Friendship Care Home

Type of visit: Required - 1 Year

On 07/09/26 at 1PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (HM, ADM) and explained the purpose of the visit. At 1:15PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 74 deg F. Hot water temperature was measured at 107 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. LPA reviewed 2 staff and 5 resident files. Updated copies of the following documents were obtained for facility file:  LIC500- Personnel Report  Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiency observed during visit. Exit interview conducted and a copy of this report providedthe state’s words, verbatim · CDSS document, Jul 9, 2026

Allegation investigated: Staff did not properly transfer resident resulting in resident sustaining a fracture. Staff punched resident Staff handles resident in a rough manner Staff does not treat resident with dignity and respect Facility is not providing assistance with receiving incidental medical care Staff are not adequetly trained Facility not following reporting requirements

On 12/04/25 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit, met with staff (S1) and spoke to administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA explained the purpose of the visit with staff (ADM, S1) and delivered investigation findings. During investigation, the Department obtained the following documents from administrator – staff roster with contact information, LIC500, resident roster, admission agreement, physician's report, appraisal/Needs and Service Plan, responsible party (POA) information, hospital discharge summary reports, police report, incident report. Health & safety check conducted see LIC 809 dated 06/11/25. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Staff did not properly transfer resident resulting in resident sustaining a fracture Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ADM, S1, S2, S3, S4) & R1’s responsible party (POA) and reviewed resident (R1) documents. Staff stated that R1 requires assistance with all activities of daily living and that a Hoyer lift is required to move R1 from the bed to her wheelchair. Review of R1’s documents showed no previous falls were documented or reported. On 05/26/25, R1 had an unwitnessed fall in her bedroom at approximately 0530 hours. Staff evaluated R1 and no injuries or complaints of pain were noted at the time of her being found. R1 went about her day as normal. Around 1000 hours, R1 complained of pain to staff who sent her to the hospital. Review of R1’s medical records showed R1 was admitted to the hospital on 05/26/25 and discharged on 06/01/25. R1 was diagnosed with a “right distal femur fracture.” R1 stated that she did not remember how she got on the floor. R1 noted that her bed had bed rails and believed she must have just “rolled off the bed”. Staff stated they did not know how R1 ended up on the floor in her room at 0530 hours on 05/26/25. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not properly transfer resident resulting in resident sustaining a fracture is unsubstantiated. Allegation: Staff punched resident Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of residents (R1, R2, R3) and facility staff (ADM, S1, S2, S3, S4). Review of police report dated 06/15/25 showed S3 denied punching R1. During visit, police officer checked R1’s stomach and did not see any bruising or marks. Residents (R1, R2, R3) denied any abuse (physical or verbal) from staff. During unannounced visits on 05/21/25, 08/20/25 and 1022/25, LPA did not observe staff hit, punch, abuse or mistreat any resident at the facility Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff punched resident in care is unsubstantiated. Continued on next page, LIC-9099 C pg2 Allegation: Staff handles resident in a rough manner Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of residents (R1, R2, R3) and facility staff (ADM, S1, S2, S3, S4). Residents (R1, R2, R3) denied any abuse (physical or verbal) from staff. Staff (ADM, S1, S2, S3, S4) denied handling R1 or any other resident in a rough manner. ADM stated she has never seen any staff hurt a resident. During unannounced visits on 05/21/25, 08/20/25 and 1022/25, LPA did not observe staff hit, punch, abuse or mistreat any resident at the facility. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff handles resident in a rough manner is unsubstantiated. Allegation: Staff does not treat resident with dignity and respect Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of residents (R1, R2, R3) and facility staff (ADM, S1, S2, S3, S4). Residents (R1, R2, R3) denied any abuse (verbal or physical) from staff. Staff (ADM, S1, S2, S3, S4) denied being rude to any resident in care. ADM stated she has never seen any staff rude to any resident. During unannounced visits on 05/21/25, 08/20/25 and 1022/25, LPA did not observe staff hit, punch, verbally abuse or mistreat any resident at the facility. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff does not treat resident with dignity and respect is unsubstantiated. Allegation: Facility is not providing assistance with receiving incidental medical care Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ADM, S1, S2, S3, S4) & and reviewed resident (R1) documents. Review of R1’ s admission agreement showed she was first admitted at the facility on 02/15/23. Staff stated that R1 requires assistance with all activities of daily living and that a Hoyer lift is required to move R1 from the bed to her wheelchair. Residents (R1, R2, R3) stated staff assist them with their activities of daily living such as personal hygiene, toileting, incontinence care, doctors’ appointments, medication administration, pharmacy refills and that they have no issues with staff failing to meet their needs. On 05/26/25, R1 had an un-witnessed fall and staff sent R1 to the hospital for evaluation and treatment the same day. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility is not providing assistance with receiving incidental medical care is unsubstantiated. Continued on next page, LIC-9099 pg 3 Allegation: Staff are not adequately trained Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ADM, S1, S2, S3, S4), reviewed resident (R1) documents and staff training records. Review of R1’ s admission agreement showed she was first admitted at the facility on 02/15/23. Staff stated they assisted R1 with her special diet, incontinence care, transfers from bed to wheelchair using the Hoyer lift, bathing, dressing, toileting, medication administration and meals. ADM stated she is a licensed registered nurse and has trained staff on how to properly use the Hoyer lift. Residents (R1, R2, R3) stated they like living at the facility and had no issues with staff failing to meet their needs. Review of staff 2025 training records showed they completed the required 20 hours of annual training for dementia care. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not adequately trained is unsubstantiated. Allegation: Facility does not follow reporting requirements Investigation Finding: Unsubstantiated During investigation, the Department conducted interviews of residents (R1, R2, R3), facility staff (ADM, S1, S2, S3, S4) and reviewed resident (R1) documents. Review of incident report regarding R1’s hospitalization on 05/26/25 showed facility submitted the completed self-report to CCLD on 05/30/25. ADM stated they complete and submit each incident report to CCLD within 7 days if non-serious and within 24 hours for serious incidents such as death, AWOL or outbreaks. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility does not follow reporting requirements is unsubstantiated. No deficiency cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 15-AS-20250609100754

Allegation investigated: Facility did not give refund to Resident's responsible party

On 10/22/25 at 10AM, Licensing Program Analyst (LPA) D Panlilio conducted a complaint visit, gathered information and delivered investigation finding to administrator (ADM). LPA explained the purpose of the visit with ADM. During investigation, LPA interviewed reporting party(RP/POA), facility staff (ADM, S1) and obtained the following documents from administrator: Personnel record (LIC500), Resident roster (LIC9020), Resident’s (R1) admission agreement, Physician’s report, Needs & Services plan, death report. Continued on next page, LIC 9099-C Substantiated Allegation: Facility did not give refund to resident’s responsible party Finding: Substantiated During investigation, LPA interviewed reporting party (RP), facility staff (ADM, S1) and reviewed former resident’s (R1) documents. Review of R1’s admission agreement and death report showed he was first admitted at the facility on 10/30/2020 and expired on 03/09/25. RP stated she sent several text messages to ADM and a priority letter with tracking to the facility requesting for a refund on 06/10/25 with no response. RP also stated she donated all of R1’s belongings to the other residents when he passed away on 03/09/25. On 10/22/25 at 11:15 AM, ADM spoke with RP on the phone and both agreed to a final refund amount of $3,477.46. LPA observed ADM mail the refund check to RP during visit. Based on interviews and observations which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that facility did not give refund to resident’s responsible party is substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (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. Appeal rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 22, 2025 · control 15-AS-20251020151658

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Oct 22, 2025

A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed… This requirement was not met as evidenced by facility not giving the refund to resident’s responsible party which posed a potential health & safety risk to resident in care.the state’s words, verbatim · CDSS document, Oct 22, 2025

Plan of correction: Defiiciency corrected during visit. ADM issued refund check to POA on 10/22/25.

Allegation investigated: Facility does not have enough afternoon and night staff to meet residents needs Facility is not equipped to serve residents in dining area Administrator is not at the facility a sufficient number of hours per week

On 08/20/25 at 2:45PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with staff (ADM, S1), gathered information and delivered investigation findings to ADM, S1. LPA explained the purpose of the visit with staff. During investigation, LPA conducted interviews with reporting party (RP), staff (ADM, S1) and obtained the following documents from administrator – Personnel record (LIC500), Residents roster, incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Facility does not have enough afternoon and night staff to meet residents’ needs Investigation Finding: Substantiated During investigation, LPA conducted interviews with reporting party (RP), staff (ADM, S1) and reviewed facility’s personnel record (LIC500), work schedules and residents’ roster. Review of residents’ roster (LIC9020) showed a total of 33 residents residing at the facility. Staff (S1) confirmed with LPA that there is not enough staff in the PM and Night (NOC) shifts to meet residents’ care needs. S1 stated that there is 1 medtech and 2 caregivers in the PM shift and 1 medtech and 1 caregiver in the NOC shift. S1 also stated that approximately 11 of the 33 residents require 2+assist. Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that facility does not have enough PM and NOC staff to meet residents’ needs was found to be substantiated. Allegation: Facility is not equipped to serve residents in the dining area Investigation Finding: Substantiated During investigation, LPA conducted interviews with reporting party (RP), staff (ADM, S1) and LPA A Gomez. Prior unannounced visits conducted by LPA A Gomez on 07/01/25, 07/24/25 and 08/13/25 showed that LPAs observed the facility’s dining room area only had 4 tables that could seat 4 residents at any given time and that staff was using the activities/TV room area to feed the other residents. On 08/15/25, LPA confirmed with S1 that ADM has not purchased the additional dining tables for residents’ use and has not implemented a dining plan to properly feed all residents for each meal without using the activities/TV room for residents’ meals.. Based on LPAs’ observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that facility is not equipped to serve residents in the dining area was found to be substantiated. Continued on next page, LIC 9099-C Allegation: Administrator is not at the facility a sufficient number of hours per week Investigation Finding: Substantiated During investigation, LPA conducted interviews with reporting party (RP), staff (S1) and LPA A Gomez. Prior unannounced visits conducted by LPAs on 05/21/25, 07/24/25 and 08/13/25 showed that LPAs observed ADM was not present at the facility during these visits. S1 stated that ADM comes to the facility 1 to 2 times per week for about an hour and then leaves. Based on LPAs’ observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that Administrator is not at the facility a sufficient number of hours per week was found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 15-AS-20250813184430

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Sep 19, 2025

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 facility does not have enough afternoon and night staff to meet residents’ need which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: By POC due date, ADM agrees to hire additional staffing for PM and NOC shifts and submit to CCLD an updated Personnel record (LIC500) showing additional staff in compliance with Section 87411 (a) regulation

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(1) · Plan of correction due date: Sep 19, 2025

The following space and safety provisions shall apply to all facilities: Sufficient room shall be available to accommodate persons served in comfort and safety. This requirement was not met as evidenced by facility is not equipped to serve residents in the dining area which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: By POC due date, ADM agrees to purchase additional dining tables to accommodate residents’ dining needs and submit to CCLD an updated dining plan in compliance with Section 87307 (d)(1) regulation

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Sep 19, 2025

The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not met as evidenced by administrator is not at the facility a sufficient number of hours per week which posed a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: By POC due date, ADM agrees to be at the facility a sufficient number of hours (minimum 20 hours per week) to permit adequate attention to the management and administration of the facility. ADM agrees to complete and submit to CCLD updated Personnel record (LIC 500) showing Administrator's sufficient number of work hours per week at the facility (minimum 20 hours per week) in compliance with Section 87405(a) regulation.

Allegation investigated: Staff did not address residents change in condition Staff took residents personal belongings Facility is not feeding residents the appropriate quantity of food Staff did not provide proper incontinence care to resident

On 09/09/25 at 2:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit to amend the complaint report dated 08/20/25. LPA explained the purpose of the visit with ADM. During visit, LPA obtained the original complaint reports from ADM. Allegation: Staff did not address resident’s change in condition Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), staff (ADM, S1) and reviewed resident (R1) documents. ADM stated residents are monitored every 2 hours on each shift and 911 is called whenever any resident has a change in condition Review of R1’s physician report dated 05/06/25 showed R1 is ambulatory, weighs 164 lbs, diabetic and has severe dementia. S1 stated R1 is very confused and does not remember events such as staff changing her diapers every 2 hours (due to constant urination) or that she already ate her meal and still thinks that she needs to have her meal. LPA observed R1 to be hydrated, nourished and odor free. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not address resident’s change in condition is unsubstantiated. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Staff took resident’s personal belongings Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), staff (ADM, S1) and reviewed resident (R1) documents. Staff denied taking R1’s personal belongings (diapers). S1 stated R1 is very confused due to dementia and tends to wear 2 to 3 diaper pull-ups each time. On 08/20/25 at 1:30PM, LPA toured R1’ bedroom and observed R1 had sufficient incontinence supplies which ADM stated were purchased and delivered to R1 by her responsible party (POA) each week. Review of R1's admission agreement dated 05/13/25 showed the facility was not responsible for R1's incontinence supplies. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff took resident’s personal belongings is unsubstantiated Allegation: Facility is not feeding residents the appropriate quantity of food Investigation Finding: Unsubstantiated During investigation, staff (ADM, S1) stated R1 is very confused and does not remember events such as she already ate her meal and still thinks that she needs to have her meal. Prior unannounced visits conducted by LPAs on 05/21/25, 07/24/25 and 08/13/25 showed that LPAs observed residents were being served an appropriate quantity of food during lunch service. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that facility is not feeding residents the appropriate quantity of food is unsubstantiated. Continued on next page LIC9099-C pg1 Allegation: Staff did not provide proper incontinence care to resident Investigation Finding: Unsubstantiated During investigation, LPA conducted interviews with reporting party (RP), staff (ADM, S1) and reviewed resident (R1) documents. On 08/20/25 at 1:30PM, LPA toured R1’ bedroom and observed R1 had sufficient incontinence supplies which ADM stated were purchased and delivered to R1 by her responsible party (POA) once a week. Review of R1’s admission agreement dated 05/13/25 showed no incontinence supply included. S1 stated R1 is very confused due to dementia and tends to wear 2 to 3 diaper pull-ups each time. Staff continually remind R1 that she only needs to use one diaper pull up. ADM stated that residents are monitored and diapers changed every two hours or as needed. LPA observed R1 to be hydrated, nourished and odor free. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not provide proper incontinence care to resident is unsubstantiated. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 15-AS-20250813161718

Type of visit: POC

On 8/13/2025 at 9:00am, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct proof of correction (POC) visit. LPAs met with Facility Nurse, Cynthia Murphy and explained the purpose of the visit. LPA A Gomez conducted a POC visit on 7/24/2025 and cited facility for the following: 87555(b)(6)LPA observed that facility has created and is now following the weekly menu. POC Clear 87465(d): LPA observed that staff are now accurately completing the MAR. POC Clear No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 13, 2025

Type of visit: POC

On 7/24/2025 at 9:35am, Licensing Program Analysts (LPAs) A. Gomez and A Christy arrived unannounced to conduct proof of correction (POC) visit. LPAs met with Facility Nurse, Cynthia Murphy and explained the purpose of the visit. LPA A Gomez conducted an Case Management on 7/01/2025 and cited facility for the following: 87468(c)(2)(A) Personal Rights: PUB 475 poster is now adequately posted POC Clear 87307(a)(1) Personal Accommodations and Services: Dining areas now available for all residents POC Clear 87555(b)(8) General Food Service Requirements: Food available was all of good quality POC clear 87555(b)(9) General Food Service Requirements: All food was stored adequately POC clear 87411(a) Personnel Requirements - General: Facility has hired additional staff POC clear 87303(a)(1) Maintenance and Operation: Floors in kitchen were observed clean Report continues on LIC809-C LPA A Gomez conducted an Case Management on 7/01/2025 and will recite facility for the following: 87555(b)(6): LPA observed that facility is not creating and following the weekly menu. 87465(d): LPA observed that staff are still not accurately completing the MAR. ***A civil penalty in the amount of $500 is being assessed on todays date for repeat violations ($250 X 2) *** Administrator/Licensee unable to come to visit. Facility nurse approved to sign report. The following deficiencies were observed (see LIC 809D) and 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. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 24, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(6) · Plan of correction due date: Aug 1, 2025

b) The following..shall apply:(6)In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance... This requirement is not met as evidence by: Based on observation the facility did not comply with the section above by not creating and following a weekly menu which poses a potential personal rights violation for residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: By POC facility agrees to create and impliment a weekly menu and document the dishes when served and also provide kitchen staff with training on nutrition and notify CCLD. **menus are to be written at least one week in advanced

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(d) · Plan of correction due date: Aug 1, 2025

(d)If the resident is unable to determine...all of the following requirements are met: This requirement is not met as evidence by: Based on observation and record review the facility did not comply with the section above by having an inaccurate MAR which poses a potential health and safety violation for residents in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: By POC Facility agrees to update and maintain the MAR as well as provide additional training to staff and notify CCLD.

Type of visit: Case Management - Other

On 7/1/25 at 9:00AM, Licensing Program Analyst (LPA) A. Gomez conducted a case management visit as a result of observations made during a facility visit on 6/11/2025. LPA met with Facility Manager/Nurse, Cindy Murphy and explained the purpose of the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, common areas, and out door patios. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: PUB 475 Poster is not the correct dimensions 87468(c)(2)(A) Facility is placing residents in walkways to eat meals because dining area can not accommodate all residents. 87307(a)(1) R1 and R2 are both utilizing chairs with attached lap trays however there is not an exception or doctors orders for the postural supports 87608(a) LPA observed expired Almond milk for the residents being used in the kitchen 87555(b)(8) LPA observed the floors in the kitchen/food area sticky and dirty with debris and food 87303(a)(1) LPA observed that food is not properly stored in the kitchen. 87555(b)(9) LPA observed that the MAR is incomplete for all residents. 87465(d) LPA observed the file incomplete for R1 87506(b) LPA observed R1 asking S1 to go outside and S1 telling them they would have to go later. When LPA asked why S1 stated because there were not enough staff to supervise them outside. 87411(a) LPA observed unlocked scissors at the front desk accessible to residents.87309(a)*** Facility is not developing and following a weekly menu 87555(b)(6) ***Civil Penalty issued in the amount of $250 for repeat violation*** The following deficiencies were observed (see LIC 809D) and 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. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 1, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(c)(2)(A) · Plan of correction due date: Jul 17, 2025

(c)Licensees shall prominently post(2)Information...shall be posted as follows:(A) Licensees may use...PUB 475. The poster that is posted shall be 20" x 26" in size... This requirement is not met as evidence by: Based on observation the facility did not comply with the section above by PUB 475 poster being the incorrect dimensions and too small which poses a potential personal rights violation for residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: By POC facility agrees to obtain the PUB 475 with the correct dimensions and notify CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(a)(1) · Plan of correction due date: Jul 17, 2025

(a) Living...shall be large enough...The following provisions shall apply:(1) There shall be...dining rooms...shall be of sufficient...from interfering with other functions. This requirement is not met as evidence by: Based on observation the facility did not comply with the section above by placing residents in the walkways to eat because the dining area is insufficient which poses a potential personal rights violation for residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: By POC Facility agrees to develop a plan for meal times where clients are not placed in walkways and notify CCLD

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a) · Plan of correction due date: Jul 8, 2025

(a) Based on the individual's preadmission appraisal...Postural supports may be used under the following conditions This Requirement is not met as evidence by: Based on observation and file review the facility did not comply with the section above by R1 and R2 utilizing postural supports that are not documented in their file and do not have spring releases which pose an immediate personal rights violation for residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: By POC facility agrees to obtain new 602s and physcians orders for all residents utilizing postural supports.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Jul 1, 2025

(a) Except as specified.. sharp objects, and other similar items..are in locked storage ... This Requirement is not met as evidence by: Based on observation the facility did not comply with the section above by having unlocked and accessible scissors which pose an immediate personal rights violation safety risk for residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: Facility locked away scissors POC Clear.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 8755(b)(8) · Plan of correction due date: Jul 17, 2025

(b) The following..shall apply:(8) All food shall be of good quality... This requirement is not met as evidence by: Based on observation the facility did not comply with the section above having expired food which poses a potential health and personal rights violation for residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: By POC facility agrees to audit and dispose of all expired foods and notify CCLD

From the deficiency page — Deficiency type: Type B · Section cited: CCR8755(b)(9) · Plan of correction due date: Jul 17, 2025

(b) The following..shall apply:(9)Procedures.. of food shall be observed in food storage... This requirement is not met as evidence by: Based on observation the facility did not comply with the section above by not storing food properly which poses a potential health violation for residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: By POC facility agrees to conduct an inservice with kitchen staff and purchase food storage containers and notify CCLD

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(6) · Plan of correction due date: Jul 17, 2025

(b) The following..shall apply:(6)In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance... This requirement i not met as evidence by: Based on observation the facility did not comply with the section above by not creating and following a weekly menu which poses a potential personal rights violation for residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: By POC facility agrees to create and impliment a weekly menu and document the dishes when served and also provide kitchen staff with training on nutrition and notify CCLD

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a)(1) · Plan of correction due date: Jul 17, 2025

(a) The facility shall be clean...(1) Floor surfaces in ... kitchen areas... This requirement i not met as evidence by: Based on observation the facility did not comply with the section above by kitchen floors being dirty which poses a potential health risk for residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: By POC facility agrees to clean the kitchen and kitchen floors and notify CCLD

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(d) · Plan of correction due date: Jul 17, 2025

(d)If the resident is unable to determine...all of the following requirements are met: This requirement is not met as evidence by: Based on observation and record review the facility did not comply with the section above by having an inaccurate MAR which poses a potential health and safety violation for residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: By POC Facility agrees to update and maintain the MAR as well as provide additional training to staff and notify CCLD.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(b) · Plan of correction due date: Jul 17, 2025

(b) Each resident’s record shall contain at least the following information: This requirement is not met as evidence by: Based on record review the facility did not comply with the section above by having incomplete resident records which poses a potential personal rights violation for residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: By POC facility agrees to review all resident records and update them as necessary and notify CCLD

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jul 17, 2025

(a)Facility personnel shall at all times be sufficient in numbers... to meet resident needs... This requirement is not met as evidence by: Based on observation and conversation the facility did not comply with the section above by not having a sufficient number of staff to meet the residents needs which poses a potetional personal rights violation for residents in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: By POC facility agrees to hire an additional caregiver for each shift and notify CCLD.

Type of visit: Case Management - Health Checks

On 6/11/25 at 10:15AM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of a priority 1 complaint. LPA met with Administrator, Seema Sandu and explained the purpose of the visit. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 114.8 degrees F. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Refrigerator temperature was observed at 38 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 1/20/25. There are no accessible bodies of water observed. Report Continues on LIC809-C THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: Upon arrival LPA observed the facility front door locked from the inside and had to be unlocked with a key also other exit doors have child locks hindering exit. LPA identified multiple Fire Exits and walkways blocked with items ($500 Civil Penalty) LPA observed that the kitchen lock was broken and inside hazards such as knives and open flames were left unattended (no staff present) and later observed that room labeled "Salon" was unlocked and that there are dangerous chemicals inside LPA observed that the facility is in disrepair with multiple broken door locks and broken door in activity room. ***Civil penalties in the amount of $500 was assessed*** The following deficiencies were observed (see LIC 809D) and 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. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 11, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Jun 16, 2025

All facilities shall be maintained in...regulations adopted by the State Fire Marshal... This requirement was not met as evidence by Based on observation the facility did not comply with the section above by having multiple fire exits blocked which poses an immediete safety violation for residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: By POC Administrator will notify CCLD that all fire exits have been cleared. $500 Civil Penalty assesed

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Jun 16, 2025

(a) Except as specified...the licensee shall ensure that disinfectants... are in locked storage... Based on observation the facility did not comply with the section above by having room with disinfectent unlocked and kitchen unsecured which poses an immediete safety violation for residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: By POC Administrator will notify CCLD that all dangerous items are secured.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 16, 2025

The facility shall ... in good repair at all times... This requirement is not met as evidenced by: Based on observation the facility did not comply with the section above by having multiple broken locks and door which poses a potential personal rights violation for residents in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: By POC Administrator will notify CCLD that all repairs have been made

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Jun 16, 2025

(a) Residents in all residential care... shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building.... This requirement is not met as evidenced by: Based on observation the , Licensee did not comply with the regulation cited above by locking front main entrance door with a key and having child locks on perimeter doors which poses an immediate personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: By POC Administrator will review the regulations and provide, remove all child locks, and provide an in service to all employees and notify CCLD

Type of visit: Required - 1 Year

On 05/21/25 at 1:30PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. ADM has a current administrator certificate# 7036001740 which expires 11/16/26. At 2PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 75 deg F. Hot water temperature was measured at 115 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguishers were observed fully charged and last inspected on 01/20/25. LPA reviewed 5 staff and 5 resident files. LPA also conducted 5 staff and 5 resident interviews during visit. Continued on next page, LIC 809-C At 3PM, LPA observed the following defiiciencies: Common hallway flooring needs repairs in areas near the common shower room Water Leak from common hallway shower room and kitchen causing common hallway flooring to buckle and retain water/develop mold Back porch asphalt driveway has a large hole that is a safety hazard Disorganized office with various unfiled documents Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Updated copies of the following documents were obtained from ADM:  LIC500- Personnel Report  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan/Infection Control Plans  Evidence of Liability Insurance Exit interview conducted, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, May 21, 2025

Type of visit: Case Management - Health Checks

On 07/30/24 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Health and Safety check. LPA explained the purpose of the visit with house manager (HM). During the health and safety check, LPA observed a total of 9 staff and 27 residents at the facility. LPA toured facility with HM, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 30, 2024

Type of visit: Required - 1 Year

On 05/28/24 at 11AM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with administrator (ADM) and explained the purpose of the visit. ADM has a current administrator certificate# 6042535740 which expires 11/16/24. At 11:20AM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 73 deg F. Hot water temperature was measured at 117 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguishers were observed fully charged and last inspected on 04/24/24. LPA reviewed 5 staff and 5 resident files. LPA also conducted 5 staff and 5 resident interviews during visit. Updated copies of the following documents were obtained from ADM:  LIC500- Personnel Report  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan/Infection Control Plans  Evidence of Liability Insurance No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 28, 2024

Allegation investigated: Facility withheld resident's personal belongings

On 11/08/23 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with manager on duty (MOD), gathered information and delivered investigation findings of above allegations. LPA explained the purpose of the visit with MOD. During investigation, the department obtained the following documents from manager on duty - staff roster, residents’ roster, admission agreement, physicians report, ID/Emergency information, hospice records, Safeguard of property & valuables form and incident reports. Continued on next page, LIC 9099-C Substantiated Allegation: Facility withheld resident’s personal belongings Investigation Finding: Substantiated During investigation, LPA interviewed staff (MOD) who confirmed that they withheld resident’s (R1) personal belongings from authorized representative (POA) around 1:40PM on 11/01/23 because POA refused to sign for R1's remaining personal items being collected that day which were a wall decor wreath, black IPad, photo album binder, rose colored floral twin quilted bedspread and eye glasses with red case. Review of incident report dated 11/01/23 showed R1's family members came to pick up R1's personal belongings around 1:40PM and became aggressive with staff (pushing staff against the front door, grabbing R1's personal items, yelling at staff) when they refused to sign the release form given by staff for R1's remaining personal items. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that facility withheld resident’s personal belongings was found to be substantiated. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, appeal rights and copy of report provided. Allegation: Facility did not prevent resident's personal belongings from becoming damaged. Investigation Finding: Unsubstantiated During investigation, the department conducted interviews of facility staff and reviewed resident (R1) documents. Staff (MOD) stated that when R1 passed away on 01/12/23, R1's family member collected her personal belongings inside her bedroom which were a cloth suitcase, photo albums, box of clothes, bible, black fanny pack, pillow, red IPad, rose bed sheet set. MOD stated she observed all items collected on 01/12/23 were in good condition and that the bible had no water damage. Review of R1's property & valuables form dated 01/12/23 showed R1's listed personal items were released and signed by staff and R1's family member that day with no written observation of damage to any of the items collected. During visit on 11/08/23 at 1:45PM, LPA observed R1's remaining personal items (wall decor wreath, photo album, black IPad, eye glasses in red case and twin quilted bedspread) were not damaged and kept locked inside the facility's office for safekeeping. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility did not prevent resident's personal belongings from becoming damaged and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that the facility did not prevent resident's personal belongings from becoming damaged is unsubstantiated.the state’s words, verbatim · CDSS document, Nov 8, 2023 · control 15-AS-20231102093631

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(j)(2) · Plan of correction due date: Nov 30, 2023

The executor or the administrator of the estate shall be notified by the licensee, and the cash resources, personal property, and valuables surrendered to said party. This requirement was not met as evidenced by staff withholding resident’s personal belongings to authorized representative on 11/01/23.the state’s words, verbatim · CDSS document, Nov 8, 2023

Plan of correction: By POC due date, administrator agreed to complete and submit in-service staff retraining certificates on how to properly safeguard & surrender residents’ personal belongings & valuables in compliance with Title 22 Section 87217(j)(2).

Allegation investigated: Facility staff not treating for scabies at facility

On 10/05/23 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit, met with manager on duty (MOD), gathered information and delivered investigation finding of above allegation. LPA explained the purpose of the visit with MOD. During investigation, the department obtained the following documents from manager on duty - staff roster, residents roster, admission agreement, physicians report, ID/Emergency information, centrally stored medication logs, medication administration records, public health and incident reports. Allegation: Facility staff not treating for scabies at facility Investigation Finding: Unsubstantiated During investigation, LPA interviewed staff (ADM) who stated that resident (R1) was initially sent to the hospital on 09/04/23 due to low blood pressure & oxygen. R1 returned from the hospital on 09/08/23 with new medications. ADM stated staff noticed R1 itching on 09/10/23 and consulted with his health care team who stated it could be his medications side effect. On 09/30/23, R1 was again sent back to the hospital due to a change in condition (weakness). Continued on next page, LIC 9099-C Unsubstantiated The hospital evaluated R1 and confirmed he had scabies on 10/02/23. ADM immediately contacted local public health and implemented infection control plan. ADM stated all residents’ linens and clothing were hot water washed and cleaned on 10/03/23. Additional staff was hired to implement infection control. ADM stated all staff and residents were evaluated for scabies and only one resident (R2) displayed itching. ADM stated R2 is scheduled to see his doctor on 10/06/23 for evaluation & treatment. ADM stated R1 is scheduled to come back from the hospital on 10/05/23. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the facility staff are not treating for scabies and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that the facility staff are not treating residents for scabies is unsubstantiated. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 5, 2023 · control 15-AS-20231003161047