Gardena Retirement Center

Allegation investigated: Staff do not allow resident(s) to go on outings while in care. Staff do not ensure resident(s) attend their medical appointments while in care.

On 07/28/26 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Administrator Suzie Fuentes as the purpose of today’s visit was explained. The investigation consisted of the following: On 07/29/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1(R1): Emergency ID form, pre-appraisal dated: 4/16/25, admission agreement dated: 01/13/26, capacity evaluation note dated: 06/30/26, Physicians report dated: 07/14/26, needs and service plan dated: 07/01/26, medication list, medication administration record (MAR) for 07/2026, and primary physician notes dated: 01/13/26- 07/21/26. On 07/28/26 from 9:30 am- 11 am LPA conducted Interviews Unsubstantiated with and Residents # 1-8 (R1-R8), and from 11:15 am-12:45 pm staff #1-4 (S1-S4), and witness #1 (W1). LPA conducted a review of R1's file. The investigation consisted of the following: Allegation: Staff do not allow resident(s) to go on outings while in care. It is alleged that facility staff do not allow residents to have access to outside community resources. On 07/28/26 from 9:30am - 11 am LPA conducted Interviews R1-R8 regarding the allegation above. 7 of the 8 residents interviewed denied the allegation above. 2 of the 7 residents stated they are able to leave the facility unassisted, 5 of the 7 residents reported that they have access to the outside community but have to be accompanied by a staff member, family, friend or case worker. 1 of the 8 residents confirmed the allegation above and reported that staff do not allow resident to go out to the community whenever they want to, although resident believes they can access the outside community unassisted. On 07/28/26 from 11:15 am-12:45 pm LPA conducted interviews with S1-S4 regarding the allegation above. 4 of 4 staff denied the allegation above and reported that residents are not allowed to access the outside community alone if their physicians report indicates that resident(s) in care is unable to leave the facility unsupervised. Per 4 of 4 staff, if a resident wants to go out to the community the residents will ask the front desk if a staff member is available. LPA conducted interview with W1 regarding the allegation above, per W1 R1 is unable to access the community unassisted due to safety concerns. LPA conducted a review of R1's file. Per Physicians report dated: 07/14/26, R1 is unable to leave the facility unsupervised. Allegation: Staff do not ensure resident(s) attend their medical appointments while in care. It is alleged that staff did not make sure that resident(s) in care attended medical appointment with outside providers. On 07/28/26 from 9:30am - 11 am LPA conducted Interviews R1-R8 regarding the allegation above. 4 of the 8 residents interviewed denied the allegation above and reported they have outside medical providers and that their case workers assist with transportation. 4 of the 8 residents reported that the facility has not refused to assist with transportation. 3 of the 8 residents having no knowledge of the allegation above as they see the in house Dr.. Additionally, 7 of 8 residents reported they have not missed any medical appointments due to facility staff. 1 of the 8 residents confirmed the allegation above and reported that facility staff and case worker are not ensuring that resident in care is attended medical appointment with outside providers. On 07/28/26 from 11:15 am-12:45 pm LPA conducted interviews with S1-S4 regarding the allegation above and reported that the facility will make transportation arrangements for residents who request it. Additionally, 4 of 4 staff reported that residents are reminded of any upcoming medical appointments that day before and the day of the appointment. LPA conducted interview with W1 regarding the allegation above, per W1 R1 does not have an outside medical provider. LPA conducted a review of R1's file. Per capacity evaluation note dated: 06/30/26, R1 does not have the capacity to make informed medical decisions. Per primary physician notes dated: 01/13/26- 07/21/26, LPA was able to confirm that R1 is receiving services from in house Dr. and R1 does not have an outside medical provider. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 11-AS-20260722115250

Allegation investigated: Due to staff neglect, resident fell and sustained a fractured nose and black eye

On 7/9/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Susie Fuentes and explained the purpose of the visit is to investigate and deliver findings for the allegation mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 7/9/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Facility Fall Risk List, Unusual Incident/Injury Report, Face Sheet/Admission Record, Identification and Emergency Information, Medical Assessment for Residential Care Facilities for the Elderly, Functional Capability Assessment, Resident Appraisal, Dietary Instructions to Kitchen, Appraisal/Needs and Services Plan, Detailed Written Orders and Harbor – UCLA Medical Center Medical Report. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff -1 – Staff -5 (S1 – S5), and Resident -1 – Resident -6 (R1-R6). Staff 6 (S6) was interviewed on 12/4/25 during Case Management visit. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Due to staff neglect, resident fell and sustained a fractured nose and black eye The department received and reviewed the Unusual Incident Report dated 12/2/25, stating R1 was being transported to her room when S6 reported she tripped, and R1 fell forward out of her wheelchair and hit her face. Upon review of medical records from Harbor – UCLA Medical Center dated 11/29/25, R1 was admitted due to a mechanical fall. On 7/9/26, the department reviewed Admission Record and noted R1 was admitted to the Gardena Retirement Center on 9/20/24 and has a history of falls. Diagnosis per Physician’s Report dated 7/29/25, HTN (hypertension), HLD (hyperlipidemia), hypothyroidism, and dementia. Per review of Resident Appraisal dated, 12/2/25, R1 was hospitalized (11/29/25 – 12/1/25) for an accidental injury – resulting in a nasal bone fracture. CT scan shows nasal bone fracture, negative head CT for acute bleed. Overall health condition included dementia, non-ambulatory, motor impairment: uses a wheelchair, special diet: Low carb, puree, need assistance with bathing and dressing. Per review of Appraisal/Needs and Services, 12/15/25, R1 has no known allergies, poor posture and poor appetite. Per interview with S1, 7/9/26, R1 did not fall in the shower, she fell while being transported to her room following being showered. S1 stated it was an accident. On 7/9/26, R1 stated she was scared as S6 was going to fast. Per interview with S5, 7/9/26, R1 leans to the side. Staff repositions R1 in the straight position, but R1 slides back down and continue to lean to the side. Per interview with S6, 12/4/25, R1 does not like to use the chair. S6 stated she almost lost her balance as she pushed R1 in the wheelchair after R1 abruptly put her feet on the floor which caused R1 to fall forward. LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 3 out of 5 denied the allegation and 2 staff did not know. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 5 out of 6 denied the allegation and 1 resident confirmed it. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Due to staff neglect, resident fell and sustained a fractured nose and black eye,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Administrator, Susie Fuentes.the state’s words, verbatim · CDSS document, Jul 9, 2026 · control 11-AS-20251208142435

Type of visit: Required - 1 Year

On 4/27/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with the Administrator, Susie Fuentes and explained the purpose of today’s visit. The facility is licensed to serve elderly developmentally disabled adults ages 60 and above. Currently they are (83) residents living in the facility. LPA reviewed five (5) staff files, and five (5) residents files which were maintained and in order. During file review, LPA reviewed Liability insurance documents, Surety Bond, Emergency and Disaster Plan and Fire Inspection Report. LPA Shirley and Susie toured the facility. The facility is a two-story structure located in a commercial neighborhood. The facility consists of (54) resident bedrooms which include a bathroom in each unit. There is an activity room, upstairs TV room, dining room, kitchen and administrative offices. Facility maintains all required posting throughout the facility. LPA Shirley inspected 10 bedrooms. Bedrooms 12, 15, 16, 17, 18, 19, 20, 21, 46, and 47. Beds and bedding supplies were in good condition. LPA observed ample lighting in all the units. Bathrooms were found to be within Title 22 regulations and were operational. LPA observed that medications were safe, locked and inaccessible to clients in care. Last Disaster drill was conducted on 4/23/26. con'd on 809-C First aid kit is fully stocked with manual. No firearms are stored at this facility. LPA Shirley and Susie walked through all common areas and there is ample seating and space for all residents. All sharps were locked in a container located in the medication room. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. There is a charged fire extinguisher in the kitchen. There are no bodies of water present. The water temperatures range between 105 F and 120 F. There are 24 fire extinguishers and all were last checked 2/2026. The landlines were working and are available on-site. There were no deficiencies issued. An exit interview was conducted, and a copy of this report was provided to the Administrator, Susie Fuentes.the state’s words, verbatim · CDSS document, Apr 27, 2026

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

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 2/20/26. On 2/20/2026, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. Upon arrival, LPA met with the Administrator, Susie Fuentes, and explained that the purpose of today's visit is to investigate and deliver findings for the allegations mentioned above and was granted entrance to facility grounds. The investigation consisted of the following: On 7/11/25 LPA Felisa Shirley requested copies of the following records: Staff and Resident rosters, Appraisals, Needs and Services Plans and Physicians Reports for Residents 1 and Resident 2, staff schedules for week of 7/6/25, incident reports for the past 6 months and current hospitalizations list. The Department conducted interviews with Staff 1 to staff 5(S1-S5), Witness 1 to Witness 5(W1-W5) and Resident 1 – Resident 5(R1 – R5). Con’d on 9099-C Unsubstantiated Allegation: Staff did not seek medical treatment for residents in a timely manner It is being alleged that staff neglected to provide prompt medical attention to residents after an altercation. LPA Shirley reviewed Special Incident Report dated 7/10/25, which noted the following: Staff 2(S2) reported that on 7/9/25, Resident 1 (R1) and Resident 2 (R2) were arguing. R2 stated that while he was tying his shoes, R1 turned the bedroom light off. When R2 got up to turn the light back on, R1 hit him in the face with his shoe, so R2 hit him back. The staff initiated medical attention but both residents declined further medical services at that time. The Department reviewed R1 and R2’s Physician Reports, dated 1/1/25. Upon review of the physicians reports for both residents involved in the altercation, LPA Shirley noted identified diagnoses that if involved in an altercation would’ve required immediate medical attention by a licensed medical staff. The Department reviewed R1 and R2’s Resident Appraisals, dated 1/2025, stating that both residents are able to express and communicate their needs. The Department reviewed R1’s medical reports from St. Francis Medical Center – Emergency Room, dated 7/10/25. R1 presented to the emergency room staff with symptoms of pain to the side of neck and shoulders, separate and distinct from the incident reported on 7/9/25. Per interview, 10/1/25, S2 stated after the altercation both R1 and R2 were asked to go to the hospital, but they both declined. Per interview, 10/1/25, S2 stated that R2 called law enforcement and the police offered medical transport to the hospital for both residents, but both individuals declined. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not seek medical treatment for resident in a timely manner,” therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Christina Novoa, Business Office Manager.the state’s words, verbatim · CDSS document, Mar 20, 2026 · control 11-AS-20250710141135

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

On 2/19/2026, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. Upon arrival, LPA met with the Administrator, Susie Fuentes, and explained that the purpose of today's visit is to investigate and deliver findings for the allegations mentioned above and was granted entrance to facility grounds. The investigation consisted of the following: On 7/11/25 LPA Felisa Shirley requested copies of the following records: Staff and Resident rosters, Appraisals, Needs and Services Plans and Physicians Reports for Residents 1 and Resident 2, staff schedules for week of 7/6/25, incident reports for the past 6 months and current hospitalizations list. The Department conducted interviews with Staff 1 to staff 5(S1-S5), Witness 1 to Witness 5(W1-W5) and Resident 1 – Resident 5(R1 – R5). Con’d on 9099-C Unsubstantiated Allegation: Staff did not seek medical treatment for residents in a timely manner It is being alleged that staff neglected to provide prompt medical attention to residents after an altercation. LPA Shirley reviewed Special Incident Report dated 7/10/25, which noted the following: Staff 2(S2) reported that on 7/9/25, Resident 1 (R1) and Resident 2 (R2) were arguing. R2 stated that while he was tying his shoes, R1 turned the bedroom light off. When R2 got up to turn the light back on, R1 hit him in the face with his shoe, so R2 hit him back. The Department reviewed R1 and R2’s Physician Reports, dated 1/1/25. Upon review of the physicians reports for both residents involved in the altercation, LPA Shirley noted identified diagnoses that required immediate follow-up. The staff initiated medical attention but both residents declined further medical services at that time. The Department reviewed R1 and R2’s Resident Appraisals, dated 1/2025, stating that both residents are able to express and communicate their needs. The Department reviewed R1’s medical reports from St. Francis Medical Center – Emergency Room, dated 7/10/25. R1 presented to the emergency room staff with symptoms of side of neck and shoulders, separate and distinct from the incident reported on 7/9/25. Per interview, 10/1/25, S2 stated after the altercation both R1 and R2 were asked to go to the hospital, but they both declined. Per interview, 10/1/25, S2 stated that R2 called law enforcement and the police offered medical transport to the hospital for both residents, but both individuals declined. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not seek medical treatment for resident in a timely manner,” therefore, the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Xiomara Mejia, Caregiver.the state’s words, verbatim · CDSS document, Feb 20, 2026 · control 11-AS-20250710141135

Allegation investigated: Staff did not prevent resident from engaging in a physical altercation with another resident resulting in resident receiving multiple bruises

On 2/19/2026, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. Upon arrival, LPA met with the Administrator, Susie Fuentes, and explained that the purpose of today's visit is to investigate and deliver findings for the allegations mentioned above and was granted entrance to facility grounds. The investigation consisted of the following: On 7/11/25 LPA Felisa Shirley requested copies of the following records: Staff and Resident rosters, Appraisals, Needs and Services Plans and Physicians Reports for Residents 1 and Resident 2, staff schedules for week of 7/6/25, incident reports for the past 6 months and current hospitalizations list. The Department conducted interviews with Staff 1 to staff 5(S1-S5), Witness 1 to Witness 5(W1-W5) and Resident 1 – Resident 5(R1 – R5). Con’d on 9099-C Substantiated The Investigation revealed the following: Allegation: Staff did not prevent resident from engaging in a physical altercation with another resident resulting in resident receiving multiple bruises It is being alleged that staff failed to implement necessary precautions to prevent an altercation between Resident 1 and Resident 2 (R1 and R2). LPA Shirley reviewed facility Special Incident Report dated 7/10/25, which noted the following: Staff 2 reported that on 7/9/25, R1 and R2 were arguing. R2 stated that while he was tying his shoes, R1 turned the bedroom light off. When R2 got up to turn the light back on, R1 hit him in the face with his shoe, so R2 hit him back. On 1/6/2026 LPA Shirely reviewed facility records and noted the following: physician’s reports for R1 and R2 (dated 1/1/25) indicate both have aggressive tendencies. LPA Shirley also reviewed the Appraisals and Needs and Services Plans for both residents and noted the plans do not mention anything about aggressive tendencies or plans to handle those tendencies for R1 or R2. The Department conducted interviews with facility administrator Susie Fuentes on 11/19/2025. During the interview, Fuentes stated that R1 and R2 had a history of altercations and that facility staff were aware. Furthermore, Administrator Fuentes stated staff are trained to immediately notify law enforcement regarding any suspected criminal act or physical abuse involving residents and that she felt better training should be provided for the staff. The department interviewed facility Staff 1 to staff 5(S1-S5), and of those interviewed, 2 out of 5 staff stated R1 and R2 had a previous history of aggressive speech or actions, with one of the staff adding that it had caused the residents to be moved to another room. The department also conducted interviews with facility residents, Resident 1 - Resident 5 (R1 – R5). Of those interviewed, 2 out of 5 stated R1 and R2 had a history of aggression Con'd on 9099-C towards each other. On 8/4/25, the department interviewed Witness 2 (W2), who reported that R1 spoke to them and alleged that a physical altercation had occurred at the facility involving their roommate. According to W2, R1 stated the roommate struck them in the back and further alleged that facility staff failed to intervene or take action when the incident occurred. The resident reportedly noted that this is the second or third similar occurrence involving the same roommate. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. A Deficiencies was cited during today's visit. An exit interview was conducted, and plans of corrections were developed with the Administrator, Susie Fuentes. A copy of this report and appeals rights were provided.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 11-AS-20250710141135

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80078(a) · Plan of correction due date: Mar 5, 2026

80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met, as evidenced by: Based on records reviewed and interviews, facility staff did not have a plan in place to handle aggressive verbal and physical altercations between residents, which resulted in a physical altercation between R1 and R2 occurring on 7/9/25. This poses a possible health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: The Administrator shall review Title 22 section 80078 (a) and provide in-service training to staff on implementing necessary precautions to prevent altercations between residents and providing more observation of the residents. Copy of training sign in sheet and written statement acknowledging understanding of Title 22 80078(a) shall be submitted to the department by the POC due date of 3/5/26 via email to felisa.shirley@dss.ca.gov or fax to 424-544-1016.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure that resident's shower equipment was in good repair resulting in a fall.

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on the report created on 12/17/25. On 12/17/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Susie Fuentes and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 11/19/25 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Admission Record, Special Incident Report, Preplacement Appraisal Information, Medical Assessment for Residential Care Facilities for the Elderly, Appraisal/Needs and Services Plan, Enriched Residential Care Service Need and Tier Assessment, Incontinent Schedule for All Shifts, Shower List, medical reports from Gardena Memorial Hospital and a Picture. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-8 (S1 – S8), and Resident -1 – Resident -8 (R1-R8). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not ensure that resident's shower equipment was in good repair resulting in a fall. It is being reported that shower equipment was not in good repair, resulting in residents fall. On 12/17/25, LPA Felisa Shirley reviewed the Special Incident Report dated 11/13/25, which reported that R-1 slipped out of the shower chair during her scheduled shower and was able to land into a sitting position. Resident requested that staff call 911. Resident was taken to Gardena Memorial Hospital, was examined and she returned back to the facility on the same day. On 12/17/25, LPA Shirley reviewed the Preplacement Appraisal Information dated 10/22/25, which documents that R-1 needs help with bathing. A review of the medical report from Gardena Memorial Hospital dated 11/12/25 did not indicate a fracture nor a displacement. LPA Shirleys facility tour and inspection on 11/19/25 included an inspection of the designated shower chair; no deficiencies were identified. During staff interviews, S2 indicated they were able to catch the resident and gently guide R1 into a seated position, preventing a fall. The staff member stated that the resident did not hit her head or lose consciousness as a result of the incident. LPA interviewed staff 1 – staff 8 (S-1 – S-8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 8 (R1 – R8). Of those who interviewed 7 out of 8 denied the allegation, 1 confirmed the allegation. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not ensure that resident's shower equipment was in good repair resulting in a fall,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Administrator, Susie Fuentes.the state’s words, verbatim · CDSS document, Jan 8, 2026 · control 11-AS-20251119084839

Allegation investigated: Staff did not ensure that resident's shower equipment was in good repair resulting in a fall.

On 12/17/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Susie Fuentes and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 11/19/25 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Admission Record, Special Incident Report, Preplacement Appraisal Information, Medical Assessment for Residential Care Facilities for the Elderly, Appraisal/Needs and Services Plan, Enriched Residential Care Service Need and Tier Assessment, Incontinent Schedule All Shifts, Shower List, medical reports from Gardena Memorial Hospital and a Picture. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-8 (S1 – S8), and Resident -1 – Resident -8 (R1-R8). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not ensure that resident's shower equipment was in good repair resulting in a fall. It is being reported that shower equipment was not in good repair, resulting in residents fall. On 12/17/25, LPA Felisa Shirley reviewed the Special Incident Report dated 11/13/25, which reported that R1 slipped out of the shower chair during her scheduled shower, and returned back to the facility on the same day. On 12/17/25, LPA Shirley reviewed the Preplacement Appraisal Information dated 10/22/25, which documents that R1 needs help with bathing. A review of medical report from Gardena Hospital, LP dated 11/12/25 did not indicate a fracture nor a displacement. LPA Shirleys facility tour and inspection on 11/19/25 included an evaluation of the designated shower chair; no deficiencies were identified. During staff interviews, S2 indicated they were able to catch the resident and gently guide R1 into a seated position, preventing a fall. The staff member stated that there were no visible injuries and resident did not hit their head or lose consciousness as a result of the incident. LPA Shirley interviewed staff 1 – staff 8 (S-1 – S-8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 8 (R-1 – R-8). Of those who interviewed 7 out of 8 denied the allegation, and 1 confirmed the allegation. Based on information gathered, LPA Shirley did not find sufficient evidence to support the allegation “Staff did not ensure that resident's shower equipment was in good repair resulting in a fall,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Administrator, Susie Fuentes.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 11-AS-20251119084839

Type of visit: Case Management - Incident

On 12/4/25, Licensing Program Analyst (LPA) Felisa Shirley arrived at facility to investigate a special incident report received on 12/3/25. Per the incident report, on 11/29/25, resident was being transferred in a wheelchair from the showers back to their room and while enroute to the room the caregiver tripped and resident fell out of the wheelchair, face first onto the floor. On 12/4/25, LPA Shirley toured this facility and reviewed resident’s facility file and discharge papers. LPA Shirley interviewed Staff 1 – Staff 3 (S1 – S3), and Resident 1 (R1). An exit interview was conducted, and a report was left with the Administrator, Susie Fuentes whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Dec 4, 2025

Allegation investigated: Staff did not provide proper supervision to resident in care resulting in a broken hip.

On 10/28/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a subsequent unannounced Complaint Visit to the facility listed above. LPA met with Administrator Susana Fuentes, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA conducted a facility inspection, interviewed Staff S1-S6, interviewed Resident’s R2-R10, and received the Staff Roster (dated 10/28/2025), Resident Roster (dated 10/27/2025), Alert Progress Notes (dated 12/26/24, 01/01/25, 01/12/25, 01/26/25, and 02/19/25), Unusual Incident/Injury Report (dated 02/13/25 and 01/02/25), and Point of Care Audit Report (dated January 2025 to February 2025) During the initial visit on 07/30/2025, LPA Lee received the following documents Staff Roster (dated 7/30/25), Resident Roster (dated 7/28/25), R1's Resident Pre-placement Appraisal (1/30/25), R1's Incident reports (dated 2/13/25), R1's Needs and Services Plan (dated 4/9/24) R1's Physician's Report (dated 1/1/25), R1's Admission Agreement (dated 3/10/23). The investigation revealed the following: Unsubstantiated Allegation: Staff did not provide proper supervision to resident in care resulting in a broken hip. The allegation alleges a resident fell at the facility resulting in a broken hip and staff did not know how the resident fell. During the facility inspection, LPA observed all walkways and hallways were observed clean, clear, and free of hazards and obstructions. All hallways had ample lighting. During record review, LPA received and reviewed R1’s Physician’s Report, dated 01/01/2025, that indicates R1 is ambulatory and is able to independently transfer to and from bed. It is indicated R1 uses a walker for unsteady gait and requires assistance with bathing, grooming, and dressing. LPA received and reviewed R1’s Appraisal/Needs and Service Plan, dated 04/09/24, that indicates R1 requires assistance with activities of daily living (ADL), and that R1 refuses assistance and says they are able to do it themselves. LPA received and reviewed the Point of Care Audit Report that documents the time resident health and safety checks are conducted, bathing assistance is provided, and meal attendance. In the document, LPA observed health and safety checks conducted on 02/12/2025 at 11pm and 11:26pm, and on 02/13/2025 at 2:43am and 7am. Additionally, LPA observed meal attendance documented on 02/13/2025 at 8:11am. During interviews with Staff S1-S6, they were asked if R1 was a fall risk, five (5) out of six (6) stated no, R1 was not a fall risk. Additionally, Staff S1-S6 were asked how often residents who are fall risks are checked on, six (6) out of six (6) stated as frequently as possible, every 15 to 30 minutes. During interviews with Residents R2-R10, were asked if they feel there is enough staff to provide proper supervision, nine (9) out of nine (9) stated yes, there is enough staff to provide proper supervision. Additionally, Residents R2-R9 were asked if staff check on them when they are in their room, nine (9) out of nine (9) stated yes, staff conduct frequent checks on them when they are in their rooms. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. During today's visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Administrator, Susana Fuentes, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 28, 2025 · control 11-AS-20250729121705

Type of visit: POC

On September 04, 2025, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced Proof of Correction visit at the facility and met with Administrator Susie Fuentes and explained the purpose of today’s visit is to conduct a Plan of Corrections. The facility was cited with a Type B Section 87468.1(a)(2) Personal rights. 87468.1(a)(2) correction due on September 03, 2025. The facility is still not in compliance with the California Code of Regulations Title 22 Division 6. An exit interview was conducted, and a copy of this report was provided to Susana Fuentes.the state’s words, verbatim · CDSS document, Sep 4, 2025

Allegation investigated: Staff unlawfully evicted a resident.

This report supersedes the previous reports LIC9099, LIC9099-C, and LIC9099-D created on 08/25/2025, The findings regarding the complaint remain unchanged. On 08/28/2025, LPA Richard conducted a subsequent visit and met with Staff Christina Novoa, and explained the purpose of this visit. On 08/25/2025, Licensing Program Analyst (LPA) Antonine Richard conducted a complaint investigation at the above facility to address the following allegation. LPA met with the Administrator Susie Fuentes and explained the purpose of the visit. The investigation consisted of the following: On 08/22/2025, at proximately 12:30 PM, LPA Richard interviewed the Hospital Social Worker (SW). On 08/25/2025 at proximately 9:00 AM, LPA interviewed the Administrator (A1). LPA Richard also reviewed and obtained records for resident #1 (R1). LPA reviewed and obtained the Hospital Psychiatrist Progress Note (dated 08/22/2025). Substantiated Allegation #1: Staff unlawfully evicted a resident. The complaint states that the patient was taken to the Harbor UCLA Psychiatric Emergency Room (ER) and placed on a 51/50 hold. A review of the psychiatrist’s progress note, dated August 22, 2025, revealed that on August 19, 2025, the Psychiatric ER contacted the Gardena Retirement Center and spoke with Administrator A1 regarding the patient's return to the facility. A1 informed them that the facility did not want the residents to return. On August 25, 2025, the LPA interviewed A1, who reiterated that the facility did not wish to accept the resident back. During a file review for R1 conducted by LPA Richard, it was noted that R1 was admitted to Gardena Retirement on June 25, 2015. A review of the admission agreement for Gardena Retirement Center revealed that the facility is required to provide residents with 30 days' written notice before any changes (or 3 days if approved by the Department of Social Services). However, there is no record of the facility providing 30 days' notice to either the residents or their responsible party. Based on interviews and record reviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099D. Deficiencies were issued. An exit interview was conducted, and plans for correction were developed. A copy of this report and appeals rights was reviewed and left with the facility Staff Christina Novoathe state’s words, verbatim · CDSS document, Aug 28, 2025 · control 11-AS-20250820134633

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 3, 2025

(a) Residents in all residential care facilities for the elderly shall have all the following personal rights: (2) to be accorded safe, heathful and comfortable accommodations... This requirement was not met as evidence By: Based on record review and interviews, the Licensee did not permit R1 to return back to the facility which posed a potential personal rights risk to the resident in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: The Administrator will make arrangements to bring the resident back to the facility. And also the Administrator will review title 22 eviction regulations and submit a statement of acknowleding the review and understanding of title 22. POC 09/03/2025 via email to LPA Antonine.Richard@dss.ca.gov

Allegation investigated: Staff unlawfully evicted a resident.

On 08/25/2025, Licensing Program Analyst (LPA) Antonine Richard conducted a complaint investigation at the above facility to address the following allegation. LPA met with the Administrator Susie Fuentes and explained the purpose of the visit. The investigation consisted of the following: On 08/22/2025, at proximately 12:30 PM, LPA Richard interviewed the Hospital Social Worker (SW). On 08/25/2025 at proximately 9:00 AM, LPA interviewed the Administrator (A1). LPA Richard also reviewed and obtained records for resident #1 (R1). LPA reviewed and obtained the Hospital Psychiatrist Progress Note (dated 08/22/2025). Continue to LIC 9099-C. Substantiated Allegation #1: Staff unlawfully evicted a resident. The complaint states that the patient was taken to the Harbor UCLA Psychiatric Emergency Room (ER) and placed on a 51/50 hold. A review of the psychiatrist’s progress note, dated August 22, 2025, revealed that on August 19, 2025, the Psychiatric ER contacted the Gardena Retirement Center and spoke with Administrator A1 regarding the patient's return to the facility. A1 informed them that the facility did not want the residents to return. On August 25, 2025, the LPA interviewed A1, who reiterated that the facility did not wish to accept the resident back. During a file review for R1 conducted by LPA Richard, it was noted that R1 was admitted to Gardena Retirement on June 25, 2015. A review of the admission agreement for Gardena Retirement Center revealed that the facility is required to provide residents with 30 days' written notice before any changes (or 3 days if approved by the Department of Social Services). However, there is no record of the facility providing 30 days' notice to either the residents or their responsible party. Based on interviews and record reviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099D. Deficiencies were issued. An exit interview was conducted, and plans for correction were developed. A copy of this report and appeals rights was reviewed and left with the facility Administrator, Susie Fuentes.the state’s words, verbatim · CDSS document, Aug 25, 2025 · control 11-AS-20250820134633

From the deficiency page — Deficiency type: Type B · Section cited: CCR 877224(a)(4) · Plan of correction due date: Aug 29, 2025

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons... Thirty (30) days written notice to the resident is required except...(4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. Based on interviewed and record review the licensee did not comply with the section cited above. On 08/19/2025 the facility was informed that the R1 was ready to be discharged form the hospital A1 did not want R1 back which posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Aug 25, 2025

Plan of correction: The Administrator will make arrangements to bring the resident back to the facility. And also The Administrator will review title 22 eviction regulations and submit a statement of acknowleding the review and understanding of title 22. POC 08/29/2025 via email to LPA Antonine.Richard@dss.ca.gov.

Type of visit: Required - 1 Year

On 4/7/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with the Administrator, Susie Fuentes and explained the purpose of today’s visit. The facility is licensed to serve elderly developmentally disabled adults ages 60 and above. Currently they are (83) residents living in the facility. LPA reviewed five (5) staff files, and five (5) resident’s files and MARs were maintained and in order. During file review, LPA reviewed Liability insurance documents and Surety Bond. LPA Shirley and Susie toured the facility. The facility is a two-story structure located in a commercial neighborhood. The facility consists of (54) resident bedrooms which includes a bathroom in each unit. There is an activity room, upstairs TV room, dining room, kitchen and administrative offices. Facility maintains all required posting throughout the facility. LPA Shirley inspected 10 bedrooms. Bedrooms 4, 5, 6, 7, 8, 15, 17, 18, 19, and 43. Beds and bedding supplies were in good condition. LPA observed ample lighting in all the unites. All call buttons were operational and received response back from the front desk. Bathrooms were found to be within Title 22 regulations and were operational. First aid kit is fully stocked with manual. No firearms are stored at this facility. LPA Shirley and Susie walked through all common areas and there is ample seating and space for all residents. All sharps were locked in a container located in the medication room. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. There is a charged fire extinguisher in the kitchen. There are no bodies of water present. con'd 809-C The water temperatures range between 111.9F and 113.1F. There are 24 fire extinguishers and all were last checked 2/2025. The landlines were working and are available on-site. There were no deficiencies issued. An exit interview was conducted, and a copy of this report and appeals rights was provided to the Administrator, Susie Fuentes.the state’s words, verbatim · CDSS document, Apr 7, 2025

Allegation investigated: Resident sustained multiple unexplained bruises

On 2/14/25, Licensing Program Analyst (LPA) Felisa Shirley, conducted a subsequent unannounced complaint visit to the address listed above. LPA arrived and spoke to the Administrator Susie Fuentes and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 1/29/25, LPA Shirley toured the facility and reviewed Residents file. LPA Shirley requested and reviewed copies of the following records: Staff Roster, Resident roster, Admission Record, ID and Emergency Info, Physician’s Report, Admission Agreement, Appraisal Needs and Services, Progress notes, Podiatric Evaluation & Treatment Form, Conservatorship documents, Medication Review Report, Clinical Progress Notes, Resident Personal Property and valuables, visitor log, incident reports. LPA interviewed staff 1 -staff 5(S1 - S5) and resident 1 - resident 8 (R1 - R8). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Resident sustained multiple unexplained bruises On 1/28/25, the department reviewed facility records. Per incident report sent to the facility on 12/24/2024, on 12/23/2024 staff 6 (S6) found bruising on right and left arm of resident 1(R1). Incident reported also noted that R1 was taken out of the facility on 12/18/2024 and 12/21/2024 and that no bruises were noted at the time of departure. R1 denied any injuries or trauma when asked by facility staff. On 1/29/2025 the department requested a list of R1’s medications. R1’s current medications include Brimonidine Tartrate Ophthalmic Solution, which has a side effect of bruising and unusual bleeding. On 1/29/2025 the department interviewed to Administrator Susie Fuentes, who stated that she observed a family member hurrying R1 along as they walked out the door. Per administrator, R1 walks slowly, so family member was pulling her out of the door by her wrists. On 2/13/2025 the department spoke with witness 1 (W1) who stated R1 told them someone at the facility was yanking on them and squeezing on their wrist. On 1/29/25, the department interviewed R1. During the interview, LPA Shirley noted bruises on both of R1’s arms, which appeared to be healing. During interview on 1/29/2025 R1 stated that she did not know who caused the bruises on her wrists. On 1/29/2025 the department interviewed Staff 1 - Staff 5, (S1-S5). LPA asked staff if any of the residents had bruises on their arms. Of those interviewed, 2 out of 5 stated yes, and 3 answered no. on 1/29/2025 the department interviewed resident 1 - resident 8 (R1-R8). The department asked residents if they had any bruises. Of those interviewed, 6 out of 8 answered no, and 2 did not answer the question. 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 allegations are Unsubstantiated. There were no deficiencies cited during this visit. LPA Shirley conducted an exit interview and a copy of this report was signed by the Administrator, Susie Fuentes.the state’s words, verbatim · CDSS document, Feb 14, 2025 · control 11-AS-20250127144734

Allegation investigated: Staff are not permitting resident to have visitors Staff are not permitting resident to receive phone calls Staff are not safeguarding resident's belongings

On 1/29/25 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA arrived and spoke to the Administrator Susie Fuentes and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 1/29/25, LPA Shirley toured the facility and reviewed Residents file. LPA Shirley requested and reviewed copies of the following records: Staff Roster, Resident roster, Admission Record, ID and Emergency Info, Physician’s Report, Admission Agreement, Appraisal Needs and Services, Progress notes, Podiatric Evaluation & Treatment Form, Conservatorship documents, Medication Review Report, Clinical Progress Notes, Resident Personal Property and valuables, visitor log, incident reports. LPA interviewed staff 1 thru staff 5(S-1 thru S-5) and resident 1 thru resident 8 (R-1 thru R-8). The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Staff are not permitting resident to have visitors It was reported that staff interferes with the resident’s visitation. Per Section XV Family Visits, in the facility’s Admission Agreement, it states that Management encourages family and friends to visit, subject to the Community Rules and Regulations. During Interviews with S1, LPA learned that a specific family member visit was being denied pending an investigation by the conservator. LPA Shirley requested and reviewed the visitors log and observed that R-1 receives visitors by family, friends and her conservator. R-1 has a visitor that refuses to sign the visitors log. LPA interviewed staff S1-S5, LPA ask, is staff not permitting residents from having visitors. Of those interviewed, 5 out of 5 answered, no they can have visits anytime they’d like. LPA interviewed residents R1 – R8, LPA ask, does staff allow you to have visitors. Of those interviewed, 8 out of 8 answered yes. 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. Allegation: Staff are not permitting resident to receive phone calls The details of the complaint allege that staff are not permitting residents to receive their phone calls. On 1/29/25, LPA Shirley reviewed an email to R-1’s conservator, dated 12/6/24, that the police were called to conduct a safety check as R-1 refused to come to the phone. The police came in and went to R-1’s room and the police were told by R-1 that she did not want to come to the phone because she was asleep. LPA interviewed staff 1 through Staff 5, (S1-S5). LPA ask, does staff allow residents to have phone calls. Of those interviewed, 5 out of 5 stated yes. LPA interviewed resident 1 through resident 8, (R1-R8) LPA ask, are you allowed to receive phone calls. Of those interviewed, 8 out of 8 answered, yes. 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 allegations are Unsubstantiated. Con'd on 9099-C Allegation: Staff are not safeguarding resident's belongings It was reported that the resident’s slippers, clothing, money and driver’s license were stolen by the staff. LPA Shirley reviewed the Personal Property and Valuables form and it has one item recently listed but does not include an ID card. There are no incident reports reporting stolen ID’s. Staff S2 stated that R1 arrived with nothing besides the clothes they were wearing. LPA spoke with R-1 and she stated that she has not had a drivers license in years. Per S-1, on one occasion R-1 left this facility with a full duffle bag. S-1 tried to check the bag but R-1 did not allow her to check. When R-1 returned to the facility the duffle bag was not full. Per S-1, R-1’s money is managed by the conservator who sends money to facility and money is given to R-1. LPA reviewed R-1’s special incident reports and did not observe any reports of money being stolen. LPA interviewed staff 1 through Staff 5, (S1-S5). LPA ask, “are staff safeguarding resident’s personal belongings.” Of those interviewed, 5 out of 5 stated yes. LPA interviewed resident 1 through resident 8, (R1-R8) LPA ask, does staff make sure that you have all of your personal belongings. Of those interviewed, 6 out of 8 answered yes, and 2 answered no. 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 allegations are Unsubstantiated. There were no deficiencies cited during this visit. LPA Shirley conducted an exit interview and a copy of this report was signed by staff Xiomara Mejia and a copy left for the Administrator, Susie Fuentes.the state’s words, verbatim · CDSS document, Jan 29, 2025 · control 11-AS-20250127144734

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

Allegation investigated: Resident developed pressure injuries while in care. Staff did not seek medical attention to resident.

On 11/13/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by facility Administrator, Susie Fuentes, and explained the purpose of the visit is to deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 11/21/2023 The department toured the facility to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. The department requested and received copies of the following records: Staff Roster, Resident Rosters, files of residents on hospice services, and list of residents recently hospitalized. On 11/30/2023 the department requested Harbor-UCLA medical records, facility chart, and conducted interviews with staff from this facility, facility residents, family members and staff from Harbor-UCLA, and reviewed medical records/reports. The department conducted interviews with residents 1-resident 3 (R1-R3) and staff 1-staff6(S1-S6). The investigation revealed the following: Substantiated Allegation: Resident developed pressure injuries while in care. It is alleged that due to staff neglect, Resident 1 (R1) was observed with stage 3 pressure injuries. The department reviewed facility Admissions Agreement which shows that R1 was admitted to the above-mentioned facility on 06/8/2023. During admission, the facility staff conducted a skin check and noted closed wounds on the left lower buttocks area. The Department interviewed facility Administrator, Susie Fuentes, who stated that R1 did have a pressure injury, but it was within guidelines. The department reviewed Nova Vita medical records, which show that from 7/16/23 thru 11/8/23, R1 was receiving home health for skilled nursing services and physical therapy. No orders for wound care were found in Nova Vita’s records. The department reviewed facilities Resident Rotation Log for R1 for the month of October. The log has entries from 10/8/2023 to 10/29/2023 and shows sporadic notations of dates and times R1 was rotated from 10/8/2023 to 10/14/2023. The log the skips to 10/17/2023 with one entry and then again skips to 10/29/2023 with one entry. Per records from Harbor UCLA Medical Center, on 11/11/2023, R1 was admitted to the Harbor UCLA Medical Center for the chief complaint of basic life support measures, and shortness of breath. Further review of Harbor UCLA medical records indicates that on 11/12/23 R1 was found to have two pressure injuries: Stage 2 pressure injury to sacral coccyx area, and stage 3 pressure injury to right ischium. A review of facility records indicates that on a body check conducted on 10/31/2023, facility staff noted a change in condition to R1, and under pressure injury, they noted small open sore. The accompanying diagram has markings over the lower right and left ischial tuberosity. A body check conducted by Con'd on 9099-C facility staff on 11/11/2023 when R1 was transferred to Harbor UCLA Medical Center indicated R1 had a continuous sore. Further review of facility records found no indication of pressure injuries being treated by or assessed by a doctor or another licensed medical professional. The Department interviewed facility staff 1 – Staff 6 (S1-S6), and asked if R1 had any pressures injuries, of those interviewed 5 out of 6 staff were aware of pressure injury, and 2 out of 6 admitted to treating R1’s pressure injuries with A+D topical ointment. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. Allegation: Staff did not seek medical attention to resident. The department reviewed facility Admissions Agreement which shows that R1 was admitted to the facility on 06/8/2023. Nova Vita medical records show that R1 was receiving home health service from 7/16/23 thru 11/8/23, R1 was receiving home health for skilled nursing services and physical therapy. The home health records did not show any wound care orders. A review of Nova Vita’s notes shows no indications of pressure injuries. A review of facility records indicates that on a body check conducted on 10/31/2023, facility staff noted a change in condition to R1, and under pressure injury, they noted small open sore. The accompanying diagram has markings over the lower right and left ischial tuberosity. A body check conducted by facility staff on 11/11/2023 Con'd on 9099-C indicated R1 had a continuous sore. The Department interviewed facility staff 1 – Staff 6 (S1-S6), and asked if R1 had any pressures injuries, of those interviewed 5 out of 6 staff were aware of pressure injury, and 2 out of 6 admitted to treating R1’s pressure injuries with A+D topical ointment at the direction of the facilities medical technicians(med-techs). The department conducted a further review of facility records and found no indication of pressure injuries being treated by or assessed by a doctor or another licensed medical professional from 10/31/2023 to 11/11/2023 when R1 was admitted Harbor UCLA Medical Center. The department reviewed Harbor UCLA medical records which indicate that R1 was admitted on 11/11/2023 and that on 11/12/23 R1 was found to have two pressure injuries: Stage 2 pressure injury to sacral coccyx area, and stage 3 pressure injury to right ischium. Based on records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. Civil Penalty: An immediate $500 Civil Penalty assessed. Enhanced Civil Penalty: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An exit interview was completed with Administrator Susie Fuentes, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 13, 2024 · control 11-AS-20231120204358

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(8) · Plan of correction due date: Nov 14, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities 8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: Based on interviews and record reviews, due to facility staffs neglect in the care of R1 led to pressure injuries. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2024

Plan of correction: The Director shall retrain all staff on incontinence and medical referrrals, and to review regulation and submit a written acknowledgement that regulation is understood and provide evidence of training to CCLD via fax or email by POC due date of 11/27/24. Proof of correction can be emailed to felisa.shirley@dss.ca.gov.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Nov 14, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews and record reviews, facility staff failed to not ensure R1 received timely medical attention. This poses a potential health and safety risk to all residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2024

Plan of correction: The Director shall retrain all staff on incontinence and medical referrals to review regulation and submit a written acknowledgement that regulation is understood and provide evidence of training to CCLD via fax or email by POC due date of 11/27/24. Proof of correction can be emailed to felisa.shirley@dss.ca.gov.

Allegation investigated: Staff do not allow visitors to visit resident. Staff are not suppling hygiene products to resident. Staff are not providing food to resident. Staff hit resident. Staff are not assisting resident in the shower.

On 07/08/2024, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint visit to deliver findings regarding the above allegations. LPA met with administrator Susana Fuentes. The investigation consisted of the following. On 07/02/2024, Licensing Program Analyst (LPA) Antonine Richard conducted an annannounced complaint visit. LPA met with the administrator, Susana Fuentes and explainted the purposed of today's visit and was granted entry. During today's investigation, LPA toured the facility inside and out and requested copies of the staff roster, resident roster, and residents' files. LPA also reviewed records, interviewed 8 residents and 6 staff members, and obtained documents. Due to time constraints, the above allegations need further investigation. On 07/08/2024, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint visit to deliver findings regarding the above allegations. Report Continues, See LIC9099C Unsubstantiated Continued LIC9099-C Page 2 Allegation #1: Staff do not allow visitor to visit resident. The details of the complaint alleged that the staff are not allowing the resident to have visitors. LPA interviewed the administrator Susana Fuentes (A1) denied the allegation. A1 stated that all the residents have visitors seven day a week. The residents if they share rooms, they could not have visitors inside the room, unless it’s a private room. The residents can have visitors on the front porch, and in the back in the patio with the gazebo. LPA interviewed the Business Office Manager (BOM 2) stated that most of the residents have visitors and they most sign in and out. Sometimes the family members call the front desk to reserve the patio with the gazebo for the residents if they are going to have more than 4 to 6 visitors that day or to celebrate a special occasion. LPA interviewed eight residents (R1-R8) 7 out of 8 stated that they do have family members visited them, they all know if you have a roommate, you cannot have visitors inside your room unless the roommate agrees to let your visitors come inside the room. The residents (R2-R8) and staff (S1-S2) all denied the allegation. Records reviewed showed that resident have visitors at the facility on 06/01/2024 through 06/29/2024. During the visit to the facility on 07/02/2024, LPA observed several family members visiting the residents outside on the porch and the patio. Based on interviews, observation, and records reviewed there was not enough sufficient evidence to support the allegation. 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 deemed unsubstantiated. Continued LIC9099-C page 3 Continued LIC9099-C page 3 Allegation #2: Staff are not suppling hygiene product to resident. The details of the complaint alleged that the staff are not giving hygiene products. LPA interviewed the administrator Susana Fuentes (A1) denied the allegation stated that the facility does not provide hygiene needs to the residents, however when the resident comes and asks the staff to provide them hygiene because they run out the staff will provide the residents with the supplies until the family bring them their hygiene supplies. LPA interviewed six staff (S1-S6) 6 out of 6 stated that is very seldom a resident would ask them for hygiene products. LPA interviewed eight residents (R1-R8) 8 out of 8 residents stated that they bought their own hygiene products, sometimes they might miss one or two things, however the staff does provide them the items. LPA interviewed R1, and R1 stated that the cabinet in R1’s room was full of hygiene products, LPA confirmed. R1 also stated that the staff would give some items when R1 run out. A review of the resident’s admission agreement on 07/02/2024 indicated that residents and their families are responsible for their hygiene products. The residents (R1-R8) 8 out of 8 and staff (S1-S6) 6 out of 6 denied the allegation. Based on interviews, observation, and records reviewed there was not enough sufficient evidence to support the allegation. 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 deemed unsubstantiated. Continued LIC9099-C page 4 Continued LIC9099-C page 4 Allegation #3: Staff are not providing food to the resident. The details of the complaint alleged that staff are not providing food to resident. The department interviewed the Administrator#1 (A1) stated that residents are provided with a variety of quality food to eat. Staff (S1-S6) 6 out of 6, and Residents (R1-R8) 8 out of 8, all stated the residents receive enough food, and vegetable, including three (3) meals, breakfast, lunch, and dinner. The Administrator stated that the staff serves a well-balanced meal with a variety of food option to choose from each day. The department interviewed six staff (S1-S6) 6 out of 6 who stated that the food menu changes daily, and residents can select something different if they prefer. The department interviewed eight residents (R1-R8) 8 out of 8 stated that they had no issues with the food. Sometimes, they like to order food outside the facility. On 07/02/2024, the department observed the residents (R1-R8) 3 out of 8 ordering food from the outside stated they wanted to eat a different type of food for lunch that day. On 07/02/2024, the department reviewed the facility menu for the week and observed a variety of food options listed on the menu. Based on the interviews, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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 deemed unsubstantiated. This report serves as an amendment to clarify lines number 15, 16, 17 and 18. It does not supersede the complaint investigation findings reflected in the report created on 07/08/2024. Continued LIC9099-C page 5 Continued LIC9099-C page 5 Allegation #4: Staff hit resident. The details of the complaint alleged that resident is being hit by staff. During today’s visit, the administrator (A1) stated that the staff would not hit any residents, that would result in firing the staff. LPA interviewed six staff, and (S1-S6) 6 out of 6 stated that they would not hit or mistreat any resident at the facility. Staff (S2-S3) stated that they have been hit in the face by residents, and they are now going to physical therapy. LPA interviewed eight residents, and (R1-R8) 8 out of 8 stated that they had not been physically or hit by any staff at the facility. The residents denied the allegation and stated that staff hitting the resident did not happen. Based on the interviews, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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 deemed unsubstantiated. Allegation #5: Staff are not assisting resident in the shower. The details of the complaint alleged that the staff is not assisting residents in the shower resulting in residents falling in the shower. During today’s visit, the administrator (A1) stated that the staff would assist residents in the shower because every resident in a wheelchair has a daily incontinence, and shower schedule. LPA interviewed six staff (caregivers) (S1-S6) 6 out of 6 stated that they would assist residents in the shower by bathing them. Continued LIC9099-C page 6 Continued LIC9099-C page 7 LPA interviewed eight residents, (R1-R8) and 8 out of 8 stated that the staff does help them shower. LPA interviewed R1, R1 stated that R1 had no problems with the showers. R1 noted that the staff had not let R1 fall in the shower. R1 also stated that sometimes R1 refused to shower if the assigned caregiver was not working that day because R1 likes the way R1 regular caregiver assists R1 with daily showers. All the residents denied the allegation that the staff were not assisting resident in the shower resulting in resident falling in the shower, did not happen. During the record review, no SIRs of any resident falling in the shower occurred. Based on the interviews, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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 deemed unsubstantiated. There were no deficiencies cited. Exit interview conducted. A copy of the Complaint Investigation Report LIC9099-C and LIC9099C were provided to the Administrator Susana Fuentes.the state’s words, verbatim · CDSS document, Jul 8, 2024 · control 11-AS-20240624161033

Allegation investigated: Facility staff did not treat resident with dignity

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 6/5/24. On 6/5/24 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA arrived and spoke to the Director, Susie Fuentes and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: 5/23/24 LPA toured the facility and reviewed both Staff and Residents roster and files. LPA requested and received copies of ID and Emergency Information, Physician’s Reports, Enriched Residential Care Service Need and Tier Assessment, Resident Appraisals, Dietary Instructions to Kitchen, Appraisal/Needs and Services, Community Rules, Inservice training on Residents rights, and 3/23/24 Incident Report The investigation revealed the following: Con’d on 9099-C Substantiated Allegation: Facility staff did not treat resident with dignity It is being alleged that a resident was not treated with respect and dignity by staff and that staff were very disrespectful to them and offered no assistance in their time of need. Resident stated that staff bullied them after they requested to report an incident to the police. Staff never called the police, they only reported to facility’s administrator, (S1) who could be overheard on the phone stating that, “The cops don’t care.” It was also reported that this resident requested to be moved to another facility due to safety issues as resident stated that they were referred to as a snitch. Staff were discussing the resident’s personal business amongst each other which proved that there was no confidentiality of resident issues. Record review revealed that staff received in-service training on residents’ rights on 04/20/2023 which was prior to date of incident. LPA interviewed staff S2-S8, LPA ask, does the facility staff treat residents with dignity. Of those interviewed, 7 out of 7 answered, yes. LPA interviewed residents R1 – R8, LPA ask, does facility staff treat you with dignity. Of those interviewed, 7 out of 8 answered, yes, and 1 answered no. Based on interviews, the preponderance of evidence has been met therefore the allegation is Substantiated. Deficiencies were issued for this allegation. An exit interview was conducted and plans of correction developed with the Administrator Susie Fuentes. A copy of this report and appeals rights was reviewed and left with the Business Office Manager, Christina Novoa.the state’s words, verbatim · CDSS document, Jun 5, 2024 · control 11-AS-20240418115622

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1)(3) · Plan of correction due date: Jun 19, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not as evidenced by Based on interview, facility staff did not treat resident with dignity and respect. This poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: The Director shall retrain all staff on Resident rights and to review regulation and submit a written acknowledgement that regulation is understood and provide evidence of training to CCLD via fax or email by POC due date of 6/19/24. Proof of correction can be emailed to felisa.shirley@dss.ca.gov.

Allegation investigated: Facility staff not allowing visitation. Resident has unexplained bruises.

**This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 6/5/24. On 6/5/24 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA arrived and spoke to the Director, Susie Fuentes and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 4/11/24 LPA toured the facility and reviewed both Staff and Residents files. LPA requested and reviewed copies of the following records: Staff Roster, Resident roster, Physician’s Report, Id form, Appraisal Needs and Services, Progress notes, Conservatorship documents, MAR, expired prescriptions, monthly assessments, Podiatry appointment, Resident Personal Property and valuables, IHSS documents, visitor log, and incident reports. The investigation revealed the following: Con'd 0n 9099-C Unsubstantiated Allegation: Staff is not allowing visitation It was reported that staff interferes with the resident’s visitation. Per Section XV Family Visits, in the facility’s Admission Agreement, it states that Management encourages family and friends to visit, subject to the Community Rules and Regulations. During Interviews with S1, LPA learned that visitors are not allowed in the resident’s rooms if resident has an assigned roommate. It is being reported that planned visitors are being turned away. During interview with S1, LPA Shirley learned that specific visitors can visit at the front door or on the facility’s patio. Per S2, visits are scheduled for family members but sometimes they do not show up. On prior visits to this facility, it's been LPA's experience that R1 does not like to be bothered or want to talk when they are in their room. LPA interviewed staff S1-S9, LPA ask, does this facility have anyone that is not allowed to visit. Of those interviewed, 7 out of 9 answered no. LPA interviewed residents R1 – R9, LPA Does this facility allow your visitors to visit. Of those interviewed, 9 out of 9 answered yes. 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. Con'd on 9099-C Allegation: Resident has unexplained bruises During a visit a bruise was observed on R1's wrist. On 4/11/24, LPA observed a big bluish black bruise on R-1’s left wrist. LPA ask staff what happened to R1. Staff had no idea that R1 had a bruise. LPA instructed staff to fill out and submit an incident report. LPA Shirley spoke with the Director and ask about the bruise, as it should’ve been observed and reported by staff. The Director provided progress notes stating that R-1 sometimes refuses assistance with getting dressed and showers. On 5/23/24, LPA spoke to R1 and observed that their wrist was completely healed. LPA Shirley interviewed staff -1 – Staff - 9 (S1-S9). LPA ask, does staff report bruises upon observation, and of those interviewed, 9 out of 9 answered yes. LPA Shirley interviewed residents -1- resident- 9 (R1-R9). LPA ask, have you had any bruises that you didn’t know how it happened. Out of those interviewed, 8 out of 9 answered no. 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. An exit interview was conducted and a copy of the LIC 9099 was provided to Business Office Manager, Christina Novoa.the state’s words, verbatim · CDSS document, Jun 5, 2024 · control 11-AS-20240405100037

Allegation investigated: Lack of supervision resulted in physical altercation between residents

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 5/23/24 On 5/23/24 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA arrived and spoke to the Business Office Manager, Christina Novoa and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: 4/18/24 LPA toured the facility and reviewed both Staff and Residents roster and files. The investigation revealed the following: Con’d on 9099-C Unsubstantiated Allegation: Lack of supervision resulted in physical altercation between residents It is being reported that a resident kicked another resident while in care. During interviews, LPA learned both residents moved into this facility together as a couple and resided in the same room. On 3/23/24 staff observed R1 and R6 walking down the hallway and R1 was crying. S4 start walking towards the residents to find out why R1 was crying when R6 kicked R1 twice. S4 ran to intervene and divided and redirected the two residents. S4 reported the altercation to the Med Tech on duty. On 5/23/24, LPA Shirley interviewed staff 2 through staff 8(S2-S8). S1 was not available. LPA asked staff, do you believe a lack of supervision resulted in a physical altercation between residents. Of those interviewed, 7 out of 7 answered, no. LPA Shirley interviewed resident 1 – resident 8 (R1-R8). LPA ask residents, do you believe that lack of supervision results in physical altercations between residents. Of those interviewed, 6 out of 8 answered, yes, 1 answered no, and 1 had an answer other than yes or no. 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.the state’s words, verbatim · CDSS document, May 23, 2024 · control 11-AS-20240418115622

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

Allegation investigated: Staff refused to provide resident with medications.

On 05/01/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent complaint visit at the above mentioned facility. LPA met with Office Manager Christina Novoa and explained the purpose of the visit is to interview (3) caregivers and deliver findings. LPA also met with Administrator Susie Fuentes. On 04/29/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPA met with Administrator Susie Fuentes and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA reviewed (03/30/2024) Register of Residents, (04/23/2024) Personnel Report, Centrally Stored Medication & Destruction Record File, Destruction File Binder, (9) Resident Records, (9) Staff Trainings Records, In-Service Trainings binder, Medication Transfer Sheet/Release of Responsibility template, reviewed (9) residents' medication, and interviewed 9 residents and 6 staff members which includes the Administrator, Business Office Manager, (2) MedTechs, and (2) Caregivers. Continue to LIC809-C. Substantiated Allegation(s): Staff refused to provide resident with medications. The investigation revealed the following: Regarding the allegation "Staff refused to provide resident with medications,” it is being alleged that upon R1’s departure, R1 requested for R1’s medications and the staff refused to provide blood pressure medication. LPA observed packs of R1’s blood pressure medication in the med room. Record review of the 10/12/23 physician’s report revealed that R1 is able to manage R1’s own medication. Centrally Stored Medication and Destruction Record reveals that blood pressure medication is to be taken daily. Regarding the allegation “Staff refused to provide resident with medications," based on observation and record reviews, the preponderance of evidence has been met therefore the allegation is Substantiated. Deficiencies were issued for this allegation. An exit interview was conducted and plans of correction developed with the Administrator Susie Fuentes. A copy of this report and appeals rights was reviewed and left with Office Manager Christina Novoa. The investigation revealed the following: Regarding the allegation "Staff does not treat resident with dignity and respect,” it is being alleged that R1 was not treated with respect and dignity by staff and staff are very disrespectful to residents in general. Interviews conducted indicate the following: 5 out of 9 staff members are knowledgeable with residents’ rights, 7 out of 9 staff are knowledgeable about elderly abuse(s), and 9 out of 9 staff members have not witnessed staff speak disrespectfully to residents. Resident interviews revealed: 8 out of 9 residents indicated that staff speak to them respectfully and 7 out 9 residents have not witnessed staff speak disrespectful to other residents. Record review revealed that staff received in-service training on residents’ rights on 04/20/2023. Based on the interviews and record review, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiencies cited for this allegation. An exit interview was conducted and a copy of this report was reviewed and left with Office Manager Christina Novoa.the state’s words, verbatim · CDSS document, May 1, 2024 · control 11-AS-20240419131644

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: May 3, 2024

Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This requirement was not met: Based on LPA observeation and record review, the facility did not release R1's medication upon request at discharge which poses a potential health risk to resident in care. LPA observed R1's medication in med room, blood pressure meds are to be taken daily, and R1's physcians report says R1 is able to manage R1's own medication.the state’s words, verbatim · CDSS document, May 1, 2024

Plan of correction: The Administrator will make arrangements to release medication to R1 by the POC due date. See details on LIC811. Proof of correction will be emailed to regina.cloyd@dss.ca.gov

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

Allegation investigated: Facility staff did not allow resident access to make, receive private phone calls

On 4/18/24, Licensing Program Analyst, Felisa Shirley, returned to above name facility to conclude investigation into said allegations. LPA Shirley met with Director, Susie Fuentes and explained the purpose of today's visit and was granted access. The investigation consisted of the following: On 9/1123 LPA requested received and reviewed the following: Staff and Resident rosters, facility visitor list, and facility files. LPA interviewed Administrator Susie Fuentes, S-1 and S-2 through - staff S-8 (S-2 - S-8). LPA interviewed resident R-1 through R-8. The investigation revealed the following: Cont'd on 9099-C Substantiated Allegation: Facility staff did not allow resident access to make, receive private phone calls It is being reported that resident had all forms of communication taken away. On 9/4/23 resident’s family visited the facility as they could not get through to the resident. The police were called by resident’s family in regards to missing phones and a report was filed. When police came out to investigate, the policeman gave the cell phone to resident’s family and stated it’s a crime to call the police and there’s no crime. During interviews LPA Shirley learned that resident was making prank calls to the police station and the police told the director to take the phone, and landline was unplugged as well. The police confirmed the landline phone was in the room, just not plugged in. On 9/11/23 LPA interviewed staff 1 – staff 8 (S1 – S8) asking them if any residents phone calls are being refused. Of those interviewed, 6 out of 8 answered, no. On 9/11/23 LPA Shirley interviewed residents 1 – resident 8 (R1-R8). LPA asked, do you receive calls at the front desk. Of those interviewed 3 out of 8 answered, yes. Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to the Director, Susie Fuentes.the state’s words, verbatim · CDSS document, Apr 18, 2024 · control 11-AS-20230905083922

From the deficiency page — Deficiency type: Type B · Section cited: CCR 85072(b)(9) · Plan of correction due date: May 2, 2024

85072 Personal Rights (b) The licensee shall insure that each client is accorded the following personal rights. (9) To have access to telephones in order to make and receive confidential calls, provided that such calls do not infringe upon the rights of other clients and do not restrict availability of the telephone during emergencies. Based on interview and record review administrator confiscated residents personal cellphone and unplugged residents landline in residents private room of whom requires elements of care and supervision poses an immediate Health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 18, 2024

Plan of correction: Administrator shall review the personal rights of clients and adhere to all rules and regulations for residents in care. Administrator shall return resident's personal cellphone and landline phone shall be plugged up in residents room by POC due date of 5/2/24.

Allegation investigated: Facility staff stole ID from resident Facility is not ensuring resident goes to medical appointments Facility is not administering medications as ordered by doctor Facility is not allowing resident to communicate with family members

On 4/11/24 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA arrived and spoke to the Director, Susie Fuentes and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 4/11/24 LPA toured the facility and reviewed both Staff and Residents files. LPA requested and reviewed copies of the following records: Staff Roster, Resident roster, Physician’s Report, Id form, Appraisal Needs and Services, Progress notes, Conservatorship documents, MAR, expired prescriptions, monthly assessments, Podiatry appointment, Resident Personal Property and valuables, IHSS documents, visitor log, incident reports and picture of resident. The investigation revealed the following: Con'd 0n 9099-C Unsubstantiated Allegation: Facility staff stole ID from resident It was reported that the resident’s Identification Card was stolen by the staff. During file review, LPA did not observe copies of an Identification card upon admission. LPA observed that Personal Property and Valuables page has one item recently listed but does not include an ID card. There are no incident reports reporting stolen ID’s. Staff S2 stated that R1 arrived with nothing besides the clothes they were wearing. LPA interviewed staff 1 through Staff 9, (S1-S9). LPA ask, “Did staff steal ID card from resident.” Of those interviewed, 9 out of 9 stated No. LPA interviewed resident 1 through resident 9, (R1-R9) LPA ask, Has staff stolen your ID card. Of those interviewed, 8 out of 8 answered no. 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 allegations are Unsubstantiated. Allegation: Facility is not ensuring resident goes to medical appointments It is being reported that this facility is not ensuring that resident goes to all medical appointments. On 4/11/24, upon R1’s file review, LPA Shirley observed 9 monthly 30 min assessments, a copy of a podiatry appointment which was refused by R1. On 4/11/24, LPA Shirley interviewed staff 1 through staff 9(S1-S9). LPA asked staff, is facility staff ensuring that residents go to medical appointments. Of those interviewed, 8 out of 9 answered yes. LPA Shirley interviewed resident 1 – resident 9 (R1-R9). LPA ask residents, are you allowed to see the doctor or attend medical appointments, 8 out of 9 answered, yes. 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 allegations are Unsubstantiated. Allegation: Facility is not administering medications as ordered by doctor It was reported that staff is not administering medications as instructed by doctor. During file review, LPA Shirley observed copies of the MAR for R1 which records last date of medication administered was 6/7/23. S3 stated that R1 does allow appointment for in-house doctor assessments but refuses to go to the doctor to have prescription updated and filled. R1 is out of medication as of 4/11/24. LPA interviewed staff 1 through Staff 9, (S1-S9). LPA ask, is medication being administered as ordered by the doctor. Of those interviewed, 8 out of 9 stated yes. LPA interviewed resident 1 through resident 9, (R1-R9) LPA ask, are you receiving your medications as ordered by the doctor. Of those interviewed, 6 out of 9 answered, yes. 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 allegations are Unsubstantiated. Cond'd on 9099-C Allegation: Facility is not allowing resident to communicate with family members It was reported that staff is not allowing phone calls from one specific family member. When LPA arrived at this facility, LPA Shirley observed R1 at the front desk talking on the phone. When R1 was done with their phone call, LPA approached R1 and advised them that I am here to investigate a complaint and if I could ask them a couple of questions regarding this complaint. R1 answered yes. LPA ask R1 who were they speaking to on the phone. R1 answered that they were talking to their family member that they speak to every morning. LPA interviewed staff 1 through Staff 9, (S1-S9). LPA ask, does staff not allow residents to communicate with family members. Of those interviewed, 6 out of 9 stated yes residents are allowed to communicate with family members. LPA interviewed resident 1 through resident 9, (R1-R9) LPA ask, are you allowed to communicate with your family members. Of those interviewed, 9 out of 9 answered, yes. 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 allegations are Unsubstantiated. Based on information gathered, the department did not find sufficient evidence to support these allegations, therefore these allegations are Unsubstantiated. An exit interview was conducted and a copy of the LIC 9099 was provided to Director, Susie Fuentes.the state’s words, verbatim · CDSS document, Apr 11, 2024 · control 11-AS-20240405100037

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

Allegation investigated: Illegal Eviction

On 3/25/24 Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent complaint visit. LPA met with the Director, Susie Fuentes and explained the purpose of today's visit and was granted entry. The investigation consisted of the following: On 2/7/24 LPA Shirley toured first floor of facility for resident interviews. LPA also requested and reviewed copies of the following records: Resident Roster, Staff roster, Physicians report, Id and Emergency Info, Preplacement Appraisal, Appraisal Needs and Services, LCD Pharmacy/Medication Info, MAR’s, Facility Agreement Form/5150 Hold, Initial Psychological Eval 4/30/21, Progress Note from PCP visit 1/16/24, Admission Agreement and SIR’s that involved resident. Investigation revealed the following: Con'd on 809-C Unsubstantiated Allegation: Illegal Eviction The complainant alleges that this facility is illegally evicting resident – 1 (R-1.) During Visit on 2/7/24 LPA Shirley spoke with Administrator Susie Fuentes who stated R-1 was transferred to another facility because R-1 was determined to need a higher level of. R-1 was involved in several incidents which were reported to CCLD. The last incident on 1/20/24 against a staff member resulted in R-1 being transported to the hospital and treating doctor making the determination that resident needed a more controlled environment for herself and for others. LPA Shirley interviewed staff 1-8 (S1-S8), and of those interviewed, only 2 staff knew what the grounds were for an eviction. LPA Shirley spoke with residents 2-8 (R2-R8). R1 was unavailable for interview and 5 out of 8 stated that no they had never faced an eviction. Based on information gathered, the department did not find sufficient evidence to support allegation of an "Illegal Eviction.” 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 An exit interview was conducted and a copy of the LIC 9099 was provided to Administrator, Susie Fuentes.the state’s words, verbatim · CDSS document, Mar 25, 2024 · control 11-AS-20240129123701

Type of visit: Required - 1 Year

On 3/25/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Susana Fuentes/Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (108) non-ambulatory elderly adults ages 60 and above. Today’s census is 96. The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (54) resident bedrooms. Each room has a bathroom in the unit. The facility houses an activity room, dining area, kitchen, administrative offices, outside patio with shaded area and TV room on second floor. LPA Shirley and Susie toured the physical plant. There are no bodies of water or firearms on the premises. Five (5) client rooms were checked, rooms: 9,39,44,45 and 47and call buttons. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bathrooms were found to be within Title 22 regulations and were clean and operational. A comfortable temperature is maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. The kitchen was inspected and LPA observed supplies of perishable and non-perishable food available for a minimum of one week which is stored properly. Fire extinguishers were charged, smoke detectors and carbon Monoxide were operable. LPA checked first aid kit; and found that it was compliant with a manual. The water temperature measured 105.6 F. There is a working landline phone available in the lobby for client use. Con'd on 809-C LPA reviewed P&I money for 2 of the 5 residents, P&I were intact. LPA observed that medications were safe, locked and inaccessible to clients in care. Last Disaster drill was conducted on 2/17/24. There were no deficiencies observed during today’s visit. Exit interview held and a copy of the report was provided to the Administrator, Susie Fuentes.the state’s words, verbatim · CDSS document, Mar 25, 2024

Allegation investigated: Staff did not release residen'ts personal items upon discharge

On 3/18/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced complaint visit to this facility. LPA was met by Director, Susie Fuentes, and explained the purpose of today’s visit. The investigation consisted of the following: On 3/18/24, LPA Shirley conducted interviews with the Director Susie Fuentes (S1) and Staff 2 through 7 (S2 – S7) and resident 1 through resident 9 (R1 – R9). LPA requested and reviewed copies of the following documents: Staff and Resident Rosters, resident file which contained, Resident Appraisals, Physician’s Reports, Resident Identification and Emergency Information, Appraisals Needs and Services Plan and ALW Program Individual Service Plan (ISP). LPA took pictures of contents in room 32. The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Staff did not release resident’s personal items upon discharge Resident is concerned about not being able to get their personal items back. R-1 does not know where his belongings are. On 7/19/23, LPA Felisa Shirley came to Gardena Retirement Center to take pictures of the contents in the room that was assigned to former resident and to assure that their personal belongings were still in the room that was assigned to them. LPA did take pictures and resident was informed that their items were still in the room. On 3/18/24 LPA Shirley again went to take pictures of room 32 which still contains resident’s belongings. LPA spoke with the Director who stated that R-1 can retrieve their belongings any time. R-1 called to inform the Director that his nurse Irma would be coming to get their belongings. The Director does not recall the actual date last year. The nurse never came to the facility and the Director has not received any more calls from R-1. LPA interviewed staff, staff 1 – staff 7 (S-1 – S-7). LPA asked staff, “When a resident is evicted from this facility, does staff release the resident’s personal items upon discharge?” Of those interviewed 6 out of 7 answered yes. LPA interviewed residents 1 – resident 9 (R-1 – R-9). LPA ask residents, were you ever faced with an eviction? Of those interviewed, 7 out of 9 answered, no. Based on information gathered and interviews, LPA did not find sufficient evidence to support the allegation “Staff did not release resident’s personal items upon discharge,” therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of the LIC 9099 report was provided to the Director, Susie Fuentes.the state’s words, verbatim · CDSS document, Mar 18, 2024 · control 11-AS-20240311162032

Allegation investigated: Staff left resident unattended in a wheelchair for an extended period Staff did not meet residents needs

On 1/25/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Director, Susie Fuentes, and explained the purpose of the visit is to deliver findings for the allegations mentioned above and was granted access to the facility. The investigation consisted of the following: On 11/30/23 LPA reviewed resident files and toured the facility. LPA reviewed and requested copies of the following records: Resident Roster, Staff Roster, list of residents recently hospitalized, and Resident roster from 11/29/23. LPA interviewed residents only due to time constraints. On 1/18/24, LPA interviewed staff and requested and received copies of the following records: Copy of emergency services at Antelope Valley Medical Center from 11/8/23, Records from Kaiser Permanente 11/15/23, Physician's Report, and Gardena Retirement Center Community Rules. The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Staff left resident unattended in a wheelchair for an extended period It is alleged that R-1 was left in their wheelchair unattended outside while they were smoking a cigarette. RP stated that they were on the phone with the resident and overheard staff telling resident to just roll their wheelchair down the ramp as the staff was now off of work. During interviews LPA found that residents are not in their wheelchairs all day. After meals residents are taken to the activities room and placed on the sofa for activities or to watch tv. Some go back to their rooms to go back to bed. They can go to the activity room upstairs if they choose to. If they are more independent then they do their own thing. LPA observes the residents in wheelchairs during every visit to the facility rolling going into the activity room after breakfast and placed on the sofa for activities. Resident was only at the facility for 3 days. On 11/30/23 LPA interviewed residents 2 – resident 10 (R-2 – R-10). LPA asked residents, have you ever needed help from your wheelchair and did not get it? Of those interviewed, 6 out of 9 answered, no. R-1 was not available for interview. Residents generally stated that they always get help. On 1/18/24, LPA interviewed staff, staff 1 – staff 10 (S-1 – S-10). LPA asked staff, regarding wheelchair bound residents, how long are they generally in the chair? Of those interviewed 10 out of 10 stated no they are not in their wheelchairs for extended periods of time, they are taken to activities to be placed on the sofa after meals for fall risk or returned back to their rooms. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. con'd on 9099-C Allegation: Staff did not meet residents needs It is alleged that staff did not meet residents needs. Resident wants to be able to smoke in their room and to be able to use their electric wheelchair as resident is not able to use the manual wheelchair that was provided during the time of admission. During interviews, LPA found that resident was caught smoking in their room after the resident was told numerous times that they were not allowed to smoke in the residents rooms. Resident refused to sign the Admission Agreement and did not pay the Smokers Deposit Fee $250 that is required for all resident who wish to smoke in the permitted common areas. Electric wheelchairs were not allowed at the time the resident resided at this facility per Community rules. LPA Shirley interviewed residents 2 – resident 10 (R2-R10). LPA ask, are all of your basic needs being met? Of those interviewed, 9 out of 9 answered yes. R-1 was not available for interview. LPA interviewed staff -1 – staff -10, (S1-S10). LPA ask, Is anyone/staff assigned to assist wheelchair residents with their daily needs. Of those interviewed, 10 out of 10 answered, yes everyone helps with their needs. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. An exit interview was conducted and a copy of the LIC 9099 was provided to Director Susie Fuentes.the state’s words, verbatim · CDSS document, Feb 26, 2024 · control 11-AS-20231121081626

Allegation investigated: Facility staff did not arrange for medical care as needed. Facility staff did not dispense medications as prescribed.

On 2/7/24 Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced complaint visit to the address listed above. LPA arrived and spoke to Administrator Susie Fuentes and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 2/7/24 LPA Shirley toured first floor of facility for resident interviews. LPA also requested and reviewed copies of the following records: Resident Roster, Staff roster, Physicians report, Id and Emergency Info, Preplacement Appraisal, Appraisal Needs and Services, LCD Pharmacy/Medication Info, MAR’s, Facility Agreement Form/5150 Hold, Initial Psychological Eval 4/30/21, Progress Note from PCP visit 1/16/24, Admission Agreement and SIR’s that involved resident. The investigation revealed the following: Con’d on 9099-C Unsubstantiated Allegation: Facility staff did not arrange for medical care as needed It is being reported that resident requested to be seen by a therapist. There was a new resident assigned to R-1’s room. Per RP, that is when the problems began. New roommate triggered R-1’s behaviors. R-1 would become anxious and displayed aggressive behaviors. RP stated R-1 requested to be seen by a therapist. LPA reviewed resident’s facility file and observed Initial Psychological Eval dated 4/30/21. R-1 was given numerous opportunities to be evaluated by in-house therapist. R-1 refused to be evaluated as hours were too early. R-1 was given the therapist number to call anytime to be seen. R-1 never called to schedule an appointment. On 2/7/24 LPA Shirley interviewed resident 2 – resident 8 (R-2 - R-8). LPA asked residents, do you feel that you get the medical care that you need here. Of those interviewed, 5 out of the 8 answered yes. R-1 was not available for interview. On 2/7/24 LPA Shirley interviewed staff 1-staff 8 (S-1 - S-8). LPA asked staff, do you arrange for medical care as needed. Of those interviewed, 7 out of 8 staff answered yes. Based on information gathered, the department did not find sufficient evidence to support allegations " Facility staff did not arrange for medical care as needed.” 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. Allegation: Facility staff did not dispense medications as prescribed It is being reported that every time R-1 request anxiety medications the staff would put her off. During file review, LPA reviewed Medication Information from LCD Pharmacy prescribing anxiety medications from Dr. Pantea Farhadi, Psychiatrist. LPA called doctor to verify services for R-1. LPA was told by Dr. Pantea Farhadi that R-1 is seen monthly. LPA also reviewed the MAR for R-1 and observed that resident did not miss a dose of medication up until their last day at the facility on 1/22/24. The days following last day at facility, the MAR is initialed “H” for hospital. LPA was told by S-1 and S-3 that R-1 would arrive early for medication to be dispensed and R-1 was told to return at a specific time to be given medication as per prescribed time. On 2/7/24 LPA Shirley interviewed resident 2 – resident 8 (R-2 - R-8). LPA asked residents, when you request prescribed medication from the staff do you usually get what you need. Of those interviewed, 6 out of the 8 answered yes. R-1 was not available for interview. On 2/7/24 LPA Shirley interviewed staff 1-staff 8 (S-1 - S-8). LPA asked staff, when a resident request prescribed medication, does the resident get the medication. Of those interviewed, 4 out of 8 staff answered yes, if prescribed. Two answered they would tell the med techs as they are caregivers and two did not know. Based on information gathered, the department did not find sufficient evidence to support allegations " Facility staff did not arrange for medical care as needed.” 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 An exit interview was conducted and a copy of the LIC 9099 was provided to Director Susie Fuentes.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 11-AS-20240129123701

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

Allegation investigated: Staff withheld resident's personal mobility device

On 1/18/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Director, Susie Fuentes, and explained the purpose of the visit is to deliver findings for the allegations mentioned above and was granted access to the facility. The investigation consisted of the following: On 12/20/23 LPA reviewed resident files and toured the facility. LPA reviewed and requested copies of the following records: Resident Roster, Staff Roster, and resident files. LPA interviewed residents only due to time constraints. On 1/11/24, LPA interviewed staff and requested the copy of note from doctor stating that R-1 is restricted from leaving the facility. The investigation revealed the following: Con'd on 9099-C Substantiated Allegation: Staff withheld resident's personal mobility device It is being reported that resident is not allowed to use their personal mobility device. On 1/18/24, LPA Shirley reviewed facility file for Gardena Retirement Center. During file review, LPA reviewed program plan for this facility. LPA observed that the Community Rules were not apart of the program plan received by Community Care Licensing Division and therefore not approved. Community Rules stated, “Motorized scooters, wheelchairs, etc are not permitted for use in the facility for safety purposes. On 12/20/23, LPA Shirley interviewed resident 1 – resident 8 (R1-R8). LPA asked if resident has a wheelchair? Of those interviewed, 6 out of 8 did not have a wheelchair. On 1/11/24, LPA Shirley interviewed staff 1 - staff 8(S1-S8). LPA asked staff, does staff confiscate resident’s personal electrical wheelchairs? Of those interviewed, 5 out of 8 staff answered, they’re not allowed. Based on information gathered, the department did find sufficient evidence to support allegation, Staff withheld resident's personal mobility device. Based on interviews conducted and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to the Director, Susie Fuentes.the state’s words, verbatim · CDSS document, Jan 18, 2024 · control 11-AS-20231215151234

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80072(a)(2) · Plan of correction due date: Feb 1, 2024

80072 Personal Rights (a) each client shall have personal rights which include, but are not limited to the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not being met by: Based on interview and record review administrator did not allow R1 to ulilize their mobility device which poses a potential Health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 18, 2024

Plan of correction: Administrator will amend Community Rules and Submit to Community Care Licensing Division for approval via fax or email by POC due date.

Allegation investigated: Staff do not allow resident in care to leave the facility Staff did not ensure resident in care attended his medical appointments Residents in care are not provided adequate meals Resident's room is in disrepair Staff mismanaged resident's funds

On 1/11/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Director, Susie Fuentes, and explained the purpose of the visit is to deliver findings for the allegations mentioned above and was granted access to the facility. The investigation consisted of the following: On 12/20/23 LPA reviewed resident files and toured the facility. LPA reviewed and requested copies of the following records: Resident Roster, Staff Roster, and resident files. LPA interviewed residents only due to time constraints. On 1/11/24, LPA requested the copy of note from doctor stating that R-1 is restricted from leaving the facility. The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Staff do not allow resident in care to leave the facility It is alleged that R-1 is not being allowed to leave the facility with or without assistance. On 12/20/23 LPA Shirley reviewed resident files. Based on records review, LPA observed physician’s report stating R-1 is not able to leave the facility unassisted. LPA observed ANS’s stating, unable to leave facility unassisted due to physical limitations. There is an incident report dated 3/9/23 and photo submitted to the department indicating that R-1 left the facility and was found inebriated and retrieved back to the facility. On 12/20/23 LPA interviewed residents 1 – resident 8 (R-1 – R-8). LPA asked residents, when you request to leave the facility are you allowed to leave? Of those interviewed, 6 out of 8 answered, yes. On 1/11/24, LPA interviewed staff, staff 1 – staff 7 (S-8 – S-8). LPA asked if staff, are the residents allowed to leave this facility? Of those interviewed 8 out of 8 stated yes, if there are no restrictions on file. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Staff did not ensure resident in care attended his medical appointments It is alleged that staff did not ensure resident in care attended their medical appointments. During interviews LPA Shirley learned that all medical appointments for resident are in house with his treating doctor. Resident is assisted to medical office by facility staff. During file review, LPA observed the last date of medical exam by house doctor was on 12/3/23. Last date of catheter cleaning on 12/3/23. LPA Shirley interviewed residents 1 – resident 8 (R1-R8). LPA ask, when you have medical or dental appointments does facility staff arrange for transportation? Of those interviewed, 4 out of 8 answered yes and 2 out of 8 answered no they have other means of transportation. LPA interviewed staff -1 – staff -8, (S1-S8). LPA ask, what is office policy for allowing residents to go to medical and/or dental appointments. Of those interviewed, 8 out of 8 answered yes they are permitted to go to appointments if their physician’s report allows them to leave. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Con'd on 9099-C Allegation: Residents in care are not provided adequate meals It is alleged that residents are not provided adequate meals. Resident sometimes wants larger portions or seconds. On 1/11/24, LPA reviewed weekly menus and found the selections to be quite nutritious and well balanced. During interviews, LPA found that average sized portions are given per meal. Seconds are given to residents if food is available after the meal is served. LPA Shirley interviewed residents 1 – resident 8 (R1-R8). LPA ask, are the meals here adequate? Of those interviewed, 7 out of 8 answered yes, they are adequate. They feel the meals are fine. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Resident’s room is in disrepair Reporting party is alleging that his room is in disrepair. R1 reports that the roof is leaking, broken cabinets and that staff has not fixed the issues. LPA toured, inspected and took pictures of the room. LPA found the roof to be repaired and painted over. Cabinets repaired. The building is old and issues are basic wear and tear. Per staff, all rooms are cleaned daily by staff. On 12/20/23 LPA interviewed residents 1 – resident 8 (R-1 – R-8). LPA asked residents, what is the condition of your room? Is your room in disrepair. Of those interviewed, 5 out of 8 answered, no. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. Allegation: Staff mismanaged resident’s funds It is being reported that resident has not received any money from facility staff. Reporting that they receive a specific amount of money per month but has not received anything from the administrators. On 12/20/23, during file review, LPA reviewed personal funds history. All deposits are credited and several withdrawals were observed. Residents are allowed to request money from their accounts. During file review, LPA learned that this resident was irresponsible with money per a documented incident on 3/9/23. On 12/20/23 this resident requested a large amount of money that resident could not justify what money was for. LPA requested to the director and made sure resident received some cash before the Christmas holiday as resident reported that they had no cash on hand. Based on information gathered, there is no sufficient evidence to corroborate the above allegation. An exit interview was conducted and a copy of the LIC 9099 was provided to Director Susie Fuentes.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 11-AS-20231215151234

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

Type of visit: Case Management - Incident

On 12/6/23 LPA Felisa Shirley conducted an unannounced visit regarding incident reports received 12/5/23. LPA met with Susie Fuentes and explained the purpose of today’s visit and was granted entry. Incident reports received 12/5/23 regarding excessive drinking by residents. Resident, (R-1) was made to sit outside until sober, and another resident, (R-2) room was checked for alcohol and confined to their room, which are violations of personal rights. Deficiencies cited under California Code of Regulations, Title 22, Division 6, and Chapter 1 & 6 are being cited on the attached LIC 809-D. An exit interview was conducted and LPA Felisa Shirley printed and left a copy for Susie Fuentes, Administrator.the state’s words, verbatim · CDSS document, Dec 6, 2023

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87468.1(a)(3) · Plan of correction due date: Dec 20, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: 3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not being met by: This requirement is not met as evidence by: Based on interview and record review administrator made resident sit outside until sober and confining a resident to their room who require elements of care and supervision poses an immediate Health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Dec 6, 2023

Plan of correction: Administrator shall review the personal rights of clients and adhere to all rules and regulations for residents in care

Allegation investigated: Due to lack of supervision, resident got into a physical altercation with another resident

On 10/30/23 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA spoke to Administrator Susie Fuentes and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 10/30/23 LPA reviewed Resident files and interviewed both facility staff and residents. LPA reviewed and requested copies of the following records: Client Roster, Staff roster, facility files and incident report dated 10/4/23. Continued on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Due to lack of supervision, resident got into a physical altercation with another resident. On 10/30/23, LPA spoke with Administrator at 10:30am she stated on 10/4/23 at 5am there was an altercation happen between two parties and the police department was called. On 10/30/23 at 10:30 am , LPA Shirley interviewed resident 1 – resident 10 (R-1 - R-10). LPA asked, “Have you ever gotten into a physical altercation with another resident”. of those interviewed, nine out of ten residents interviewed replied in the negative. LPA asked residents had you ever had a situation/altercation and staff was not available to assist you. Of those interviewed, nine out of ten answered no, there has never been a situation/altercation that staff was not there to assist them. On 10/30/23, at 12:00pm LPA Shirley interviewed staff 1 – staff 9 (S-1 - S-9). LPA asked if there had been any physical altercations with resident against another resident. Based on interviews 3 out of 9 staff interviewed stated that yes there was an incident that occurred on 10/4/23 with two residents that was reported to the administrator. On 10/30/23, at 11:15am LPA reviewed facility files. During file review, LPA found that resident visited Gardena Memorial on 10/4/23 and 10/5/23 for upper extremity pain. LPA also observed unusual incident/injury report and SOC 341 dated the same date as the incident that was reported by resident. Based on interviews and information gathered, this incident happened on 10/4/23 at around 5am, S-5 heard the commotion and intervened in the situation between the two residents and contacted Administrator. One resident elected to be taken to the hospital, the other resident chose to be patched up by ambulance but later called 911 to be transported to Gardena Memorial Hospital. Based on interviews conducted and records reviewed there is insufficient evidence to support the allegation: Due to lack of supervision, resident got into a physical altercation with another resident. 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 are Unsubstantiated. Exit interview was conducted and a copy of this report was provided to the Administrator Susie Fuentes.the state’s words, verbatim · CDSS document, Oct 30, 2023 · control 11-AS-20231024100408

Allegation investigated: Facility staff dispensed medications not prescribed to resident Facility staff did not allow resident to have private visits with family Facility staff did not allow resident to keep their own personal possessions

This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 9/29/23. On 9/29/23, Licensing Program Analyst, Felisa Shirley, returned to above name facility to conclude investigation into said allegations. LPA Shirley met with Business Office Manager, Christina Novoa and explained the purpose of today's visit and was granted access. The investigation consisted of the following: On 9/1123 LPA requested received and reviewed the following: Staff and Resident rosters, facility visitor list, and facility files. LPA interviewed Administrator Susie Fuentes, S-1 and S-2 through - staff S-8 (S-2 - S-8). LPA interviewed resident R-1 through R-8. The investigation revealed the following: Cont'd on 9099-C Unsubstantiated Allegation: Facility staff dispensed medications not prescribed to resident On 9/11/2023 LPA Shirley reviewed facility files. During file review, LPA reviewed resident’s medication records and actual medication and did not find any discrepancies. All required medications on the list are accounted for as given as prescribed. On 9/11/23 LPA Shirley interviewed residents 1 – resident 8 (R1-R8). LPA asked have you ever been given the wrong medication and all eight clients interviewed stated that they have not to their knowledge. On 9/11/23 LPA Shirley interviewed staff 1 - staff 8 (S1-S8). LPA asked staff if any resident reported that they received the wrong medication and all staff interviewed stated that no resident had reported to them that they received the wrong medication. Based on interviews and records review there is insufficient evidence to support the allegation: Facility staff dispensed medications not prescribed to resident. 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 allegations are Unsubstantiated. Allegation: Facility staff did not allow resident to have private visits with family On 9/11/23 LPA reviewed facility visitors list. During review, LPA noted that between the periods of 10/11/22 and 9/11/23, resident’s daughters visited over 30 times. This number does not include the number of visits from, “family” written on visitors list. On 9/4/23, Labor Day, S1 stated that the facility had an outbreak of covid-19 and visitors were given a choice to visit or not but must wear PPE. Cont'd On 9/11/23 LPA interviewed residents 1- resident 8 (R1 – R8). LPA asked residents has any of your visits been refused and all eight residents interviewed stated that their visits have not been refused. On 9/11/23 LPA Shirley interviewed staff 1 – staff 8 (S1 – S8). LPA asked staff if any one’s visits were being refused and all staff interviewed stated that no resident has had any visits denied. Based on interviews and records review there is insufficient evidence to support the allegation: Facility staff did not allow resident to have private visits with family. 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 allegations are Unsubstantiated. Allegation: Facility staff did not allow resident to keep their own personal possessions On 9/11/23 LPA interviewed the Director asking them if any personal possessions are being locked up in their office. The Director stated that the police called and said to take the residents personal phone because resident was making numerous calls to the police department. On 9/4/23, a family member called the police from the facility, police came out to investigate and gave the phone to the family member and verified that resident’s landline was in their room just unplugged. The Director gave the phone to the policeman. This facility has no knowledge regarding any missing items/possessions for this resident. Based on interviews and records review there is insufficient evidence to support the allegation: Facility staff did not allow resident to keep their own personal possessions. 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. An exit interview was conducted and a copy of the LIC 9099 and appeal rights forms were provided to the Director, Susie Fuentes. Page left blank as document was amended.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 11-AS-20230905083922

Allegation investigated: Staff are not assisting resident

Document is being revised but does not change the findings. On 09/29/23, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Christina Novoa, Business Office Manager, and explained the purpose of the visit is to deliver findings for the allegations mentioned above and was granted access to the facility. The investigation consisted of the following: On 9/11/23 LPA conducted interviews with the Administrator, Susana Fuentes (S1) and staff 2- Staff 8 (S2-S8) and resident 1 - resident 8 (R1 – R8.) LPA requested and obtained copies of the following documents: Staff and Resident rosters, facility visitor list, facility shower schedule, and facility files. The investigation revealed the following: Cont'd on 9099-C Unsubstantiated Regarding allegation: Staff is not assisting residents. It is being reported that staff is not assisting this resident. During file review, interviews and observations, resident is registered in the Assisted Living Waiver program and receives assistance with all ADL’s. Resident has excessive behaviors and there is currently no formal written plan in place. The current plan is redirecting residents behavior. There is no written assessment from treating doctor but family is aware of behaviors and have been in communication with staff from the facility. LPA spoke with family and LPA interviewed staff-1 to staff-8 (S1-S8). LPA asked, when a resident needs assistance as far as necessities, or help, what is the process? Of those interviewed, 7 out of 8 answered, to tell family if supplies are needed. If family is not involved, the administrator/facility provides supplies. All staff deny not helping residents when needed. LPA interviewed resident -1 – resident -8, (R-1 – R-8). LPA asked, when you ask staff for assistance, do you get the help that you need. Of those interviewed, 5 out of 5 answered yes. Based on interviews and file review there is insufficient evidence to support the allegation: Staff is not assisting residents. 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 allegations are Unsubstantiated. No deficiencies were cited during the visit.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 11-AS-20230905152123