to accuse another resident of taking it. Other residents interviewed did not express any concerns regarding residents stealing from them because every resident has a key to their room. Residents indicated that they are responsible of locking their room door at all times not facility staff. WC and staff interviews reveal that they do their best they can to prevent residents from stealing from other residents. Upon move in, staff provide every resident with their own key. A review of R1’s Resident Property and Valuables document dated 07/12/2023 indicates that R1 declined to record personal property and valuables. Based on interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 15, 2024 · control 31-AS-20240311161636

Allegation investigated: Staff did not seek medical attention for resident in a timely manner

Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to close out the investigation regarding the above allegation. It was reported that in the morning of December 7, 2022, Resident 1 (R1) had a fall sustaining a head injury. First aid applied, but R1 was not taken to the hospital until later in the afternoon. The complaint was accepted by Investigations Branch (IB) Investigator Spindola on 01/05/23. The initial 10-day visit to this complaint was made by LPAs Cava and Gary Tan on 01/06/23. IB’s investigation consisted of interviews with the facility administrator, staff and residents. IB’s investigation also included review of R1’s medical records from the hospital and the skilled nursing facility (SNF) that R1 was discharged to. IB’s investigation revealed the following: • 01/10/23: R1 and Resident 2 (R2) has lived at the facility for approximately four years. • 01/24/23: Medical Records from the SNF revealed that R1 had a ground level fall • 01/25/23: Medical Records from the hospital revealed that R1 was admitted to the hospital on 12/07/22 and discharged to the SNF on 12/14/22. R1 ambulates with a walker. R1 was found on the floor, in a pool Substantiated of blood and bleeding from the head on 12/07/22 at the facility. It was unclear how long R1 was laying on the floor. · 02/27/23: Interview with the facility administrator, Jonathan Perles confirmed R1’s admission in 2015, and acknowledges R1’s fall on 12/07/23. Interview with R2 confirms R1’s fall, but R2 could not recall much details of the incident. Interviews with Staff 1 (S1) and Staff 2 (S2) confirm R1s fall on 12/07/23, at approximately 3:00am, confirms the presence of blood to the forehead of R1, confirms cleansing and a band aid only applied, confirms that R1 was not sent to the hospital until 4:00pm on 12/07/23. Interviews with staff also confirmed that R1’s responsible person(s) was not notified of R1’s fall, but only of the hospitalization. Although Staff was made aware of R1’s fall at approximately 3:00am in morning of 12/07/22, and only basic first aid was applied, staff did not seek the medical attention for R1 until 4:00pm that afternoon. Furthermore, a review of R1’s medical records indicate that since October 22, 2022, facility staff had knowledge of and acknowledged that R1’s cognitive and physical condition had progressed, continued to decline, and required assistance with hydration to prevent an infectious disease (sepsis), which caused R1’s brain to malfunction and experience a dysfunction that altered consciousness and behavior. Therefore, based on the information obtained, the allegation is Substantiated. Citation(s) issued on the 9099D. Exit interview conducted. A copy of this report and appeal rights issued. Based on the information obtained by IB, it could not be proven that staff’s neglect could have led to R1’s severe dehydration. Therefore, the allegation is deemed Unsubstantiated at this time. The following allegations were investigated by LPA MIchael Cava on 03/09/24: Resident wandered away from facility due to lack of supervision/Staff did not notify responsible parties of a resident's unexplained absence from facility: In regards to the allegations, it was reported that R1 has been lost due to wandering multiple times for hours, but family was never notified by facility staff. There were no dates specified on when and how many times R1 has wandered away from the facility. Investigation to these allegations consisted of interviews with staff and record review. LPA was only able to identify one staff, Staff 1 (S1) who recalls when R1 resided at the facility. R1 moved out of the facility on or around June 2023. According to S1, R1 and their spouse Resident 2 (R2), never really left their room. Both residents had their meals delivered to their rooms. Both residents never participated in facility activities. Review of both R1 and R2's records reveal that both residents are ambulatory and able to leave the facility unassisted. Also review of facility incident reports for R1 and R2 show no record of either residents wandering away from the facility. Based on the information obtained, there wasn't enough evidence to prove R1 wandering away due to lack of supervision, nor staff not notifying R1's responsible person of the unexplained absences. Therefore, the allegations are deemed Unsubstantiated at this time. Staff failed to administer residents medications as prescribed: In regards to the allegation, it was reported that facility staff is supposed to check and assist R1 with medications as needed but failed to do so, for so long that it resulted in an infection. IB's investigation reveal that R1 is an independent individual. LPA's review of of R1's file reveal that R1 has the capacity for self care, which includes the ability to manage own medication, administer own prescription and PRN medication, and able to store own medications. Furthermore, there is signed documentation in R1's file, which indicates that R1 has read and understood their responsibility in keeping all medications stored in a lock box at all times, which would be the only way that R1 will be able to self medicate, control and maintain their medications. R1 was advised failure to do so will be in violation of Title 22 and Evergreens rules and regulations, subject to losing their right of self administering their medications. Signed and dated R1 on 06/14/18. A review of facility incident reports for R1 show no record for any medication error/management, which could have resulted in and infection and/or hospitalization, during their stay at the facility. R1 moved out of the facility June 2023. Based on the information obtained, there was insufficient evidence to corroborate the allegation of Staff failing to administer R1's medications as prescribed. Therefore, the allegation is deemed Unsubstantiated at this time. Staff stole resident's belongings: In regards to the allegation, it was reported that Resident 2's (R2) clothing was stolen by an employee but the bag of clothes were later returned. LPA conducted a review of facility incident reports for R2, but there is no record of R2's belongings reported being stolen during their stay at the facility. Furthermore, a review of resident file reveal that both R1 and R2 declined to fill out and complete the Client/Resident Personal and Valuables (LIC 621). R2 no longer resides at the facility. R2 moved out with R1 June 2023. Copy of their last service receipt notes that all their belongings were removed on 06/23/23. In addition, LPA conducted interviews with seven (7) of seven residents, who did not express any concerns of their belongings being lost or stolen. Note that the reporting party did indicate that the bag of clothes was later returned. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff stealing R2's belongings. Therefore, the allegation is deemed Unsubstantiated at this time. Staff are not providing adequate food service to residents: In regards to the allegation, it was reported that food is inedible and low quality. R1 and R2 could not be interviewed regarding food service as moved out on 06/23/23. Interview with S1, who recalls when both R1 and R2 resided at the facility. According to S1, both residents had their meals delivered to their room. During their stay, both residents expressed no complaints or concerns regarding the food service. LPA conducted a physical plant inspection of the food service during meals, and did not observe food to be of low quality. Furthermore, interviews with seven (7) of seven residents expressed no complaints or concerns of the food service. Based on the information obtained, there was insufficient evidence to corroborate the allegation of staff not providing an adequate food service to residents. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Mar 9, 2024 · control 28-AS-20230104121616

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Mar 9, 2024

Incidental and Medical Dental Care- The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis This requirement was not met as evidenced by, R1 experienced a fall, suffered a head injury, and was found on a pool blood in the morning of 12/07/22. R1 was not sent to the hospital until the afternoon of that date. This poses an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Mar 9, 2024

Plan of correction: As POC, administrator will hold staff training to address this section of the regulations. As proof POC was completed, administrator will submit attendance log and training topic to the licensing agency by 03/18/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a)(3) · Plan of correction due date: Mar 9, 2024

Reappraisals- The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: Any illness, injury, trauma, or change in the health care needs of the resident. This requirement was not met as evidence by: a review of R1’s medical records indicate that since October 22, 2022, facility staff had knowledge of R1’s cognitive and physical condition progressingthe state’s words, verbatim · CDSS document, Mar 9, 2024

Plan of correction: Cont. continued to decline, and required assistance with hydration to prevent an infectious disease (sepsis), which caused R1’s brain to malfunction and experience a dysfunction that altered consciousness and behavior. This posed an immediate health and safety risk to the resident in care. As POC, administrator will hold staff training to address this section of the regulations. As proof POC was completed, administrator will submit attendance log and training topic to the licensing agency by 03/18/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87455(c)(3)(B) · Plan of correction due date: Mar 9, 2024

Acceptance and Retention Limitations- No resident shall be accepted or retained if any of the following apply: Dementia, unless the requirements of Section 87705, Care of Persons with Dementia, are met. This requirement was not met as evidenced by: a review of R1’s records indicate that R1 began to express behaviors and symptoms of dementia. Staff was aware of this decline, but failed to accurately assess R1 in order to meet their needs. This posed an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Mar 9, 2024

Plan of correction: As POC, administrator will hold staff training to address this section of the regulations. As proof POC was completed, administrator will submit attendance log and training topic to the licensing agency by 03/18/24.

Allegation investigated: Facility staff did not ensure that appropriate assistance was provided Facility did not properly address bed bugs Facility staff verbally harassed resident

At 9:45a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced complaint visit to deliver the finding for the above noted allegations. At 9:55a.m. LPA met with the Executive Director and explained the reason for the visit. During initial visit on 04/24/23 at 10:16am, LPA conducted a physical plant tour, between 10:49 am – 12:30 pm LPA conducted interviews with staff involved with R1 care, and at 11:30am collected facility records, included but not limited to Professional Pest Management Invoice, Resident #1 (R1’s) Identification and Emergency Information, Physician’s Report, Resident Appraisal, and Medication Administration Records. On 02/27/2024 LPA Antonia Alvizar-Ettima reviewed the information and the documents previously obtained. During Licensing visit conducted on 03/01/2024 between 1:00p.m. -2:27p.m. LPA interviewed residents including R1. Unsubstantiated 1. Facility staff did not ensure that appropriate assistance was provided It was alleged that the staff asked Resident #2 (R2) to move to resident #1 (R1’s) room to assist R1 due to changes in R1’s condition. Staff interviews reveal that R2 was never asked to move in R1’s room to assist. Interview with R1 reveal that they do not want facility to move another resident in R1’s room. R2 verified that they were asked to move to R1’s room but was unable to explain why. Document review revealed that R1 is ambulatory resident and able to transfer to and from bed and does not require assistance. During initial visit LPA Alvizar-Ettima observed R1 getting around the facility using a walker. Based on observation, interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 2. Facility did not properly address bed bugs. It was reported that resident #3 (R3) had bed bug bites and told resident #2 (R2) that they got bed bugs because of R2. Staff interviews revealed that facility did not have bed bugs. However, staff followed bed bug procedures just in case there were some bed bugs in R2 and R3 room. Staff asked R2 and R3 to temporarily move rooms for a deep cleaning. R3 moved with the assistance of a family member and R3’s room was deep cleaned, no bedbugs where found. R2 initially agreed to move to another room then refused therefore, R2’s room was not deep cleaned. R2 refused staff assistances in cleaning the room. Interviews with R2 and R3 revealed that they denied having bed bugs in their room. At the time of inspection, LPA did not observe bed bugs in R2 and R3 rooms. Document review from Professional Pest Management revealed that on 04/18/23, R2’s and R3’s rooms #209 and #210 were inspected and did not find any life bed bugs. Based on observation, interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 3. Facility staff verbally harassed resident. It was alleged that the staff threatened resident #2 (R2) to throw them out the facility, due to R2 not allowing staff to treat the room for bed bugs. Staff denied verbally harassing R2. Staff #1(S1) indicated that R2 agreed to move to another room temporary and then refused because they did not want to move personal belongings. Resident interviews revealed that they have not experienced or witnessed any staff to be verbally abusive. They indicated that they can always talk to staff without fear of retaliation. Staff are approachable, friendly, and nice. At the time of investigation, LPA did not observe any staff verbally harassing residents. Based on observation and interviews there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard is noted during this visit. Exit interview is conducted and copy of report was provided to Executive Director.the state’s words, verbatim · CDSS document, Mar 6, 2024 · control 31-AS-20230418140931

Allegation investigated: Staff did not dispense medication as prescribed

At 9:45a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver the finding for the above noted allegation. At 9:55a.m LPA met with the Executive Director and explained the reason for the visit. During initial visit on 04/28/23 at 12:20pm, LPA conducted a physical plant check, between 12:30 pm – 2:27 pm LPA conducted interviews with staff involved with dispensing medication to R1 and R2, and at 2:50pm collected facility records, included but not limited to R1and R2 Identification and Emergency Information, Physician’s Report, Resident Appraisal, and MARs During Licensing Visit conducted on 03/01/2024 at 11:27a.m. LPA Alvizar-Ettima inspected Medication Room. Between 1:00p.m. -2:27p.m. LPA interviewed residents including R1. Unsubstantiated Prior to this visit on 02/28/2024 LPA Antonia Alvizar-Ettima reviewed the information and the documents previously obtained. 1. Staff did not dispense medication as prescribed. It was alleged that resident #1 (R1) had not received their medication for two days and resident #2 (R2) was not receiving their medications as per doctor’s order. Staff interviews reveal R1 and R2 have never missed medication. Sometimes residents forget that they already have taken medication. Staff #4(S4) revealed that R1 and R2 are able to manage their own prescription medication. Interview with R1 reveal that they did not miss medication. Records confirmed R1 and R2 are able to manage their own prescription medication. During Medication Room inspection, with S4 assistance, LPA crossed checked random selection of residents' MARs with the medications they have stored in the medication room. LPA did not observe any discrepancies. Based on observation, interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard is noted during this visit. Exit interview is conducted and copy of report was provided to Executive Director.the state’s words, verbatim · CDSS document, Mar 6, 2024 · control 31-AS-20230425154440

Allegation investigated: Residents are not getting medications as prescribed Untrained staff assisting with medication Due to a lack of staff, residents are not assisted in timely manner Staff smoking marijuana at the facility

During investigation at 9:25a.m. LPA Alvizar- Ettima and Executive Director conducted a physical plant tour. LPA Alvizar-Ettima met with Executive Director, Amber Mzczaczy and explain the reason for the visit. Between 10:15a.m. – 3:15p.m. LPA conducted interviews with six (6) out of sixty-four (64) residents, Executive Director, Administrator, Wellness Coordinator and three (3) staff. At 9:45a.m. LPA requested and reviewed medication administration documents. 1. Residents are not getting medications as prescribed It was alleged that med techs leaving medications on night stands and tables not ensuring the residents take their medications. During physical plant inspection, LPA did not notice any medications left in residents room. Staff interviews reveal that residents are getting their mediation on time and as prescribed. Unsubstantiated Interview with resident R#1 reveal that they received their medication as needed and med techs are making sure that they take the medication in their presence. Other residents interviewed did not express any concerns regarding their medication assistance. A review of medication records did not reveal any discrepancies. Based on observation, interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 2. Untrained staff assisting with medication It was alleged that Med - Techs ask caregivers to assist the residents with medications without the proper training. Staff interviews reveal that Med -Tech are not asking Caregiver to assist with medication. Staff indicated that some residents go to the Medication Room to receive their medication and they receive the pills from Med Techs only. Interview with resident R#1 reveal that they never received medication from a caregiver. Other residents also verified that medication was dispensed by the Med -Techs only. Document review revealed that medication records are completed and signed by Med Techs only and all Med Techs received required medication training. Based on observation, interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 3. Due to a lack of staff, residents are not assisted in timely manner It was alleged that due to lack of staff, residents are not showered timely and are not changed timely. (R#1) not checked on during the night and was left soiled all night. (R#2) was found with no brief. To investigate the allegation LPA Alvizar- Ettima interviewed staff and R#1 and R#2 residents. Resident R#1 reveal that they are very happy with staff help with incontinence care. Resident R#2 reveal that has never had an issue with incontinence care. Staff interviews reveal that staff assist in a timely manner and are fully staffed to assist residents with incontinence and showers. Staff interviews reveal that R#1 and R#2 are always assisted in a timely manner. Document review revealed that R#1 and R#2 do need incontinence assistance and received it as scheduled. Based on observation, interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 4. Staff smoking marijuana at the facility It was alleged that (S1) was smoking off a "weed pen". To investigate the allegation LPA Alvizar- Ettima interviewed staff and residents. Staff interviews reveal that staff are not smoking marijuana in the facility. Staff interviews reveal that they have not witness any other staff smoking marijuana. Interview with residents reveal that have not seen staff smoking marijuana. During inspection, LPA did not smell any marijuana in common areas of the facility. Based on observation and interviews there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Mar 1, 2024 · control 31-AS-20240221081352

Allegation investigated: Staff do not serve residents food of good quality

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with the administrator, Rosio Julinek, and explained the reason for the visit. --- Staff do not serve residents food of good quality It was alleged that the facility serves food that is always cold, overcooked or undercooked and that the facility does not offer a variety of foods. To investigate the allegation, on 01/31/2024, LPA conducted a physical plant tour at 3:30 PM, requested the facility menu at around 3:45 PM, interviewed three (03) staff from 4:00 PM – 5:30 PM and interviewed six (06) residents from around 5:30 PM – 6:30 PM. During the physical plant tour, LPA observed heating lamps to keep food warm and fresh foods being prepared. A review of the facility’s menu shows that residents are provided a variety of foods each day. (CONT. on LIC 9099-C) Unsubstantiated During interviews with staff, all staff stated food is served hot, is not over or undercooked and that residents are served a variety of foods daily. During interviews with resident, R1 stated that food is not delivered immediately and cold when it arrives, that the food is either over or undercooked and that there are not being provided a variety of foods. All other residents stated that they are satisfied with the quality of the food, that the food is served fresh and hot, is neither over or undercooked and that they are pleased with the variety of food served. Based on record review, observations and interviews there is enough not information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 31, 2024 · control 31-AS-20240125122220

Allegation investigated: Staff are financially abusing resident in care Staff do not safeguard resident's personal belongings

Licensing Program Analyst (LPA) Antonia Alvizar made an unannounced complaint visit to this facility. LPA was greeted by the Administrator, Rosie Julinek then Executive Director (ED) then Amber Maczaczy joined. LPA explained the purpose of the visit to ED. Staff are financially abusing residents in care. It is alleged that staff took resident debit card and made multiple unauthorized charges. To investigate this allegation, at 10:15a.m. LPA requested facility resident and staff roster. Approximately 10:40a.m. LPA and ED conducted physical plant tour. Between 10:55 a.m. and 2:00 p.m. interviewed four (04) staff, six (06) out of sixty-three (63) residents including resident #1 (R1). In addition obtained copies of R1’s Physician Report, Appraisal, Needs & Services, Unusual Incident Report, Personal Property & Valuables, and other relevant documents to the investigation. Staff revealed that R1 never provided them with a debit card and had not asked them to make a store run. R1 indicated that there is a debit card fraud but the bank has frozen the account and don’t think staff had something to do with it. Unsubstantiated Interview of residents confirmed the information received from the staff. In addition, a review of R1 facility records at approximately 2:00pm – 2:30pm verify the information discussed during interviews. Based on interviews and record review there is no pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Staff do not safeguard resident's personal belongings. It is alleged that new debit card had been stolen from facility. To investigate this allegations at 10:15a.m. LPA requested facility resident and staff roster. Approximately 10:40a.m. LPA and ED conducted physical plant tour. Between 10:55 a.m. and 2:00 p.m. interviewed four (04) staff, six (06) out of sixty-three (63) residents including resident #1(R1). In addition obtained copies of R1’s Physician Report, Appraisal, Needs & Services, Unusual Incident Report, Personal Property & Valuables, and other relevant documents to the investigation. Staff revealed that R1 never provided reported a missing debit card to them. R1 indicated that staff have exceed them expectations at this facility. Interview of residents confirmed the information received from the staff. In addition a review of R1 facility records at approximately 2:00pm – 2:30pm verify the information discussed during interviews. Based on interviews and record review there is no pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate Health and Safety hazard is noted during this visit. Exit interview conducted and a copy of the report was provided to Amber Maczaczy.the state’s words, verbatim · CDSS document, Nov 6, 2023 · control 31-AS-20231101102521

Allegation investigated: Staff does not ensure facility is free of rodents

Licensing Program Analyst (LPA) Antonia Alvizar arrived at 1:00PM to the facility to conduct an unannounced complaint visit for the allegations mentioned above. LPA met with the Executive Director Amber Maczaczyj, and explained the purpose to the visit. During the course of the investigation, interviews and record review were made. At 1:05pm LPA requested copies of resident and staff roster. Approximately 1:13 pm – 3:00 pm LPA met with Culinary Director Luis Pacheco, Maintenance Arcadio Quijada, Executive Director Amber Maczaczyj, Administrator Rosie Julinek and conducted a physical plant tour. The facility Kitchen, lobby downstairs, dining room, reception desk, mailroom, activity room and three (3) randomly selected residents’ bedrooms also were inspected, and interviewed residents residing in those rooms. At 2:00pm Amber provided three (3) Service Inspection Report for Professional Pest Management to target ants, roaches and spiders. Substantiated Allegation: Staff does not ensure facility is free of rodents. It is alleged that several mice are running around the lobby, dining room, reception desk, mail room, and activity room. At the time of inspection, LPA observed glue traps in storage room/Culinary Director’s office, underneath kitchen sink and activity room. LPA observed rodent droppings in storage room/Culinary Director’s office metal shelf, plastic containers, cardboard boxes, behind shelves, food tin cans, food bags and underneath the reception desk and kitchen sink. Wall in kitchen underneath sink has holes that are covered with metal material. Interviews with all staff members confirmed that the facility has rodents. The Service Inspection Report from Professional Pest Management indicated that they are not treating for rodents at this time. A review of facility records verified the information revealed from interviews. Based on interviews, observation, and document review, there is a sufficient information to support the allegation. Therefore, this allegation is deemed Substantiated. Deficiencies were issued and recorded on LIC9099D. Executive Director, Amber Maczaczyj had to leave and designated Culinary Director, Luis Pacheco to sign the report. No health and safety hazard were noted during this visit. Exit interview conducted. Report signed and delivered. Appeal rights delivered. Allegation: Staff does not ensure facility is free of pests. It was alleged that cockroaches have been seen multiple times in resident room. Interview with resident #1 (R1) revealed that about two (2) months ago they had cockroaches in room but no cockroaches now. Interview with staff revealed that there are no cockroaches in the facility. The facility has hired pest control company, working on the pest situation at the facility. At the time of inspection, LPA did not observed any cockroaches in resident rooms. A review of facility records verified the information revealed from interviews. Professional Pest Management services the facility two (2) times a month for roaches. Based on inspection, observation and interviews, there is an insufficient information to support the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Executive Director, Amber Maczaczyj had to leave and designated Culinary Director, Luis Pacheco to sign the report. No immediate health and safety hazard is noted during this visit. Exit interview conducted. Copy of report was provided.the state’s words, verbatim · CDSS document, Oct 4, 2023 · control 31-AS-20230928082746

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 18, 2023

87303(a) The facility shall be clean, safe, sanitary... at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. This requirement is not met as evidenced by: Based on inspection, and observation the Licensee did not ensure that the facility is safe and sanitary for wellbeing of residents and others. LPA observed rodent droppings in food storage/office, kitchen and reception desk. This poses a potential health, safety risk and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: The Administrator will take all measures to maintain the facility free from rodents. Administrator will submit updated documentation of Pest Control service agreement to LPA via fax by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80076(a)(17) · Plan of correction due date: Oct 18, 2023

80076(a)(17) Food Service. Kitchens, food preparation, and storage areas shall be kept clean... free of rodents, and other vermin. This requirement is not met as evidenced by: Based on inspection, and observation the Licensee did not ensure that the kitchen was free from rodents. LPA observed rodent droppings in storage room/office on metal shelf, containers, boxes, food tin cans, food bags and underneath kitchen sink. This poses a potential health, safety risk and personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: The Administrator will instruct staff to cover holes on the wall to maintain the kitchen free from rodents. Staff will keep kichen clean at all times. Adminstrator will submit updated documentation of Pest Control service agreement to LPA via fax by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tuesday Cabiness met with Administrator Rosio Julinek & in training Executive Director Amber Maczaczyj, and informed them the reason of the visit, which is to conduct additional interviews in conjunction with control # (28-AS-20230213105132). During the visit, LPA interviewed residents to obtain further information pertaining to the complaint. Exit interview and copy of report provided.the state’s words, verbatim · CDSS document, Oct 3, 2023