Excellence Board and Care

Allegation investigated: Resident sustained multiple pressure injuries due to staff neglect Facility staff did not assist resident in a timely manner. Staff did not ensure that resident's hygiene needs are met Staff did not follow instructions from care plan Staff did not seek timely medical care for resident in care

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Administrator Ivy Jane Bertulfo and Licensee Rey Bertulfo explained reason for visit. The investigation consisted of the following: During the initial visit conducted on 07/22/2025, LPA conducted an unannounced Health and safety inspection LPA toured the facility and obtained copies of the following documents: staff roster, resident roster, R1 physicians report (602), medication sheet, medical documents, and hospital discharge paperwork. LPA observed a sufficient supply of perishable and non-perishable foods. LPA observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns. From 07/21/25 – 10/29/25 investigator D. Seng with the Investigations Branch (IB) investigated the reported allegation. On 07/26/2025 LPA Gutierrez interviewed staff 1-staff 4 (S1-S4) and residents 2-residents 4 (R2-R4). During today’s visit LPA Gutierrez interviewed resident 1 (R1) by telephone and delivered findings. See LIC 9099C Unsubstantiated The investigation revealed the following: Allegation: Resident sustained multiple pressure injuries due to staff neglect (investigated by IB) It is alleged that the facility’s neglect caused the resident R1, tosustain a fever, diarrhea, pressure ulcers in his heels/ coccyx, and sepsis while in care at the facility. This allegation was investigated by Investigations Branch (IB) investigator D. Seng which revealed the following: Based on file reviews, and interviews conducted, there was insufficient evidence to prove that the facility’s neglect led R1 to sustain to sustain a fever, diarrhea, pressure ulcers in his/her heels/ coccyx, and sepsis while in care at the facility. R1 was placed at the facility from 04/01/2025 to 05/05/2025. Per my interview with the facility staff, R1 was repositioned at least once every two hours. He/she was on home health and received two visits weekly via his Neo Gen Registered Nurse, who was directly responsible for his/her wound care. RN stated that R1 sustained stage two pressure ulcers to his/her right and left buttocks on 04/02/2025 and these wounds never progressed to a stage three or above at any time while R1 was at the facility. RN added that R1 was discharged to Kaiser on 05/05/2025 and his/her pressure ulcers only became worse during his/her stay at Kaiser. R1’s PCP stated that the facility would not have any way to know if he/she was septic unless there were laboratory tests conducted. PCP added that they was in communication with R1 and had a phone encounter with him/her on 04/23/2025. W2 and R1’s PCP added that it was difficult to prevent sepsis or the pressure ulcer on his/her coccyx due to R1’s gunshot wounds, his/her lack of mobility, and his/her catheter. The staff stated that they would contact R1’s PCP/ Wound Care Nurse/ R1’s family immediately when there was a change of condition. Based on the evidence and interviews conducted, the allegation of Neglect/ Lack of Supervision was unsubstantiated. Allegation: Staff did not seek timely medical care for resident in care (investigated by IB) It is alleged due to the facility’s neglect due, and lack of timely medical care caused the resident R1, to sustain a fever, diarrhea, pressure ulcers in his/her heels/ coccyx, and sepsis while in care at the facility. Based on file reviews, and interviews conducted, there was insufficient evidence to prove that the facility’s neglect due to lack of timely medical care led R1 to sustain a fever, diarrhea, pressure ulcers in his/her heels/ coccyx, and sepsis while in care at the facility. Per R1’s home health nurse W1, he/she stated that R1 sustained stage two pressure ulcers to his /her right and left buttocks on 04/02/2025 and these wounds never progressed to a stage three or above at any time while R1 was at the facility until he/she was discharged to Kaiser on 05/05/2025 R1’s PCP added that they believed the facility staff followed his/her care plan, did their best to meet R1’s hygiene standards, and sought timely medical care. They added that R1’s condition was unavoidable and difficult to prevent. Based on the evidence and interviews conducted, the allegation of Neglect/ Lack of Supervision was unsubstantiated. In regard to the allegation” Facility staff did not assist resident in a timely manner”, It is alleged that during a visit it was observed a resident was left screaming for help and facility staff did not respond. During interview with Licensee, Administrator, and staff five (5) out of five (5) staff stated that they always responded to residents. Staff stated that residents have a buzzer and if they need help, they can just press it and staff will come. Administrator stated that R4 does not like to use the buzzer and that he/she like the attention of staff and if R4 needs help R4 will just scream. During interviews with residents one (1) resident stated that staff would leave them for hours because they were understaffed and to busy, two (2) residents stated that staff assisted them in a timely manner, R3 stated that if staff were busy you might have to wait a little bit, but they would come, and one (1) resident was confused by LPA’s questions. During interviews with residents LPA observed R4 yelling for help and when LPA and staff entered room R4 wanted staff to sit with him/her and hold there hand. Staff held R4’s hand and resident calmed down. In regard to the allegation” Staff did not ensure that resident's hygiene needs are met “, It is alleged that facility failed to provide R1 with frequent baths resulting in body odor. During interview with License, Administrator, and staff four (4) out of five (5) stated that residents are given baths 2x a week or more if needed. One (1) staff does not assist in bathing so was unaware of how many times residents are bathed. S2 stated that R1 would only let them bathe him/her and that he/she requested a sponge bath more than 2x a week and S1 would do it. During interviews with residents, two (2) out of four (4) stated that they were bathed regularly and had no problems with hygiene R4 was confused and could not answer the question. One (1) resident stated that staff did not bathe him/her. R1 stated that in the 35 days of stay they were only bathed maybe three (3) time by staff and maybe once by a home health nurse. In regard to the allegation” Staff did not follow instructions from care plan”, It is alleged that during the time of R1’s stay at the facility staff was trained by a home health agency to provide physical therapy three times per week, as part of recovery plan. Despite this clear instruction, not a single physical therapy session was conducted During interview with Administrator, and staff all five (5) stated that home health agency was in charge of PT and OT. Staff stated that only home health took care of therapy staff was not trained for that. During interview with R1 it was revealed that home health care came 2x a week for physical therapy. R1 stated he/she thought staff was supposed to help him/her with physical therapy. LPA obtained documents from Home Health Care dated 04/02/2025 that an order was placed for therapy 3x a week for 3 weeks effective 04/02/2025. Documents reviewed did not indicate staff was to assist with any physical therapy. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was given to licensee.the state’s words, verbatim · CDSS document, Mar 24, 2026 · control 28-AS-20250721115708

Type of visit: Office

An informal Conference was conducted today in the Monterey Park Regional Office. The purpose of this informal conference meeting is to discuss the large number of citations the facility has received along with additional concerns that were observed. Present in the meeting is Licensing Program Manager David Sicairos, Licensing Program Analyst Christian Gutierrez, along with facility Licensee Rey Bertulfo, and Administrator Ivy Bertulfo. The informal Conference process was explained during this meeting. Issues Discussed during the meeting: High number of annual citations. Annual visit 11/22/2024: Three A citations, and Five B citations issued. All Citations cleared. Annual Visit 01/22/2026: One A citation, and Four B citations issued. Four citations cleared. Annual continuation visit 01/28/2025: Two A citations, Six B citations. Two citations have been cleared. Staff room with multiple sleeping cots. Question about current Administrator. Submit Plan of Operation with changes. Holiday party with staff consuming alcohol at the facility. TSP services. SEE 809C The facility has stated they will do the following to achieve and maintain substantial compliance: Licensee will submit remaining POC’s by due date and request extension if needed. Licensee will follow up with physicians and family to obtain current medication orders for residents. Licensee stated three staff members living at facility and cots in staff room are just overflow beds. Licensee confirmed Administrator on record is not current. Licensee will submit documents for Administrator change within two weeks (02/18/2026) Licensee will submit a current Plan of Operation for review as there may have been changes made to it without licensing approval within two weeks. (02/28/2026) Licensee held meeting with staff and discussed zero alcohol at facility. Licensee agreed there will be no more staff parties on the facility premises moving forward. Licensee agreed to TSP services. LPM Sicairos will submit email to TSP for referral services. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies issued following the meeting. Exit interview held and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 4, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Licensee Rey John Bertulfo and Administrator Ivy Jane Bertulfo and explained reason for visit. The facility is licensed for an age range 60 and over. Fire clearance approved for six (6) non-ambulatories where four (4) can be bedridden in room #5,6,7 and 8. Room #3 and #4 is for non-ambulatory only. Waiver/granted for hospice care for six (6) residents. Facility is a single-story home located in a residential area off of a main street consisting of eight (8) bedrooms; 6 private resident bedrooms and 2 staff bedrooms, 10 bathrooms, kitchen, dining room, living room, two (2) covered fireplaces (1 electrical fireplace & 1 gas), laundry room, large backyard outdoor covered patio, storage structure in the rear, and attached garage. LPA toured the facility and observed the following: Each resident bedroom has the required furniture and bedding. LPA observed cameras in each resident’s bedroom that can be viewed on an app called LA view from staff I pad. Extra linen was observed in hallway storage cabinets. The Smoke detectors and carbon monoxide detectors were observed throughout the facility and are properly operating. The facility has multiple fully charged fire extinguishers located throughout the facility. Cleaning supplies and toxic substances were observed to be inaccessible in a locked cabinet in laundry area, knives were locked in kitchen cabinet. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Facility was observed to have sufficient supply of 7 days non-perishable foods and enough 2-day perishable foods for three (3) residents. During tour of facility LPA observed an open can of Budweiser beer in bathroom #4, a case of unopened beer in laundry room, and a trash can in garage filled with empty beer cans. Staff stated they had a late holiday party and residents were asked not to go outside during the party. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The resident bathrooms have the required grabs bars and non-skid mats. Bathroom #3 sink was not working. LPA observed a file cabinet with key in lock with residents’ medication accessible to residents in care. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents in backyard. LPA observed chairs, metal and other debris in back yard. ***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection. ***Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 22, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Reyes conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with with Licensee Rey John Bertulfo and Administrator Ivy Bertuifo and explained the reason for the visit. The facility is licensed for an age range 60 and over. Fire clearance approved for six (6) non-ambulatories where four (4) can be bedridden in room #5,6,7 and 8. Room #3 and #4 is for non-ambulatory only. Waiver/granted for hospice care for six (6) residents. Dementia and bedridden plan submitted. Administrator Ivy’s Residential Care for the Elderly (RCFE) certificate for administration expires 2/16/25. LPA obtained a current copy of the Certificate of Liability Insurance for Excellence Board and Care LLC. Licensee Rey did not have any documents supporting an Emergency Disaster Drill was completed. Facility is a single-story home located in a residential area off of a main street consisting of eight (8) bedrooms; 6 private resident bedrooms and 2 staff bedrooms, 10 bathrooms, kitchen, dining room, living room, two (2) covered fireplaces (1 electrical fireplace & 1 gas), laundry room, large backyard outdoor covered patio, storage structure in the rear, and attached garage. Front and back yards are landscaped with grass. Total of 10 bathrooms, one (1) half bath and 9 full bathrooms with working toilets, wash basins, and walk-in showers, with the exception of room #2, which has a large bathtub. The one (1) half bath in the kitchen water temperature measured at 71.4 degrees f, restroom #4 water temperature measured at 86.7 degrees f., and restroom #9 outside water temperature measured below the 105 degrees f. The water temperature in three (3) restrooms did not meet Title 22 regulations, which require a range of 105 – 120 degrees f. LPA observed cleaning products stored inside a kitchen cabinet underneath the sink accessible to residents. The cabinet did not have a lock or other safety mechanism in place to prevent access. Cleaning products included (2) powder cleanser (Bar Keepers Friend). Located in the kitchen island cabinet were (2) cleaning sprays Weiman Stainless Steel and an unidentified cleaning solution. The cabinet did not have a lock or safety mechanism. Stored in the pantry cabinet unlocked and accessible to residents was a can of butane fuel (First Street brand). In the unlock laundry area was (2) Clorox and (1) detergent bottle. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer are in working condition. The residence is equipped with central heating and air conditioning --Continued LIC809-C-- LPA observed a box cutter with blade attached and scissors in an unlocked drawer in the office area. The tool and scissors were accessible and not secured. LPA observed in the office area a filing cabinet ajar and unlocked contents were residents and staff medication. In staff room #1 the door was unlocked and medication was present and accessible to residents. Located in the dresser in the dining room was a (1) bubble pack of pills Hydroxyzine HCL 25 MG in the drawer. LPA observed a closet door in resident #1 (R1) room was inoperable. The issue appeared to be caused by significant rust damage to the door track, preventing proper opening and closing. LPA observed resident #1 (R1) with full bed rails and R2 with half bed rails. R1 is not receiving hospice care. Licensee does not a have a note from R2's physician for half bed rails. In R2’s closet and on top over the dresser in a small box was eye drops. Per R2's Physican Report R2 is unable to “administer and store own medications”. Smoke Detectors: There are electrical & inter-connected smoke detectors located in all bedrooms, common areas, and hallways Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in hallway closets. During review of R1 and R2's medication for the November 2024 facility has not been documenting each does of medication administer or missed by residents. When LPA requested the November 2024 medication sheet for R1 Licensee Rey and Administrator Ivy was only able to provide an August 2024 medication sheet with no staff initials. The medication sheet that was provided for R2 was missing the month label and staff initials. It was observed for R1 that medication was not being given as prescribed by a physician. R1's PM Medication- Temazepam 15 mg QTY 30 (Take 1 capsule by mouth at bedtime) was full despite date being filled on 9/23/24. R1's PM Medication- Temazepam 15 mg QTY 30 (Take 1 capsule by mouth at bedtime) had twenty-eight (28) pills despite being filled on 1111/24. This revealed that facility had two of the same medication Temazepam 15 mg QTY 30 and was not being given. --Continued LIC809-C-- It was observed that R2's medication was not being given as prescribed by a physician. R2's AM Medication - Eliquis 2.5 MG (Take 1 tablet by mouth every morning and evening) twenty-three (23) pills had been administered for November 22, 2024. R2's AM Medication- Senna Plus 50-8,6 MG (Take two tablets by mouth every morning and evening) November 6, 2024 medication was not administered no supporting documents was provided no supporting documents was provided for reason. R2's AM Medication - Risperidone 0.5 MG ( Take 1 tablet by mouth every morning and evening) November 4th - November 11th 2024 medication was not administered no supporting documents was provided for the reason. R2's Evening Medication - Senna Plus 50-8,6 MG (Take two tablets by mouth every morning and evening) November 5, 6, 10, and 16th medication was not administered no supporting documents was provided for the reason. LPA observed in the backyard outside the shed a mattress, shopping cart, television, two (2) dressers, and an unhinged door. On the side of the shed was broken pieces of tile. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were providedthe state’s words, verbatim · CDSS document, Nov 22, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Galarza conducted a follow-up Pre-licensing visit to verify corrections. The purpose of the visit was explained to Licensee Rey John Bertulfo and Administrator Alma Espinal. An initial Pre-licensing visit was conducted on 12/22/2023. The items listed below have been corrected: 1. The exit door lock in the north side yard has been removed. 2. Window screens were installed in the ten (10) windows identified windows that did not have screens. 3. All sliding doors have installed window screens. 4. The storage structure in the rear of the property was cleaned. All discarded personal belongings, discarded furniture, gardening equipment, gardening tools and grass weed killer were removed and/or locked in storage. 5. Outdoor surveillance cameras that were observed inoperable were removed. 6. Auditory alarms were installed in all exit doors and windows. An exit interview was conducted, and a copy of this report has been furnished to applicant Rey John Bertulfo. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Jan 18, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Galarza made an Announced visit and met with Licensee Rey John Bertulfo and Administrator Alma Espinal to conduct a Pre-Licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) on for an initial application of a Residential Care Facilities for the Elderly (RCFE) to serve adults ages 60 and over. A Dementia waiver and a hospice waiver for six (6) is in place. The requested capacity is for two (2) non-ambulatory and four (4) bedridden in rooms #5, #6, #7, and #8. Structure: Facility is a single-story home located in a residential area off of a main street consisting of eight (8) bedrooms; 6 private resident bedrooms and 2 staff bedrooms, 10 bathrooms, kitchen, dining room, living room, two (2) covered fireplaces (1 electrical fireplace & 1 gas), laundry room, large backyard outdoor covered patio, storage structure in the rear, and attached garage.Front and back yards are landscaped with grass. Bedroom Clients: Each bedroom is designated as a private bedroom. Bedrooms are equipped with one bed, night-stand, chair, lamp, and overhead lighting. Bathrooms: Total of 10 bathrooms, one (1) half bath and 9 full bathrooms with working toilets, wash basins, and walk-in showers, with the exception of room #2, which has a large bathtub. Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in hallway closets. Emergency Phone Numbers, Exit Plan: Emergency numbers are posted and readily available for review. Seven (7) fully charged fire extinguishers were observed. Facility has a land line telephone. Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils were observed locked and inaccessible. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Emergency water supply was observed. Smoke Detectors: There are electrical & inter-connected smoke detectors located in all bedrooms, common areas, and hallways. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer are in working condition. The residence is equipped with central heating and air conditioning. Toxins: Cleaning supplies, and toxins are locked only accessible to staff. ***Narrative continues next page.**** Water Temperature: Hot water was tested in all bathrooms, and kitchen sink. Water temperature was not within normal limits 105 degrees Fahrenheit (40.5 degrees C) and not more than 120 degrees Fahrenheit (48.8 degrees C). Medication, First-Aid Kit & Book: Designated centrally stored medications cabinet, and the first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. Clients & Staff Files: Designated area for files will be in the dining room. Pools/Jacuzzi/Body of Water & Pets: The backyard has one (1) inoperable (covered) water fountain in the backyard, and one (1) jacuzzi bathtub in room #2, designated as a staff room. Fire Clearance: Fire clearance was approved on 9/12/23 for two (2) non-ambulatory residents and four (4) bedridden residents. The facility has fire sprinklers. Per Fire Marshall the facility was required to install three (3) fire doors in the north side facility wing, which were tested and observed operational. Component III: Component III was completed. The following items must be corrected and proof of correction shall be submitted to the CCLD office to the attention of LPA Galarza by 1/19/2024. If additional time is required to complete noted items to correct, then the applicant will request an extension in writing prior to the due date. Some items may require a follow up inspection for verification of correction. 1. The exit door in the north side yard has a lock that requires a key and the two side gates have lock mechanism that need to be removed for fire safety. 2. A total of ten (10) windows were observed without screens. Install screens in a windows. 3. Three (3) sliding doors did not have screens. Install sliding door window screens. 4. The storage structure in the rear of the property has personal belongings, discarded furniture, and gardening equipment. Gardening tools and grass weed killer were observed unlocked in the backyard/ patio area. 5. Outdoor surveillance cameras were observed. Applicant stated they are inoperable. Applicant will remove them or install new cameras. 6. None of the exit doors and windows have auditory alarms; only sliding doors have them. Install auditory alarms in all exit door and windows. An exit interview was conducted and a copy of this report has been furnished to Rey John Bertulfo. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Dec 22, 2023

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for Elderly (RCFE) Application Type: Initial Capacity: 6 Census (if any clients in care): none COMP II Participants: Alma Espinal, Administrator Rey John Bertulfo, Applicant Interview Method: Telephone interview On November 9, 2023, Applicant and Administrator participated in COMP II. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with Applicant and Administrator. Copy of report sent via email and informed to return sign copy to CAB by end of business day today.the state’s words, verbatim · CDSS document, Nov 9, 2023