Family Courtyard

Type of visit: Case Management - Health Checks

On 06/08/2026 at 10:30 AM, Licensing Program Analysts (LPA) David Doidge arrived unannounced to conduct a health and safety check as a result of the department receiving a complaint with the control number (15-AS-20260605115519). LPA met with Administrator Norma Tejero and explained the purpose for the visit. LPA toured the interior and exterior of the facility, including but not limited to residents’ rooms, bathrooms, kitchen, common areas, and the backyard. LPA observed adequate lighting for the comfort and safety of residents in all rooms. Inside and outside areas are free of obstruction and no bodies of water. Hot water temperature was measured at 107.6 degrees Fahrenheit. There is more than the minimum of a one week supply of nonperishable foods and 2 days of perishable foods. Smoke and carbon monoxide detectors were in operating condition. Fire extinguishers were fully charged and last serviced on 06/18/2025 The medications were stored in a locked cabinet. First aid kit was observed to be complete. No citations were issued during the inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 8, 2026

Type of visit: Case Management - Incident

On 05/27/2026 at 9:10 AM, Licensing Program Analyst (LPA) P.Manalo arrived unannounced to conduct a case management visit on this date to follow-up on an incident report and SOC341 that was faxed to CCLD on 05/15/2026. LPA met with Administrator Lenie Ibe and Norma Tejero and explained the purpose of the visit. Incident report and SOC341 dated 05/15/2026 indicated that R1 did not come home on 05/10/2026. When R1 returned, R1 told the S2 that R1 and S1 were together and R1 is in a relationship with S1. S2 and S3 spoke with S1 about the incident with R1, but S1 denied any relationship with R1. As of 05/14/2026, S1 received a Administrative Leave Notification from the facility. The facility also reported the incident report and SOC341 to the Ombudsman. During the visit, LPA interviewed R1, S2, S3, and S4. Interview with R1 revealed that R1 and S1 are in a relationship. LPA obtained and reviewed the following documents included but not limited to Staff Contact Information, Communication Log, Staff Schedule, internal incident report, Identification and Emergency Information, Medical Assessment, Identification Card, Staff Fingerprint Response, Personnel Record, Application for Employment, Termination Letter and Facility's Memo for Administrative Leave. While LPA was in the facility, LPA received the Termination Letter from S3 that S1 has been terminated effective 05/27/2026. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 27, 2026

Allegation investigated: esident sexually abused while in care Resident physically assaulted while in care Resident subjected to being yelled at while in care

On 03/17/2026 at 3:15PM, Licensing Program Analysts (LPAs), T. Syess-Gibson and L. Hall arrived unannounced to deliver a complaint finding for the allegations above. LPAs met with Lenie Ibe, Caregiver and explained the reason for the visit. During the course of the investigation the Department conducted interviews with staff, witnesses, collected and reviewed records. Allegation: Resident sexually abused while in care During the initial interview, witness 1 (W1) reported that R1 disclosed she was sexually abused by two employees while residing at the facility. R1 no longer resides at the facility. When interviewed, R1 was unable to provide specific dates of the alleged incidents and stated only that the incidents occurred sometime in November or December 2024. Continue on LIC9099C Unsubstantiated Continued from LIC9099 A review with the Richmond Police Department revealed there were no reports or records on file regarding allegations of staff sexually abusing a resident at the facility during that time period. Interviews were conducted with staff (S1, S2, S3, and S4) and residents (R2, R3, and R4). None of the individuals interviewed were able to corroborate R1’s allegation. Staff member S2 reported that the facility maintains a zero-tolerance policy for physical or sexual abuse. Documentation reviewed included R1’s Appraisal Needs and Services Plan dated July 4, 2022. Documentation and statements obtained from staff indicated that R1 has a history of making prior sexual abuse allegations that were determined to be unfounded. Allegation: Resident physically assaulted while in care. Based on interviews and record review, the allegation that Resident 1 (R1) was physically assaulted by other residents while in care is unsubstantiated. During the initial interview, R1 stated that she had been beaten by four residents while residing at the facility. However, during a subsequent interview conducted on September 9, 2025, R1 stated that she had not been physically harmed or assaulted by any residents while living at the facility. R1 reported that the only physical assault she experienced while living at Family Courtyard involved her former partner. A review of a Richmond Police Department report dated March 6, 2020, documented an incident involving misdemeanor domestic violence between R1 and her former partner. The report did not indicate that the incident involved any residents or staff from the facility. Continue on LIC9099C....... Continued from LIC9099C Facility staff did not provide any information supporting the allegation that R1 was physically assaulted by other residents while in care. No additional information was obtained to corroborate the allegation. Allegation: Resident subjected to being yelled at while in care. During initial interview R1 stated someone (unknown name) was yelling and screaming at her. The Department interviewed R1 on 9/9/2025, and R1 made no reference of staff yelling at her. R1 stated another resident (R5) yelled at her (unknown date) one time and R1 reported the incident to W2 and S2. R1 denied having any other verbal or physical confrontation with R5. No additional information was provided by staff or residents. Based upon the information obtained and the interviews conducted during the investigation. The above allegations are unsubstantiated. The finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Mar 17, 2026 · control 15-AS-20250828114215

Type of visit: Case Management - Incident

On 3/9/2026 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to an incident report. LPA met with Administrator, Lenie Ibe and explained the purpose of the visit. Based incident report, resident (R1) was seen at the facility around 10:00AM on Wednesday, 2/18/2026 after taking morning medications and did not sleep at the facility that same night. Staff search the facility and surrounding neighborhood for R1 and did not find R1. Local police was called for missing person (R1) and responsible parties were notified. During visit, LPA interviewed staff and resident (R1). LPA reviewed R1's physician's report which stated that R1 can leave the facility unassisted. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Mar 9, 2026

Type of visit: Required - 1 Year

On 10/16/2027 at 1015 AM, Licensing Program Analyst (LPA) David Doidge and Licensing Program Manager (LPM) J. Fong arrived unannounced to conduct a 1-Year Annual Required Inspection. LPA met with Administrator Norma Tejero and explained the purpose of the visit. The LPA and LPM toured the facility inside and out with Licensee Joseph Taburaza. LPA and LPM inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and back yards. LPA and LPM observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. Hallway temperature was maintained at 61 degrees Fahrenheit. The hot water temperature was measured in multiple bathrooms between 116 and 116.7, and degrees Fahrenheit. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications are locked and inaccessible to residents in care. The facility is an RCFE, however, it does not provide dementia care. 5 resident files were reviewed and had no information to indicate that sharp or other hazardous items would be danger to them. Smoke detectors and carbon monoxide detectors were in operating condition. Fire extinguisher was last serviced on 07/18/2025. Emergency Disaster Plan was last posted on 10/18/2025. Emergency disaster and fire drills are conducted quarterly; last conducted on 05/07/2025. First aid kit was observed to be complete. Continued on LIC809-C Continued from LIC809 The following deficiency were observed: At 10:45 AM, LPA and LPM observed cold water faucet in bathroom by unoccupied room 20 does not run. At 11:30 AM, LPA and LPM observed hallway air temperature measured at 61 degrees Fahrenheit, which felt cold. Two resident also expressed feeling cold while walking around hallways. LPA and LPM also observed inadequate lighting in hallways. At 11:35 AM, LPA and LPM observed no window covering on window in room 35 allowing others to look in on the resident. At 12:00 PM, LPA and LPM observed that the facility does not have an operating signal system. LPA and LPM overserved a pull call in residents’ bedroom, however they were nonfunctioning. An immediate and repeat civil penalty of $250 is hereby assessed for inadequate lighting in hallways. This is the second time this regulation was cited in a 12 month period. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 16, 2025

Type of visit: Case Management - Health Checks

On 09/26/2025 at 8:00 AM, Licensing Program Analyst (LPA) P. Manalo to conduct a health and safety check as a result of the death of the licensee. LPA met with Staff, Lenie Ibe, and explained the purpose of the visit. Licensee, Joseph Taburaza, gave verbal authorization for staff to sign the report. LPA toured facility inside and out including but not limited to 8 bedrooms, bathrooms, kitchen, common area and courtyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 94.3, 95.9, 115.4, 107.7, 114.7, and 85.2 degrees Fahrenheit. Residents’ showers are equipped with grab bars and non-skid mats. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detector and alarm system was last certified on 08/14/2025. Smoke alarm and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 06/18/2025. First aid kit was observed to be complete. During the visit, LPA discussed with the licensee will update the documents with the Secretary of the State. Proof of documents will be submitted to CCLD. Continue to LIC809-C... Continue from LIC809... LPA observed the following deficiencies: At 8:28 AM, LPA observed the outside wooden fence leaning towards the facility and debris on the side of the fence. Staff stated that the items on the floor was used for the roof. Starting at 8:30 AM, hot water temperature measured at 94.3 degrees Fahrenheit in Room #11, 94.9 degrees Fahrenheit in Room #18, and 85.2 degrees Fahrenheit in Room #22. At 8:39 AM, LPA observed resident's bathroom soiled and flies all around the facility. At 8:49 AM, LPA observed the fire extinguisher case in disrepair. At 8:54 AM, LPA observed two wooden dresser in the hallway. At 9:02 AM, LPA observed a cart filled with wooden planks. At 9:04 AM, LPA observed the overgrown tree in the courtyard. At 9:34 AM, LPA observed the emergency food supply in the same storage as the cleaning products. At 10:00 AM, interview with staff revealed that the shower room #2 has been in disrepair. Staff stated there is water coming from the bottom of the drainage. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with Staff. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 26, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Oct 3, 2025

(e) ... (2) ...the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by... Based on observation the licensee did not comply with the section cited above by having the hot water temperature measured at 94.3, 94.9, and 85.2 degree Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 26, 2025

Plan of correction: The Administrator agrees to self certify the regulation and send proof of the water temperature within range to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Oct 10, 2025

(a) 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. Based on observation, the licensee did not comply with the section cited above by having the wooden fence in disrepair, debris all around the facility, resident bathroom soiled, flies around the facility, fire extinguisher case in disrepair, two wooden dressers in the hallway near Room #36, cart filled with wooden planks, overgrow tree in the courtyard, shower room # 2 drainage is not properly working, etc. which poses a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2025

Plan of correction: The Administrator agrees to fix the items in disrepair and clean the facility. Proof of correction will be sent to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(25) · Plan of correction due date: Oct 3, 2025

(25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having the emergency food supply in the same storage room as the cleaning products which poses a potential health and safety risk to person in care.the state’s words, verbatim · CDSS document, Sep 26, 2025

Plan of correction: The Administrator agrees to separate the food and cleaning products and send proof to CCLD by POC date.

Type of visit: Office

At 2:30 pm on this day, September 26, 2025, a virtual meeting was called due to death of one of the licensees. The meeting was attended by the following: · Regional Manager Isaac Taggart · Licensing Program Manager Jeremy Fong · Licensing Program Manager Harpreet Humpal · Licensing Program Analyst Alicia Delmundo · Joseph Taburaza, licensee · Janelle Taburaza, co-administrator · Jonahlee Taburaza · Jasmine Taburaza · Joshua Taburaza The following were discussed: 1. Licensee’s commitment to continue the operation of the facility. 2. Permission to operate the facility under an Emergency Approval to Operate (EAO) for 60 days and documents required to be submitted to Regional Office for EAO. 3. Submission of application for license to Centralized Application Bureau. A copy of this report provided to Janelle Taburaza via email.the state’s words, verbatim · CDSS document, Sep 26, 2025

Type of visit: Case Management - Deficiencies

On 09/09/2025 around 10:00 AM, Licensing Program Analyst (LPA) L. Holmes amended report for complaint #15-AS-20250414163708 dated 04/14/25 to add a citation on this Case Management (CM) that was not included in the report delivered on 08/14/25. LPA met with Lenie Ibe, Staff and explained the purpose of the visit. Deficiency cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided to Lenie Ibe, Staff.the state’s words, verbatim · CDSS document, Sep 9, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87415(a)(2) · Plan of correction due date: Sep 16, 2025

87415 Night Supervision (a)...from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required...(2 )In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes. - This requirement was not met as evidenced by: Based on records reviewed, Licensee did maintain the staff schedule to cover all shifts with contact information for on-call staff which poses/posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 9, 2025

Plan of correction: Licensee/ADM agreed to update that staff schedule and/or use LIC500 to cover all shifts and contact information for on-call staff; submit correction as proof to CCLD by POC date.

Type of visit: Case Management - Health Checks

On 08/29/2025 at 12:10 PM, Licensing Program Analysts (LPAs),Ardalan Gharachorloo and David Doidge arrived unannounced to conduct a health and safety check as a result of the department receiving a complaint with the control number (15-AS-20250828114215). LPAs met with Lenie Ibe and explained the purpose for the visit. LPAs toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 94 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked in the med room. Smoke detectors and carbon monoxide detector were observed to be operational. Fire extinguisher was observed to be full and last serviced on 07/18/2025. The following deficiencies were observed during the visit: At 12:10 pm, LPAs measured the water temperature. The water temperature was measured at 94 degrees F. At 12:20 PM, LPAs observed multiple windows with missing or broken screens. At 12:22 PM, LPAs observed various construction tools such as bucket, 2 by 4s, caulking tubes a puddy knife, etc... At 12:33 PM, LPAs observed multiple areas with debris/ trash. ***CONTINUED ON 809C*** ***CONTINUED FROM 809*** At 12:45 PM , LPAs observed two bicycles in disrepair in the gazebo area. At 12:46 PM, LPAs observed trash in the gazebo area. At 12:50 PM, LPAs observed three paint cans on the table outside of the dining area. At 1 PM, LPAs observed most bathrooms missing toilet papers and hand soup. At 1 PM, LPAs observed two bathrooms out of service. LPAs observed facility to not have adequate lighting throughout hallways. Deficiencies cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided to Norma Tejero, Administrator.the state’s words, verbatim · CDSS document, Aug 29, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(c) · Plan of correction due date: Sep 12, 2025

87303 Maintenance and Operation. (c) All window screens shall be clean and maintained in good repair. LPAs observed multiple windows with missing or broken screens.the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: Administrator agrees to have screen repaiers and photos sent to LPA in twpo weeks.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(d) · Plan of correction due date: Sep 12, 2025

87303 Maintenance and Operation. (d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. LPAs observed facility to not have adequate lighting throughout hallways.the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: Administrator agrees to come up with a solution for lights being left on in the hallways.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 12, 2025

87303 Maintenance and Operation. (a) The facility shall be clean...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. LPAs observed two bicycles in disrepairin the gazebo area, trash in the gazebo area, various construction tools such as a bucket, 2 by 4s, caulking tubes, a puddy knife, ect., multiple areas with debris/tras, three paint cans on the table outside of the dining area, most bathrooms missing toilet paper and hand soup and two out of service.the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: Administrator agrees to have trash, building materials and bicycles cleaned up. Administrator will take pictures and send to LPA by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80088(e)(1) · Plan of correction due date: Aug 30, 2025

(e) Faucets used by clients... shall deliver hot water.(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water... a hot water temperature of not less than 105 degrees F and not more than 120 degrees F Based on observation, the licensee did not comply with the section cited above by having hot water temperature at 94.6 which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 29, 2025

Plan of correction: Administrator will have water tempurature corrected and send a photo to LPA with water tempurature with range

Allegation investigated: Facility is not clean and sanitary A comfortable tempature is not maintained for the residents at the facility Disinfectants and poisons are not inaccessible to residents Facility is not providing a weekly menu for residents in care Facility did not give written notice of a rate increase Facility toilets are in disrepair

On 08/21/2025 around 12:30 PM Licensing Program Analyst (LPA) L. Holmes conducted an unannounced visit to deliver the complaint. LPA presented the allegations to Joseph Taburaza, Licensee and Norma Tejero, Administrator. During the investigation, LPA toured the facility, interviewed Staff (S1, S2, S3, S4) and Witnesses, Residents, and requested the following documents: Staff Schedule, Resident Roster, Maintenance receipts/reports for facility repairs for March 2025, weekly menu for March & April 2025. Admission Agreement, ID/Emergency Contact informaion, LIC 602, and appraisal needs and services for Residents (R1, R2, R3, R4, R5). Allegations: SUBSTANTIATED Continued on 9099C... Substantiated ...continued from LIC9099. Facility is not clean and sanitary The pest control report from Advanced IPM dated March and April revealed that the kitchen drains, clogged sink in break room, and water heater room were unsanitary that could attract flies, roaches, and other pests. W1 reported and provided photos from 04/07/25 of a clogged toilet with what appeared to be urine; the bathroom floor had soiled medical chucks with fluids that had run onto the floors and into the crevices. Deficiency cited and civil penalties were issued on 08/14/25. A comfortable temperature is not maintained for the residents at the facility LPA, S1 and S3 inspected the thermostat at the facility, and recorded 65 degrees Fahrenheit (F) on the north wing and 66 degrees F on the south wing. S1 presented a portable thermostat that displayed 72.8 degrees F. S1 stated that there were times when the exit doors were left open by the residents and the surge of outside air affected the temperature inside the building and oftentimes the staff constantly reminded the residents, and the residents still forgot to close the doors. Although the temperature regulatory standards both thermostats affixed to the walls were inoperable or unable to be adjusted. Deficiency cited and civil penalties were issued on 08/14/25. Disinfectants and poisons are not inaccessible to residents LPA arrived unannounced on 04/08/25, observed a green grocery shopping cart in the hallway near room #11 that was used to transport linens and all-purpose cleaning supplies (what appeared to be a cleaning solution in a Fruit Punch container and Fabulosa). The cart was unattended near room #11. When S4 appeared, LPA asked S4 was she/he housekeeping and S4 replied yes. S1 stated that S4 was cleaning and that he/she had spoken to the staff before about leaving the cleaning items unattended. W1 reported and provided photos from 04/07/25 of disinfectants accessible to residents. Facility is not providing a weekly menu for residents in care S1 provided LPA the following written statement, “We do not post an alternative menu, but we do cater to residents’ requests if the served menu is not appropriate to them. The cook gave a list of alternative meals readily available upon request to W1. This list is now posted in the dining room.” LPA requested copies on the weekly menu from S3 and there was not a record kept on file for 30 days. Continued on LIC9099C... ...continued from LIC9099C. Facility did not give written notice of a rate increase LPA reviewed facility records and Admission Agreements for R1, R2, R3, R4 and R5. Page 4, 8. Rate Change, A. states “The agreement must inform the resident of the conditions under which rates may be increased and provide no less than 60 days prior written notice to the resident’s responsible person.” S1, S3 and W1 confirmed that residents were not given a 60 day notice for rate increases. Facility toilets are in disrepair W1 reported and provided photos from 04/07/25 of a clogged toilet with what appeared to be urine; the bathroom floor had soiled medical chucks with fluids that had run onto the floors and into the crevices. S1 stated that the toilet was repaired on 04/07/25. Deficiency cited and civil penalties were issued on 08/14/25. Based on LPA’s observations, interviews and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegations are SUBSTANTIATED. Deficiencies are cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and a copy of this report provided. ...continued from LIC9099A. Facility is not providing alternative foods for religious and cultural beliefs On 04/22/25, LPA and S3 toured the kitchen and observed a variety of canned and fresh vegetables, fruits, proteins, juices, milk, and water. LPA reviewed the lunch menu that offered cheese pizza, chili beans, corn, mixed vegetables, pineapple, yogurt, milk, juice and coffee that was appropriate for a variety of cultural and religious backgrounds and food habits of residents. Facility is not assisting residents with incontinence care W2 reported that R1’s hygiene needs weren’t being met. R1 needs moderate assistance when using a shower chair, does not have any diagnoses of Dementia or need for bed care; R1 is able to leave the facility unassisted, and can care for his/her own toileting. R5's care log dated April - March 2025 recorded refusals for showers, and when R5 was able to manage their own incontinence. Records revealed that R2, R3, and R4 can care for their own toileting. Facility does not have appropriate number of showers for residents in care Although a toilet was in disrepair, the facility had at least one bathtub or shower for each ten (10) persons that was able to provide personal accommodations and services, which included residents, family and live-in personnel. Based on LPA’s observations, interviews, observations, and records reviewed, the allegations are UNSUBSTANTIATED. The finding that the complaint is unsubstantiated means that the allegations are not valid because the preponderance of the evidence standard has not been met. Exit interview conducted, and a copy of this report provided to Norma Tejero, Administrator.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 15-AS-20250408085517

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Aug 21, 2025

87309 Storage Space and Access(a) ...ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger...are not left unattended if outside the locked storage. Based on observations and interviews, S5 left cleaning solutions unattended which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: Licensee/ADM in-serviced staff, and submitted proof of correction to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(6) · Plan of correction due date: Aug 28, 2025

87555 General Food Service Requirements (b) The following food service requirements ...for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days.-This requirement was not met as evidenced by: Based on observations and interviews, weekly menuswere not posted and kept on file per the regulation which poses/posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: Licensee/ADM agreed to provide in-service training to staff/cook to post weekly menus, alternative meals & retain copies for a minimum of 30 days. Submit a list of attendees’ signatures as proof to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(4) · Plan of correction due date: Sep 4, 2025

87507 Admission Agreements (g)... shall specify the following: (4) Modification conditions...at least 60 days prior written notice to the resident of any rate or rate structure change, or as soon as the licensee is notified of SSI/SSP rate changes.-This requirement was not met as evidenced by: Based on records reviewed and interviews, Licensee/ADM did not provide residences proper notice of rate increases per the regulations.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: Licensee/ADM agreed to submit a template for rate increases to CCLD by POC date.

Allegation investigated: Staff didn't keep facility free from insects and rodents Insufficient staffing

On 09/09/2025 around 10:00 AM, Licensing Program Analyst (LPA) L. Holmes amended report to add a citation that was not included on 08/14/25; see case management visit dated 09/09/2025. On 08/14/2025 around 01:00 PM Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the complaint findings for the investigation. LPA met with Norma Tejero, Administrator During the investigation, LPA toured the facility, interviewed Staff and Residents, and requested the following documents: Staff Schedule, Resident Roster, Pest Report, and Maintenance receipts/reports for facility repairs. ID/Emergency Contact information, LIC 602, and appraisal needs and services for Clients (C1, C2, C3). Allegations: SUBSTANTIATED Continued in 9099C... Substantiated ...continued from LIC9099 Staff didn't keep facility free from insects and rodents: The allegation was related to R1. LPA inspected R1’s room and observed clothing items, shoes, linen in place on the bed, books, papers and person items cluttered but organized. LPA did not observe any insects or vermin during the inspection; however, the pest control report from Advanced IPM dated March and Aprl revealed that the kitchen drains, clogged sink in break room, and water heater room were unsanitary that could attract flies, roaches, and other pests. The doors upstairs including the entrance and kitchen, and downstairs doors have gaps, and room #16 has a hole that rodents can fit through. Insufficient staffing: W1 stated that there was not any staff present when W1 and his/her colleague arrived at the facility to provide services to R1; W1's colleague had to seek out the care staff. LPA reviewed the staff schedules for April and March 2025. Although the day schedule appeared sufficient, the schedule for nights and graveyard had either one care staff or no one scheduled for graveyard, and no one noted as scheduled to be On-Call per the regulation. An immediate civil penalty of $250 is hereby assessed for the day of 8/14/2025 listed on LIC421FC. Based on LPA’s interviews and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is SUBSTANTIATED. Deficiencies are cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and a copy of this report provided. ... continued from LIC9099A Facility not meeting residents hygiene needs: The allegation was reported by W1 and is directly related to R1. R1 needs moderate assistance when using a shower chair, does not have any diagnoses of Dementia or need for bed care; R1 is able to leave the facility unassisted, and can care for his/her own toileting. R2's care log dated April - March 2025 recorded refusals for showers, and when R2 was able to manage their own incontinence. Based on LPA’s interviews, observations, and records reviewed, the allegation is UNSUBSTANTIATED. The finding that the complaint is unsubstantiated means that the allegation is not valid because the preponderance of the evidence standard has not been met. Exit interview conducted, and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 14, 2025 · control 15-AS-20250414163708

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87303 · Plan of correction due date: Aug 21, 2025

87303 Maintenance and Operation (a) 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. Based on records reviewed, Licensee did maintain clean, safe and sanitary conditions which poses/posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: Licensee/ADM agreed to in-service staff, and submit a plan with correction dates that will mitigate the spread of insects and vermin to CCLD by POC date.

Allegation investigated: Staff did not accept resident back following hospitalization.

On 07/30/2025 around 09:00 AM Licensing Program Analyst (LPA) L. Holmes conducted a 10-day complaint visit. LPA presented the allegations to Joshua Taburaza, Lenie Ibe, and Norma Tejero the Administrator. During the course of investigation, LPA interviewed three (3) Staff (S1, S2, S3) and three (3) Witnesses (W1, W2, W3). LPA obtained an email chain regarding R1’s placement status, reviewed R1’s file including but not limited to the physician's report, after-visit summaries, psychiatric Emergency Room Services (PES) Intake Evaluation, Medication List and R1’s 30 day written notice to terminate his/her admission agreement. ...continued from LIC9099. Unsubstantiated ...continued from LIC9099. On 07/24/25, R1 was placed on a 51/50 hold at Psychiatric Emergency Services (PES) of Contra Costa Regional Medical Center in Martinez, California due to destruction of property, yelling, screaming, and hitting. Prior to R1’s admission on 04/22/25, W1 verbally agreed with S1 and S2 to assist with relocating R1 if he/she became a threat to the facility due to the nature of R1’s psychiatric background; LPA confirmed the information stated by W1. W1, W2 and W3 recommended additional treatment and has confirmed that R1 has been transferred to in-patient psychiatric services with a 1:1 at Contra Costa Regional Medical Center. W1 also oversees the finances for R1 and has provided the facility with R1’s 30-day written notice to terminate his/her admission agreement with the goal of seeking an Institute for Mental Diseases along with obtaining conservatorship for R1. Based on LPA's information obtained during investigation, the preponderance of evidence standard has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. Exit interview conducted, and copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 30, 2025 · control 15-AS-20250728094001

Type of visit: Case Management - Deficiencies

On 07/30/2025 around 01:45 PM Licensing Program Analyst (LPA) L. Holmes conducted a case management in addition to complaint #15-AS-20250728094001 dated 07/28/25. LPA presented the deficiencies to Norma Tejero, Administrator. During the course of investigation and review of R1's records, LPA observed the following: -At 10:05 AM, interviwes with S1, S2 and S3 revealed that 24 hours notice of R1's interaction with the Richmond Police Department on 07/24/25 and admittance to Contra Costa Regional Medical Center in Martinez, California on 07/24/25 had not been provided to LPA of CCLD. -At 10:25 AM, R1's file was incomplete: no pre-appraisal, no personal rights, no consent for medical treatment and an incomplete ID/Emergency contact information sheet. Deficiencies cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided to Norma Tejero, Administrator.the state’s words, verbatim · CDSS document, Jul 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Aug 13, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks,poisonings, catastrophes or major accidents which... threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. -This requirement is not met as evidenced by: ADM/Licensee did not report R1's 51/50 hold to CCLD within 24 hrs.the state’s words, verbatim · CDSS document, Jul 30, 2025

Plan of correction: By POC due date, ADM agrees to complete and submit to CCLD in-service staff and Licensee training with signatures on reporting requirements and compliance.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(b) · Plan of correction due date: Aug 13, 2025

87506 Resident Records (b) Each resident’s record shall contain at least the following information: -This requirement is not met as evidenced by: -Based on recrords reviwed, the ADM/Licensee did not maintain R1's records which poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 30, 2025

Plan of correction: By POC due date, ADM agrees to complete and submit to CCLD in-service staff and Licensee training with signatures on resident record requirements and compliance.

Type of visit: Case Management - Incident

On 12/16/24 around 08:00 AM, L. Holmes Licensing Program Analyst (LPA) arrived unannounced to conduct a case management for an incident of alleged client abuse that was self-reported by the facility. The report was received by Community Care Licensing Department (CCLD) on 12/06/2024, dated 12/04/24. LPA met with Lenie Ibe, Staff and explained the purpose of the visit. During the visit LPA interviewed Staff (S1, S2), Resident #1 (R1), and obtained a Resident Roster, Staff Roster, and requested the following for Resident #1 (R1): current Physician's Report, Appraisal and ID/Emergency Contact information. LPA requested the following for Staff #1 (S1): Training Records, disciplinary action, and photo identification. S1 resigned on 12/05/24. S1 was not at the facility during the time of the visit; however, S1's name remains on the Staff Roster and removal was requested. LPA confirmed with CCLD's Staff Support, A. Christy, that S1 is associated to multiple CCLD Adult and Senior Care facilities. Once all the information has been reviewed, CCLD will determine whether an immediate exclusion or non-immediate exclusion will be initiated. -Around 10:10 AM, LPA reviewed S1's personnel records. S1's most recent training records were dated 05/08/22. S1 did not have any current training records on file. Deficiency cited from Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violations within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided to Lenie Ibe, Staff.the state’s words, verbatim · CDSS document, Dec 16, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c)(1)(A) · Plan of correction due date: Dec 30, 2024

87412 Personnel Records (c) Licensees shall maintain in the personnel records verification of records (1) training and orientation shall be documented: (A) For staff who assist with personal activities of daily living …at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually …areas as specified in Section 87411(c)(2). - This requirement was not met as evidenced by: Based on records reviewed, Licensee did maintain annual training records for S1 which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: Licensee agreed to provide in-service training to all staff and confirm that all staff’s training and records are updated. Submit a list of attendees’ signatures as proof to CCLD by POC date.

Allegation investigated: Staff did not dispense medication as prescribed by physician

On 11/4/2024 at 11:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegation above. LPA met with Administrative Assistant, Lenie Ibe and explained the purpose of the visit. During the course of investigation, LPA interviewed 3 residents, 3 staff, and complainant. LPA obtained and reviewed documents including physician's report, centrally stored records, MAR (Medication Administration Record), and medical records. R3's medical records and MAR revealed that R3 had a doctor's order for Clonazepam. However, R3's urine screens in June and August of 2023 indicated no Clonazepam presence. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Nov 4, 2024 · control 15-AS-20230906160133

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Nov 5, 2024

Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not administering medications according to physician's order which poses an immediate health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Nov 4, 2024

Plan of correction: Facility has agreed to conduct training for staff regarding medication administration and submit staff sign-in sheet to CCLD by POC date.

Type of visit: Required - 1 Year

On 10/09/24 at 01:45 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct a required annual inspection. LPA was greeted by one staff upon entry and explained the purpose of the visit. The Administrator, Norma Tejero (ADM) holds a standard certificate (#6047865740). The facility’s fire clearance was approved for a capacity of seventy (70) all may be non-ambulatory residents. LPA observed a screening station at the entry that contained a thermometer, hand sanitizer, masks, COVID-19 signage, and a visitor sign-in log; There is a surplus of face shields, gowns, gloves and other PPE centrally stored inside the facility that is accessible to all care staff. LPA observed mask, cough etiquette, social distancing and hand washing signs posted throughout. LPA toured the facility including but not limited to common areas, bathrooms, kitchen, front and backyard. Medication and sharps were locked, and there was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods. All hand washing stations were equipped with soap, paper towels and garbage cans. Hot water temperature in the shared residents' bathroom was measured at 98 Fahrenheit (F.) and the facility's temperature was 69 degrees F. First aid kit complete. Seven (7) staff and six (6) resident files were reviewed: Resident files need auditing for dates and signatures on Medical Consent forms, the LIC613 and Admission Agreements. The following forms are to be updated and submitted to CCLD: 10/23/24 -LIC500 Personnel Report -LIC308 Designation of Administrative Responsibility (Reviewed) -LIC610 Emergency Disaster Plan (Reviewed) -An updated copy of Administrator Certificate (Reviewed) -Pest Control Report for July - September 2024 Continued on LIC809C... ...continued from LIC809. -At around 1:50 PM, LPA observed exit gate and drive thru gate on the right side of building both having pad locks. On the gate of the left side; the pad lock was in place and unlocked at 3:45 PM. -At around 1:52 PM, LPA observed 2-3 black bed frames, a twin sized mattress, and several various sizes of wooden boards on right side of building. -At around 1:55 PM, LPA observed two (2) windows without screens and two (2) windows screens that had tears and was in disrepair located on the front side of building. LPA observed One (1) window without a screen and two (2) windows screens that had tears and was in disrepair located on the back side of building at 3:15 PM -At around 2:43 PM, the water in two separate shared residents' sinks measures at 91 and 98 degrees Farenheit (F.) -At around 2:50 PM, downstairs bathroom had mildew on the shower curtain, rust stains on the shower floor and around the door perimeter, and three (3)clothes were observed on the floor covering the bottom gaps of the doors. (photos taken) -At around 3:15 PM, LPA observed 5-6 PVC white tubing, 2-3 wooden pallets on the back side of the facility, 2-3 metal or silver colored strips of material about 10 x 2 feet wide under the gazebo, a tote page with worn looking clothes and plastic garage bags, several wooden boards of various sizes, a gray metal frame similar to the size of a standard coffee table. -At around 3:50 PM, Two (2) sitting chairs in the hallway were stained with dark colored spots all over the seat. Room #35, dresser has dark smudge prints and floor has small random particles. -At around 5:04 PM, LPA observed that proof of ADM's 1st aid and CPR was missing from the staff file. (corrected during visit) -At around 5:07 PM, ADM could not provide proof of liability insurance. (licensee corrected during visit) Continued on LIC809C... ...continued from LIC809C. Deficiencies observed (see LIC809D) and cited from the California Code of Regulations. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. -An immediate $500.00 civil penalty will be assessed on today's date for the emergency exit being locked.* Exit interview conducted, a copy of the LIC421IM, appeal rights and the report provided to Norma Tejedo, ADM. Physical Plant/Environmental Safety - Row13 - Maintenance and Operation Section 87303(e)(2) - Domain Focused (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).the state’s words, verbatim · CDSS document, Oct 9, 2024

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff did not prevent a resident from sexually harassing another resident while in care Staff did not prevent a resident from threatening another resident while in care Staff are interfering with a resident's visitations Staff are intimidating a resident while in care Staff are not meeting a resident's dietary needs Staff are not providing comfortable environment for a resident

On 3/08/24 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings in regard to the allegations above. LPA met with Norma Tejero, Administrator, and explained the purpose of the visit. During the course of the investigation LPA interviewed the reporting party (RP), S1 and R1 and R2. LPA also reviewed R1’s and R2’s facility file. R1 was admitted to the facility on 8/12/22 from Contra Costa Regional Medical Center’s psychiatric Unit. R1 has a history of aggressive and threatening behavior resulting in 5150 psychiatric hospitalizations. R1 is currently stable at this facility. R2 was admitted to the facility on 12/18/15 from independent living. R2 is diagnosed with schizoaffective disorder and has a long history of psychiatric hospitalizations. R2 was stable at this facility until recently when he got upset and hit a staff. R2 was 5150’d and returned to the facility with an agreement to take all his medications as prescribed. R2 is currently stable. ***report continues on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** Investigation regarding the allegations follows. Staff did not prevent a resident from sexually harassing another resident while in care: R1 denied being sexual harassed by R2 and R2 denied sexually harassing R1. R1 further stated that she hardly sees R2 anymore. R2 told LPA that his roommate is a female, stating "they trust me" and it's nothing sexual adding "sex isn't allowed." Staff did not prevent a resident from threatening another resident while in care: R1 stated that she was never threatened by any of the residents at the facility and that she enjoys living here and has made several friends. Staff are interfering with a resident's visitations: House rules state all visitors must check in at the reception desk in the front lobby. Facility staff will then go get the person they want to visit and bring them to the lobby for the visit. Residents are free to take visitors back to their room is the resident’s roommate agrees (all rooms are shared rooms). Staff are intimidating a resident while in care: R1 denied being intimidated by staff stating the staff here are “nice” and “helpful” when she asks for things. Staff are not meeting a resident's dietary needs: R1’s physicians report dated 8/18/22 indicated that R1 is on a regular diet. Staff are not providing comfortable environment for a resident: During LPA’s first visit to the facility (12/21/23) R1 was observed sleeping in her bed under several blankets. R1 stated that is comfortable at the facility and has enough clothing and blankets to keep her warm. This agency has investigated this complaint. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 8, 2024 · control 15-AS-20231215094125

Type of visit: POC

On 12/18/2023 at 3:10pm, Licensing Program Analyst (LPAs) L. Hall, C. Fowler, and T. Syess-Gibson arrived unannounced to conduct proof of correction (POC) visit. LPA met with Jiena Guam, Med tech and explained the purpose of the visit. Administrator, Norma Tejero, arrived at 3:50pm. LPA conducted an annual visit on 12/1/2023 and cited facility for the following: 87203 Fire Safety - locks on exit gate - LPA received photo with locks removed on 12/4/2023. LPAs check gates on today's date and did not observe any locks. 87555 General Food Service Requirements - Food - LPA received receipts on 12/12/2023. LPAs observed 7-day perishable foods. 87465 Incidental Medical and Dental Care - first aid kit -LPA received receipt on 12/12/2023 with first aid kit and Band-Aids. 87307 Personal Accommodations and Services - obstructions in passageway - LPA received photo with items removed from passageway. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 18, 2023

Type of visit: Required - 1 Year

On 12/1/2023 at 1:05pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Norma Tejero, Administrator, and explained the purpose of the visit. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. LPA did not observe any bodies of water. A comfortable temperature is maintained at 66 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the shared bathroom was measured at 103.9 degree F. One shower room was locked and the other shower room was equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 01/02/2023. Fire drill was last conducted on 4/5/2023. Six (6) staff records were reviewed and are complete. LPA reviewed eight (8) resident records and all were complete. Continued on LIC809. Continued from LIC809. LPA observed the following deficiencies: At 2:40pm, LPA observed exit gated and drive thru gate on right side of building both had key padlocks. At 2:40pm, LPA observed garbage cans, bed frames, window blinds, a table,, and bins located on right side of building At 2:45pm, LPA observed outside ceiling with cracks and wooden boards put together to hold ceiling up (LPA have pictures). At 2:55pm, LPA observed facility did not maintain 7-day non-perishables and 2 day perishable food for residents. LPA observed a lot of hot dogs, frozen lasagna, frozen mixed vegetables, frozen pork, milk, eggs, cake mix. At 3:05pm, LPA observed broken window located on left side of building. At 3:15PM, LA observed a portable heater in bedroom #40 and was notified the heater for the facility does not work. At 3:55pm, LPA observed facility did not have a complete first aid kit or any extra first aid supplies. LPA requested the following documents to be submitted to CCLD by 12/8/2023. LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Continued on LIC809C. Continued from LIC809C. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. *An immediate $500.00 civil penalty will be assessed on today's date for emergency exit being locked.* Exit interview conducted. A copy of the LIC421IM, this report and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 1, 2023

Type of visit: Case Management - Incident

While at licensee's other facility, Licensing Program Analyst (LPA) Delmundo conducted a case management for this facility, Family Courtyard, in response to the Unusual Incident Report (UIR) received by LPA on this day, October 19, 2023. UIR indicated that resident (R1) who was recently admitted, left the facility on October 15, 2023 and didn't return. Staff called and filed missing person report to local law enforcement on October 16, 2023. R1's conservator was informed. As of the date UIR was submitted, R1 was still missing. LPA interviewed licensee and requested for copy of LIC602A Physician's Report on this same day. LIC602A indicated R1 can leave the facility unassisted. At 4:51 pm, licensee received information from Norma Tejero, administrator, which was forwarded to LPA. Administrator indicated R1 was found by local law enforcement and is currently at the hospital for stabilization. No deficiency cited on this day. Exit interview conducted and copy of this report provided to licensee.the state’s words, verbatim · CDSS document, Oct 19, 2023