Family Choice Senior Living

Allegation investigated: Staff hit resident resulting in multiple injuries. Staff does not provide nutritious meals to residents. Staff withholding food from resident.

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to deliver findings on the allegations listed above. LPA was greeted and granted entry by staff after introducing himself and stating the purpose of the visit. The complaint investigation was initiated by LPA Jerome Haley on January 4, 2024, regarding a complaint filed on January 3, 2024. The investigation consisted of a tour of the physical plant, interviews with facility staff, residents and document review. Regarding the allegation: Staff hit resident resulting in multiple injuries 8 of 10 individuals denied the allegation and no one was able to provide any information or evidence that supports the complaint allegation. During interviews, three different facility residents including Resident (R1) denied any problems with the staff members and denied being handled in a rough manner. Continued on LIC9099C Unsubstantiated During interviews, Resident 2 (R2) was asked if staff have handled them in a rough manner and R2 said, Oh no… They’re great. When R1 was asked about how the staff treated them R1 answered, “Okay.” When asked if they like it at the facility, R1 responded with “Okay.” All but one facility staff who were interviewed denied seeing R1 or any other resident get hit by anyone or handled in a rough manner. Executive Director Pamela Junge denied seeing any bruising on any of the residents; however, ED Junge explained she does have a couple residents who are on blood thinners so they may suffer from occasional bruising. ED Junge explained R1 is on blood thinners and has sustained bruising on the arms in the past as a result of moving around the facility in their wheelchair. ED Junge says R1 may have bruising as a result of moving in and out of tight spots and bumping their arms on the sides of doors. All but one of the staff members interviewed denied seeing any resident be treated without respect or handled in a rough manner. Document review supported Executive Director Junge’s statement. R1 was prescribed to take a 20mg Xarelto tablet every morning at 8:00AM. Some of the common side effects of the medication: bruising at the top of the list, followed by nose bleeds, bleeding gums, stomach pain, dizziness, and fatigue. A family member of R1 was interviewed and explained the bruising was first observed on the right forearm and then about a week later the left forearm. The family member explained the bruising healed and has not came back since first observed. The family member could not give a reason why the bruising was observed in September 2023 and not reported until January 2024. Anaheim Police were called to the Family Choice Senior Living on September 12, 2023, for a welfare check call for service, regarding an elderly resident (R1). Anaheim PD arrived on the scene, conducted interviews with Resident 1 (R1), facility staff, and documented their observations. According to Anaheim Police Report/Incident Report number 23-136935: it could not be determined if a crime occurred, Resident (R1) was allowed to reside in the facility after alleged abuse was reported. Continued on LIC9099C page 2 of 4 Anaheim PD Observations: Resident appeared well taken care of, resident room was clean and taken care of. Regarding the allegation: Staff does not provide nutritious meals to residents 9 of 10 individuals were not able to provide any information or evidence that supports the complaint allegation. All three residents were asked about the food and did not have any problems with the food. When R1 was asked about the food, R1 said it’s okay. R2 said the food is really good and there are no complaints from them. R3 was asked about the food and said it’s good for the most part. When speaking to a family member of R1, they visit R1 daily and the family member expressed displeasure with the food and drinks being served. The family member explained they bring/donate to the facility every month. However, the family member did not elaborate on what exactly was wrong with the food other than repeat things they've heard from another resident who was not pleased with the food. The family member also denied that R1 was on any special diet. S6 was asked if the food served was adequate and the staff said, the food is always the same… always the same pasta and the same meat. S6 added the facility had a cook, but did not know the cook’s name before the cook quit. The facility uses Grove Menus, a dietitian approved menu program for Assisted Living and Memory Care Facilities. Sample menus were provided. Regarding the allegation: Staff withholding food from resident 8 of 10 individuals were not able to provide any information or evidence that supports the complaint allegation. According to R1, the food is okay and R1 said they get enough to eat. R2 also denied the allegation. When R2 was asked if they get enough food to eat, the resident said, oh yeah! Continued on LIC9099C page 3 of 4 S3 stated they think R1 was getting the same size portions as everyone else and explained R1’s spouse would come to the facility and forcefully feed the resident. S3 explained the spouse bought R1 special ice cream and would get upset if the resident didn’t eat it. S4 stated they have not observed any resident get served a smaller portion of food due to their weight. S4 says if a resident is given less food, it’s because they eat less. S4 explained residents are allowed to eat what they want and talked about a resident that eats multiple times a day. S4 says the residents likes to snack, so they (staff) provide the food for them. According to Staff 5 (S5), R1's food intake was not restricted at all. S5 explained they actually encouraged R1 to eat more. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed unsubstantiated.the state’s words, verbatim · CDSS document, May 29, 2026 · control 22-AS-20240103144033

Allegation investigated: Staff do not follow infection control requirements Staff do not provide adequate food service Staff allow the residents to share personal equipment Staff do not properly maintain the facility Staff do not keep the facility free from mold Staff do not follow proper food handling techniques

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on February 13, 2025. LPA was greeted and granted entry into the facility and met with Administrator (AD) Pamela Junge. LPA explained the reason for the visit. This Department has investigated the complaint alleging that staff do not follow Infection Control requirements. Regarding the allegation the following was revealed: During the investigation LPA reviewed the staff training/skills check list dated October/November 2024 for Staff 1 (S1) through S3. Per skills check list, S1-S3 completed their training on Infection Control. During the interviews with residents, Resident 1 (R1) reported that staff use gloves when changing diapers. Per R2, she sees staff washing their hands all the time. R3 stated that when staff are working staff use a mask and wear gloves and reported that staff use hand sanitizer after helping the residents. During the interviews with staff, Staff 1 (S1) reported that staff are following the Infection Control requirements when assisting the residents. CONTINUED ON LIC9099-C... Unsubstantiated During the interviews the AD reported that when staff get hired, they are trained on Infection Control and reported that staff wear gloves and a mask as needed, for example when changing a resident's diaper. Per AD, staff use hand sanitizer and wash their hands as needed. Regarding the allegation that staff do not provide adequate food service, the following was revealed: During the initial visit on February 20, 2025, LPA tour the facility and observed as the cook washed her hands after returning from break. LPA observed the cook preparing the meals in a clean kitchen. During the interviews with residents, R1 reported that the food is good and stated that the food is always clean and fresh. Per R2, the food is fine and stated that she never gets leftovers. R3 stated that the food service is good and reported that the food is healthy just not his favorite. During the interviews with staff, S1 stated that whatever food is left over in the residents' plates will be thrown away. S1 reported that she makes extra food in case the residents want more and stated that any extra cooked food in the refrigerator is clean. During the interviews the AD reported that staff provide adequate food service. AD stated that the cook disinfects the kitchen before and after using it and reported that the residents do not get other residents’ leftovers. Regarding the allegation that staff allow the residents to share personal equipment, the following was revealed: During the course of the interviews with residents, R1 reported that the residents share the shower chair and stated that staff clean the shower chairs. Per R2, after each shower staff clean the shower chair. R3 stated that he is not aware of residents sharing personal equipment. During the interviews with staff, S1 reported that she is not aware of the residents sharing personal equipment. During the interviews AD reported that the shower chairs get disinfected before another resident uses it. Regarding the allegation that staff do not properly maintain the facility, the following was revealed: During the initial visit on February 20, 2025, and subsequent visit on March 27, 2026, LPA tour the facility and observed the facility to be in good repair, clean and sanitary. During the interviews with residents, R1 reported that the facility is not in disrepair. Per R2, staff keep the facility clean. R3 stated that the facility is always clean, reported that there are no hazards and stated that nothing is broken. During the interviews with staff, S1 reported that staff properly maintain the facility. During the interviews AD reported that staff properly maintain the facility. CONTINUED ON LIC9099-C... Regarding the allegation that staff do not keep the facility free from mold, the following was reveled: During the initial and subsequent visits LPA tour the facility bathrooms and did not observed mold in the showers. During the interviews with residents, R1 reported that he has not seen mold in the restrooms. Per R2, there is no mold in the showers. R3 stated that he has not seen mold in the bathroom shower. During the interviews with staff, S1 reported that there is no mold in the bathrooms. During the interviews the AD reported that the facility does not have mold. Regarding the allegation that staff do not follow proper food handling techniques, the following was revealed: During the initial visit LPA observed as the cook washed her hands after coming back from their break. During the subsequent visit LPA observed the cook wearing a mask and a hat while cooking. During the interviews with residents, R1 reported that staff are following proper food handling techniques and stated that the cook is very good. Per R2, the food is good and stated that staff are following proper food handling techniques. R3 stated that staff disinfect before preparing and after serving the meals. During the interviews with staff, S1 reported that she washes her hands with antibacterial soap and stated that she changes her gloves as needed. S1 stated that she is following proper food handling techniques. Per AD, the cook is careful when cooking and reported that the cook disinfects and washes her hands as needed. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with AD Junge, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 27, 2026 · control 22-AS-20250213094301

Allegation investigated: Facility has not hired a person designated for food planning and preparation. Facility is not reporting falls and other incidents involving residents Resident fell and sustained injuries due to a lack of supervision.

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct an investigation into the above mentioned complaint allegations. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Pam Junge and discussed the purpose of the visit. The investigation into the above mentioned facility allegations revealed the following: Regarding the allegation of Facility has not hired a person designated for food planning and preparation revealed the following: LPA observed an LIC500 stating that the facility had a cook that was hired on October 6, 2025, and worked Thursday through Monday from 9:45AM-6:15PM. LPA interviewed 4 staff and it was revealed that 4 of 4 staff informed LPA that the cook no longer works at the facility. 2 of 4 staff informed LPA that they will assist with cooking due to the facility no longer having a designated cook. Continue on 9099C Substantiated Regarding the allegation of Facility is not reporting falls and other incidents involving residents revealed the following: 3 of 4 staff informed LPA that they report incidents to the Administrator. 1 of 4 staff informed LPA that they will write the reports and give them to the Administrator to submit them to licensing. 1 of 4 staff informed LPA that they had the incident reports but did not submit them to licensing. Upon records reviewed it was revealed that incident reports were written for Resident #1 (R1) that were not submitted to the Regional Office of Orange County. Regarding the facility allegation of Resident fell and sustained injuries due to a lack of supervision revealed the following: Records reviewed revealed a physicians report for R1 dated October 15, 2025, stating that R1 needs assistance with repositioning and transferring, is not able to dress, bathe or care for their own toileting needs. R1 was marked as non ambulatory due to their physical condition and unable to independently transfer to and from bed. This report was signed by a medical professional. LPA observed a needs and services plan dated January 22, 2026, stating that R1 has upper and lower extremity weakness and requires assistance with transfers and mobility. R1 was noted with poor safety awareness with attempts to get out of bed unassisted and has a history of falls. The needs and services plan states that R1 requires assistance with transfers and mobility and is often non-compliant. The plan also states that staff will assist R1 with their daily activities. LPA observed a staff schedule for the week of December 8, 2025, through December 14, 2025, that indicated 2-3 caregivers are on duty for the morning shift, 2 caregivers and a medtech for the evening shift and one caregiver and one medtech for the night shift. This schedule did not indicate any call offs for LPA to review. Interviews with staff revealed 4 of 4 staff informed LPA that there are normally 2 caregivers and a medtech on duty. 1 of 4 staff informed LPA that there is not enough staff to assist with resident needs. 1 of 4 staff informed LPA that they meet residents needs due to not having a choice regardless of staffing. 2 of 4 staff informed LPA that staff meet all residents needs. 1 of 4 staff informed LPA that the facility has staffing issues due to call offs. 1 of 4 staff informed LPA that they will take on caregiver duties to ensure resident needs are being met. 4 of 4 staff informed LPA that the facility does not have a housekeeper or a cook and caregivers do house keeping duties on top of their care giving duties. Interviews with residents revealed 2 of 4 residents informed LPA that there is a lack of staffing at the facility and it looks like the caregivers could use assistance. 1 of 4 residents informed LPA that they are independent and do not need much assistance. 2 of 4 residents informed LPA that their needs are met by staff. Continue on 9099C Based on interviews conducted, records reviewed and information gathered during the investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 are being cited on the attached LIC9099D. An exit interview was conducted and a copy of this report, LIC9099-D and appeal rights were left at the facility. LPA attempted to interview 1 of 1 bedridden residents and 1 of 1 were unable to confirm or deny the allegations. LPA observed staff assist with feeding 1 of 1 bedridden resident as soon as their food was ready. Regarding the facility allegation of Resident was able to elope due to a lack of supervision revealed the following: it was alleged that residents were able to elope from the facility due to a lack of supervision. LPA did not observe any incident reports regarding elopements from the facility. 2 of 4 staff informed LPA that there has not been an elopement at the facility to report. 1 of 4 staff informed LPA that when residents attempt to elope they are stopped at the front door due to the auditory device that signals the door has been opened. 1 of 4 staff informed LPA that a resident was recently redirected back to the facility after an attempted elopement. 1 of 4 staff informed LPA that if a resident has eloped and staff had to look for them, an incident report would be written. Based upon information gathered and interviews conducted, the Department is unable to ascertain if the above mentioned allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred: therefore the allegations are deemed UNSUBSTANTIATED. An exit interview was conducted and a copy of this report was left at the facility. LPA interviewed staff and 4 of 4 staff informed LPA that residents are given enough food and will be given more food when requested. 4 of 4 staff informed LPA that residents will be given alternative foods upon request. LPA interviewed residents and 3 of 4 residents informed LPA that they get enough food and can ask for seconds. 1 of 4 residents informed LPA that they never ask for seconds because they are given enough food to begin with. 1 of 4 residents informed LPA that they never get enough food. LPA observed 1 in 4 residents request food from staff and was provided with a snack. Regarding the facility allegation of staff are not adequately trained revealed the following: Upon records reviewed, LPA observed training records for 5 staff. LPA reviewed 3 of 5 staff have a skills checklist that went over training expectations and competency with the staff and a trainer both initialing all topics completed when first hired. 5 of 5 staff were hired in 2025. LPA reviewed current staff training on topics such as dementia, medications and care giving. LPA reviewed in service logs from September 2025 to November 2025 covering various topics such as bedridden residents, medication administration, documentation and infection control. LPA interviewed staff and 4 of 5 staff informed LPA that staff are trained when they were first hired. 2 of 5 staff informed LPA that staff are given shadow training and videos. Regarding the facility allegation of Residents are not allowed to open their windows or eat in their rooms revealed the following: LPA observed 1 of 4 resident rooms to have an open window. 2 of 4 residents informed LPA that they have no problems with opening their window. 3 of 4 staff informed LPA that residents are encouraged to keep their windows closed if the AC is on or if it is cold outside but they are not forced to keep them shut. 1 of 4 staff informed LPA that staff are not allowed to open the resident windows. Regarding the facility allegation Resident was injured by another resident due to a lack of supervision revealed the following: When reviewing the allegation there was not a concern due to the lack of supervision with resident on resident injuries. Based on information gathered the investigation into the above mentioned complaint allegations are found to be UNFOUNDED, meaning the allegation was false, could not have happened or is without reasonable basis. Therefore, the Department dismisses the complaint allegations. An exit interview was conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 6, 2026 · control 22-AS-20251203162928

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 3, 2026

Personnel Requirements 87411(a) (a) Facility personnel shall at all times be sufficient in numbers... In facilities licensed for sixteen or more, sufficient support staff shall be employed... Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering... This requirement was not met as evidence by: Based on record review and interviews, the facility personnel has not been at sufficient numbers due to not having support staff. Which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2026

Plan of correction: Licensee stated they will send LPA weekly staffing schedules of 3 caregivers and 1 medtech on duty and hire a house cleaner by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Mar 27, 2026

Reporting Requirements 87211(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement was not met as evidence by: Based on records reviewed and interview, LPA observed incident reports that were not submitted to the Regional Office regarding R1s fall. This poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2026

Plan of correction: Licensee stated they will submit an in service conducted with staff and a statement of understanding to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(16) · Plan of correction due date: Mar 27, 2026

General Food Service Requirements 87555(b)(16) In facilities licensed for sixteen (16) to forty-nine (49) residents, one person shall be designated who has primary responsibility for food planning, preparation and service. This person shall be provided with appropriate training. This requirement was not met as evidence by: Based on interview, observation and records review the facility did not have a designated cook with appropriate training and was pulling caregivers for cooking duties. This poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2026

Plan of correction: Licensee provided LPA with an updated LIC 500 with 2 cooks on shift 7 days a week. LPA observed a cook in the facility. This citation was cleared.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct a case management visit. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Pamela Junge and discussed the purpose of the visit. LPA was notified that Witness #1 (W1) was unable to visit Resident #1 (R1) at the facility due to being asked to leave the facility by the AD due to being a former employee. Based upon interviews with R1, R1 informed LPA that they wanted W1 to come visit them and would like W1 to visit them at the facility again. They had scheduled for R1 to visit them at the facility and was denied W1s visitation. LPA informed AD that W1 can visit the facility in a visitors capacity and that they must follow visitors rules when in the facility. Based on today's observations a deficiency is being noted per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with LIC809D and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jan 7, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(11) · Plan of correction due date: Jan 8, 2026

87468.1(11) Personal Rights of Residents in All Facilities (11) To have their visitors... permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidence by: Upon interviews with R1 it was revealed that they wanted W1 to come visit them at the facility, but W1 was asked to leave by the AD upon arrival. This poses an immediate personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Jan 7, 2026

Plan of correction: Licensee stated they will do a signed statement of understanding on the regulation violated and send to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hanna Gough made an unannounced visit to the facility to conduct the annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Pamela Junge and discussed the purpose of the visit. The facility currently has twenty-four residents in care. The facility is a one-story building with fifteen resident bedrooms, eight bathrooms, living room, kitchen, dining room, staff office, and attached two car garage. The facility appears clean, safe and sanitary. LPA observed the required sized see something say something poster and ombudsman poster at the entrance to the facility. LPA observed all resident bedrooms had the required components and furnishings. LPA observed the restrooms to be stocked with toilet paper, paper towels and nonslip mats in the showers. LPA tested the water to be between 105-115.1 degrees Fahrenheit in the resident restrooms. LPA observed a clean supply of linens located in the southern resident hallway. LPA observed the centrally stored medication cart in the dining room to be locked and made inaccessible to residents in care. LPA observed extra medication storage in the locked staff bathroom and made inaccessible to residents in care. LPA observed the kitchen to be clean and vermin free. LPA observed a two day perishable and seven day non perishable food supply on hand. LPA observed the appliances to be in working order. LPA observed knives to be in a locked cabinet and made inaccessible to residents in care. LPA observed a locked cabinet next to the stove that stores the toxins and chemicals and made inaccessible to residents in care. LPA observed the staff office and no issues noted. LPA observed the garage to be used for extra storage space. The garage holds two full size freezers and two full size fridges for extra food storage for residents in care. LPA observed the emergency food and water supply stored in the garage. LPA observed an extra supply of toxins and chemicals in the garage in a locked cabinet located by the washer and dryer. Continue on 809C LPA observed the courtyard to be free of debris and obstructions. LPA observed shaded seating areas for resident use. LPA observed the exit gate to be unlocked. LPA observed fire extinguishers throughout the entire facility charged and with a service dates of September 25, 2025. LPA and AD tested the carbon monoxide detector and it was found to be operational. LPA reviewed staff files and 1 of 3 staff does not have an entirely filled out health screening. LPA observed a notification from the doctor saying they pass and the report was emailed. LPA reviewed resident files and no discrepancies were observed. LPA reviewed resident medications and no discrepancies were observed. LPA reviewed a fire alarm report dated August 25, 2025 that all alarms passed and are operational. All staff present are background cleared and associated to the facility. LPA informed AD that the facility annual fees are due. Based on today’s observations one technical violation is being issued per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility along with LIC9102 and LIC859.the state’s words, verbatim · CDSS document, Nov 7, 2025

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 not providing adequate activities for residents

Regarding the allegation: Staff are not providing adequate activities for residents 9 of 12 individuals provided information that contradicts the complaint allegation. All the residents who were interviewed provided similar response when asked about activities. Residents like to participate in ping pong, bingo, puzzles, and are provided exercise time. All the staff who were asked about activities also provided similar responses regarding the activities provided and the times activities start. According to staff activities usually start around 10:00am and they go through lunch. After lunch activities resume with an exercise activity that starts around 2:00pm. According to Staff 4 (S4), we have nail day, puzzles, coloring, bingo, and workout exercises from 2:00pm – 3:00pm. Based on the information gathered through interviews and observation the following allegation: Staff are not providing adequate activities for residents is deemed unfounded, meaning the allegations are false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided. Unfoundedthe state’s words, verbatim · CDSS document, Oct 22, 2025 · control 22-AS-20240102114201

Allegation investigated: Staff are not providing adequate food service to residents Staff are not providing resident with privacy

Licensing Program Analyst (LPA) Jerome Haley made unannounced follow up visit regarding the complaint allegations above. LPA Haley was greeted by staff and granted entry after explaining the reason for the visit Regarding the allegation: Staff are not providing adequate food service to residents During the investigation 12 interviews were conducted with facility residents and staff. 9 of 12 individuals provided information that contradicts the complaint allegation. When Resident 6 (R6) was asked about the food, R6 said, It’s pretty good. I have no complaints about that. When Resident 2 (R2) was asked about the food, the R2 said, It’s good. They do a good job. According to a staff member who was asked about the food S3 said, It’s enough for them. The problem is it’s not freshly made home cooked food. Regarding the allegation: Staff are not providing resident with privacy Continued on LIC9099C Unsubstantiated 9 of 12 individuals provided information that contradicts the complaint allegation. When Resident 2 (R2) was asked if they felt they have privacy, R2 said, Yeah… for a house. Resident 4 (R4) was also asked about privacy and said, Umm… Yeah, I say so. Four of five staff members all agree that the residents have privacy. One staff member’s response could not be used to support or deny the allegation. Based on the information gathered during the investigation through interviews and observation, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 22, 2025 · control 22-AS-20240102114201

Allegation investigated: Staff are not treating residents with dignity and respect

Regarding the allegation: Staff are not treating residents with dignity and respect During the investigation 12 interviews were conducted with facility residents and staff. 5 of 12 individuals, of which four were staff members, provided information that supports the complaint allegation. According to S4, residents are treated with respect, but Resident 7 (R7) is disrespectful to staff and according to S4, staff have been disrespectful back to R7. According to Staff 3 (S3), R7 is always fighting (verbally) with Staff 5 (S5) and Staff 1 (S1). S3 says, S5 is responding to R7, and they should not be. According to S3, when S5 was hired, R7 became more aggressive. According to S2, S1 is always yelling at everybody. S2 says S5 is also yelling at everybody and saying a lot of bad words. According to S2, one day R7 was asking S5 what was for lunch and S5 was ignoring the R7. According to R7, S5 hollers at the resident and S1 has an attitude. R7 says, S1 tell the resident to go to their room and doesn’t want to hear what the resident has to say. Continued on LIC9099C Substantiated S7 claims, S1 told the resident to sit down or go to their room the day before the January 4, 2024 visit. Based on the evidence gathered through staff and resident interviews, the preponderance of evidence standard has been met, therefore, the above allegation is SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22. An exit interview was conducted, and a copy of this report and appeal right were provided.the state’s words, verbatim · CDSS document, Oct 22, 2025 · control 22-AS-20240102114201

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 23, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Facility staff witnessing Staff 5 ignoring questions from Resident 7, Staff members have witnessed S5 respond to R7 when other staff felt there should have been no response to the resident from S5. Staff 1 and Staff 5 have both been accused of yelling at R7.the state’s words, verbatim · CDSS document, Oct 22, 2025

Plan of correction: Executive Director Junge will conduct an in-service training on Personal Rights for Residents in All Facilities for all staff. Provide a sign in sheet and a summary of the topics covered during the training and the duration of the in service training to LPA Haley by 4:00pm on the POC due date.

Type of visit: POC

On 12/18/2024, LPA Dwayne Mason Jr arrived at the facility for the purpose of conducting a plan of corrections visit. LPA arrived and was greeted and granted entry by staff. LPA explained the purpose of the visit. The facility received three deficiencies as part of an annual inspection and a complaint investigation both conducted on 11/22/2024 under the following Title 22 Regulations: 87303(a), 87465(c)(2) and 87211(a)(1)(D). Regarding the 87303(a) citation: LPA observed the fence to be repaired and made inaccessible to residents in care. Regarding the 87465(c)(2) citation: LPA received an email on 12/9/2024 containing the requested documentation for a medication in-service training conducted on 12/5/24. Regarding the 87211(a)(1)(D) citation: LPA received an email on 12/9/2024 containing the requested documentation for a reporting requirement in-service training conducted on 12/6/24. Based on today's visit, the LPA determined all plans of correction were fulfilled by the assigned POC due dates. LPA reviewed this report with facility staff and provided a copy.the state’s words, verbatim · CDSS document, Dec 18, 2024

Type of visit: Case Management - Deficiencies

LPAs Dwayne Mason Jr and Nancy Guillen arrived at the facility for the purpose of conducting a Case Management visit to issue deficiencies. LPAs were greeted and granted entry by facility staff. LPAs met with Administrator, AD, Pamela Junge and explained the purpose of the visit. On 11/22/2024, LPAs issued three deficiencies as part of the facility's annual inspection. Due to a final printing error, one of the deficiency pages was deleted from the Licensing database. LPAs issued a deficiency for a medication error - Incidental Medical and Dental - Type B: 87465(c)(2) LPAs issued a deficiency for part of the facility not being safe and in good repair - Maintenance and Operation - Type B: 87303(a) Based on today's visit, two deficiencies are being issued. LPAs reviewed this report with facility staff. A copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 25, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 9, 2024

Maintenance and Operation: 87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. The Licensee did not comply with the section cited above due to the presence of an accessible collapsed fence on the side of the house. This poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 25, 2024

Plan of correction: Administrator stated they will repair the fence and ensure the side of the house is inaccessible to residents in care by the assigned plan of corrections due date of December 9, 2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(c)(2) · Plan of correction due date: Dec 9, 2024

Incidental Medical and Dental Care - 87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions. The Licensee did not comply with the section cited above due to the presence of a missed medication dose in one resident's medication. LPAs observed the dose was signed off on the Medication Administration Record, indicating it was administered.the state’s words, verbatim · CDSS document, Nov 25, 2024

Plan of correction: Administrator stated they will conduct an in-service training regarding Medication Administration and Documentation by the assigned due date. LPA advised AD to document the training with the following information: date/time the training was conducting, participating staff and topics covered. AD stated they will email LPA all documentation for this training by the assigned Plan of Correction due date of December 9, 2024.

Allegation investigated: A lack of supervision resulted in resident leaving the facility unassisted.

This unannounced investigation inspection by Licensing Program Analyst (LPAs) Dwayne Mason Jr. and Fred Arias is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by facility staff. LPA met with Pamela Junge, Administrator and explained the nature of the inspection. The department received a complaint on August 22, 2024 stating a lack of supervision resulted in resident leaving the facility unassisted. During the investigation, the Department interviewed the facility Administrator and reviewed resident documentation. (continued on LIC9099-C) Substantiated (continued from LIC9099) On November 22, 2024, LPAs conducted a visit to the facility. LPAs obtained resident roster, personnel report, physician's report, hospital discharge paperwork, Individual Service Plan, daily health check log and preplacement appraisal. LPAs reviewed hospital discharge paperwork. Per the discharge paperwork, Resident 1 (R1) was admitted to the hospital on August 21, 2024 due to "being found down in the street." The discharge paperwork goes on to say "Per EMS report, patient was found face down on the curb with possible seizure-like activity prior to EMS arrival." LPAs reviewed R1's Physician's Report dated June 3, 2024. Per physician's report, R1 is unable to leave the facility unassisted. LPA conducted an interview with Administrator. AD stated R1 left the facility unassisted. Based on records reviewed, LPAs determined a lack of supervision resulted in R1 leaving the facility unassisted. The preponderance of evidence standard has been met. The allegations are determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that one violation occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Nov 22, 2024 · control 22-AS-20240822133857

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 9, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on record review, LPA determined R1 was found outside of the facility while seizing. R1 was transported to a hospital via EMS.the state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: Administrator stated they will conduct an in-service training regarding supervision of residents and a review of functional capabilities of all residents for all facility staff by the assigned due date. LPA advised AD to document the training with the following information: date/time the training occurred, participating staff and topics covered. AD stated they will email LPA all documentation for this training by the assigned Plan of Correction due date of December 9, 2024.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Dwayne Mason Jr. and Fred Arias arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPAs were greeted at the facility by facility staff. LPAs met with Pamela Junge, Administrator and explained the purpose of the inspection. The facility is one-story building with 15 resident rooms,8 bathrooms, kitchen, dining room, living room, medication room, staff break room, front patio and 2-car garage. All resident rooms had the required elements, including bed, chair, closet space and ample lighting. LPAs observed the fence on one side of the house has fallen over. LPAs determined this side of the house is accessible to residents even though it is unsafe for residents due to the collapsed fence. One deficiency is being issued. Facility has toxins, chemicals and cleaning supplies locked in the garage and a kitchen cabinet. Restrooms are stocked with soap and paper towels. Hot water measured between 105 and 120 degrees F. LPAs observed facility has emergency food and water supply as well as additional emergency supplies. LPAs reviewed six staff files and ten resident files. LPAs conducted interviews with six residents and three staff. LPAs reviewed medication. Based on medication review, LPAs determined a resident missed a medication dose, however, facility staff signed the Medication Administration Record indicating the medication was taken at the appropriate time. One deficiency is being issued. Based on record review, LPA determined the facility did not report an incident that occurred on 8/21/2024 to Licensing. One deficiency is being issued. Based on today's inspection, three deficiencies are being issued. An exit interview was conducted and a copy of this report, deficiency page and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Nov 22, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Facility abandoned resident at the hospital Facility failed to report residents change in condition.

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and witnesses. LPA reviewed and obtained pertinent documentation such as hospital progress notes dated 04/02/2024 and 04/05/2024. Regarding the allegations that facility abandoned resident at the hospital and facility failed to report residents change in condition, the investigation revealed the following: Resident 1 (R1) was admitted to Kaiser on 03/16/2024 for evaluation of ostomy, skin wounds and urinary tract infection. Resident has a history of antibiotic resistant infection as well as fistula in the abdomen. Resident was being treated by home health at the facility for the fistula prior to hospitalization. Per Kaiser Case Manager RN, resident had no active infection and was ready for discharge on 03/19/2024. Interview with Case Manager indicated Facility Administrator did not want to accept the resident back into the facility due to the history of infection and was unresponsive to calls. CONTINUED ON LIC 9099 C DATED 04/10/2024 Unsubstantiated Facility Administrator did not assess the resident at the hospital until 04/06/2024 after multiple conversations with Licensing. Updated physician report dated 04/05/2024 indicates resident is now bedridden and outside licensing regulations as facility does not have a bedridden fire clearance. Administrator provided incident reports dated 03/13/2024 and 03/16/2024 regarding hospitalization of R1. Administrator indicates faxing the reports to the department but does not have a fax receipt. Department regulations require facilities to report incidents to responsible parties, licensing, and physician but the requirement does not apply to outside agencies. Based on interviews conducted and record review, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided to facility.the state’s words, verbatim · CDSS document, Apr 10, 2024 · control 22-AS-20240328103849

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20240328103849. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Pamela Junge arrived during the visit. During the course of the complaint investigation, LPA interviewed Facility Administrator and reviewed documents pertinent to the complaint investigation. Resident 1 (R1) admitted into the hospital on 03/16/2024 for a urinary tract infection, skin wound and assessment of ostomy. Per Kaiser Case Manager, R1 was ready to discharge from hospital on 03/19/2024. Case Manager indicated Administrator stated needing to follow up with Licensing for return protocols. Administrator indicated emailing the department for guidance and receiving no response. The department is not aware of any further requests for guidance from the facility. Case Manager states calls were not returned regarding resident discharging and Administrator did not assess resident until 04/06/2024 resulting in continuing hospital charges and a risk of the resident losing Assisted Living Waiver. Conversations with Licensing precipitated the resident being assessed. However, the hospital re-assessment took place 18 days after potential discharge. Department regulations require a re-assessment of resident when a change of condition is present. Based on the observations made from today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided to Administrator as well as Appeal Rights.the state’s words, verbatim · CDSS document, Apr 10, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(a) · Plan of correction due date: Apr 11, 2024

The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate... This requirement is not being met as evidenced by: Based on interviews conducted, Licensee failed to ensure R1 was re-assessed for suitability to return to the facility. R1 was re-assessed 18 days after potential discharge. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2024

Plan of correction: Licensee to read regulation an submit a statement of understanding nto LPA by POC due date. Licensee to submit a written plan on how to address situations that arise at the facility and forward to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d)(1) · Plan of correction due date: Apr 11, 2024

The administrator shall have the qualifications specified in Sections 87405(d)... Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not being met as evidenced by: Based on interviews conducted, Licensee failed to ensure facility has a qualified administrator. Administrator allowed R1 to remain at hospital for 18 days without following up with licensing or hospital affecting R1's finances and/ or ALW. This poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Apr 10, 2024