Garfield Terrace

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced annual visit today. LPA met with Rosalie Sandoval, Administrator, and the reason for the visit was explained. The facility is licensed to serve 60 non-ambulatory residents age 60 and over with an approved Hospice waiver for (5) residents. The facility is in a residential area of Pasadena. The building consists of 40 resident rooms with shared bathrooms, kitchenette/staff break room, dining/activity room, medication room, main office, off-site kitchen, (2) TV rooms, laundry room, (3) common area bathrooms/showers and courtyard with a designated smoking area. LPA inspected (5) resident rooms at random. Resident rooms have the required furniture and sufficient lighting. Bathrooms were observed clean and water measured between 111.5 - 113.4 degrees F which is within compliance range. Common area showers have safety grab bars and anti-slip surfaces. Bathing equipment was also observed to be in good repair. The facility has sufficient 2-day perishable and 7-day non-perishable food supply. Food preparation areas are kept clean and food is properly stored. Facility's courtyard has a shaded area and patio furniture is in good repair. Sufficient seating is available and smoking area is kept clean. Gardens are well maintained and walkways, passages and ramps are free of debris and obstruction. Five (5) client and (5) staff files were reviewed. Files contained all documents required to maintain regulatory compliance. Medication is kept centrally stored and inaccessible to residents in care. Medication for (5) residents was inspected. Medication was observed to be administered according to physician orders and documented accordingly. ***Continues on LIC 809-C*** The facility is equipped with (6) fire extinguishers which were last inspected on 7/8/2026. Carbon monoxide detectors were tested and found to be working properly. Facility's sprinkler system is tested yearly by the Pasadena Fire Department. Last inspection was conducted on 8/13/2025. Facility conducts monthly fire/safety drills with staff and resident participation. Last drill as conducted on 6/25/2026. No deficiencies noted during today's visit. Exit interview was conducted with Rosalie Sandoval, Administrator, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2026

Allegation investigated: Staff did not ensure that the facility is kept free of bed bugs. Staff did not provide shower assistance to resident in care. Staff left resident in care in a soiled diaper for an extended period of time. Staff did not provide feeding assistance to resident in care in a timely manner. Staff did not safeguard resident's personal items. Staff enter residents' room without permission.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit to deliver a superseded report. The reason for the visit was to add the allegation “Staff enter residents' room without permission.” On 03/03/3036, LPA Kimberly Ramirez conducted an unannounced subsequent complaint investigation and delivered findings. On 11/18/2025, LPA Ramirez conducted an initial complaint investigation visit and a need further investigation was documented. During today’s visit, LPA Ramirez was greeted by Administrator Rosalie Sandoval and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster (LIC 500), Staff#1-4 (R1-R4) interviews, Resident#1-11 (R1-R11) interviews, copy of pest control service agreement and technician notes, copies of R5's: physician's report, Appraisal/Needs and services plan, client/resident personal property and valuables log (LIC 621), copies of R2's : Hospice care plan, physician's report, Appraisal/Needs and services plan, copy of R6's physician's report, copy of facility Resident Theft and loss record, copy of facility plan of operation, and physical plant tour.SEE 9099-C Unsubstantiated The investigation revealed the following: regarding the allegation “Staff did not ensure that the facility is kept free of bed bugs.” It is alleged the facility is not kept free from bed bugs. Two (2) out of the eleven (11) residents interviewed corroborated this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. During record review, LPA observed a pest control service agreement effective from 10/21/2025 through 10/21/2026. This agreement revealed that pest control services will be provided once a month. Service report dated 11/2025, and 12/2025 revealed that no live insects were witnessed in any rooms during treatment. On 11/18/2025, LPA Ramirez inspected eight (8) resident rooms at random and did not observe insects in these rooms. 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. “Staff did not provide shower assistance to resident in care.” It is alleged the staff are providing R6 with shower assistance. Eleven (11) out of the eleven (11) residents interviewed denied this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. Interview with R6 revealed that staff does assist them with bathing at R6’s request and when R6 chooses to bathe. Staff interviews revealed that all residents have a shower schedule and staff maintain a shower log. Staff revealed that whenever a resident refuses to shower, staff will document the refusal and try at a later time to encourage the resident to shower. 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. “Staff left resident in care in a soiled diaper for an extended period of time.” It is alleged that staff left a resident soiled in a diaper for an extended period of time. Three (3) out of eleven (11) residents interviewed corroborated this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. During resident interviews, LPA observed residents to be groomed and did not observe residents to be malodorous. During resident rooms tour, LPA observed unsoiled disposable underpads on top of resident mattresses for residents with incontinence care. LPA observed extra adult diaper supply in staff office. 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. SEE 9099-C “Staff did not provide feeding assistance to resident in care in a timely manner.” It is alleged that staff do not provide R2 with feeding assistance. Eleven (11) out of eleven (11) residents interviewed denied this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. Interview with R2 revealed that staff do provide them with feeding assistance. Review of R2’s physician report revealed that R2 is able to self-feed themself. 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. “Staff did not safeguard resident's personal items.” It is alleged that staff did not safeguard R5’s personal belongings. One (1) out of eleven (11) residents interviewed corroborated this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. Interview with R5 revealed that several articles of clothing and food items went missing. R5 revealed they told staff about the missing clothing and food, but staff did nothing to locate the items. Staff interviews revealed that R5 has a history of storing expired fresh food items in their room which causes insects and odors in R5’s room. Staff interviews and records reviewed revealed that on 01/13/2023, R5 and the facility signed an agreement in which R5 agreed to allow staff to enter R5’s rooms to discard rotted food. Staff interviews revealed that they have never discarded R5’s clothing or any valuables. LPA observed documentation dated 10/27/2025, which revealed staff threw away rotted cheese in R5’s room. Review of R5’s client/resident personal property and valuables log (LIC 621) revealed several personal belongings of R5’s logged with dates from 2018 through 2024. 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. “Staff enter residents' room without permission.” Seven (7) out of eleven (11) residents interviewed denied this allegation. Residents#2, 5, 6 and 7 (R2, R5, R6, R7) were unavailable to be interviewed during LPA’s visit. Four (4) out of the four (4) staff interviewed denied this allegation. Staff interviews revealed that staff always knock before entering any resident rooms. During facility tour, LPA observed several resident doors to be wide open and LPA observed facility staff announcing their presence at the foot of the door, before being allowed entry by 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 allegation is UNSUBSTANTIATED. No deficiencies were cited. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, May 8, 2026 · control 28-AS-20251114145415

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Mayra Cota, conducted a Case Management (CM) – Deficiencies visit today. LPA met with Rosalie Sandoval, Director and the reason for this CM visit was explained. On 2/17/2026, LPA Cota attempted to review records for Resident 1 (R1) for complaint investigation #28-AS-20260212100512; however, staff were unable to provide LPA with Medication Sheets prior to January 2026 and PRN Medication Logs prior to 10/8/2024, even though R1 had been living in the facility since 10/11/2018. Interview with S2 and S3 indicated that as of 2/2/2026 R1 is no longer living in the facility but could not locate R1’s Medication Sheets and PRN Medication Logs. The fore mentioned documents were not readily available for review during the visit. Citation is issued for CCR Section 87506(a) Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. During today’s visit, a citation was issued. A copy of this report, LIC 809-D and Appeal Rights was issued. Exit interview conducted with Rosalie Sandoval, Director.the state’s words, verbatim · CDSS document, May 4, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: May 26, 2026

87506(a) Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: During LPA's visit, staff were unable to provide LPA with R1's Medication Sheets prior to January 2026 and PRN Medication Log prior to 10/8/2024, even though R1 had been living in the facility since 10/11/2018. R1's documents were not readily available for review during visit.the state’s words, verbatim · CDSS document, May 4, 2026

Plan of correction: Citation was previously cleared on 2/12/2026. Director provided LPA with copies of In-Service Training regarding: Safe Medication Management and Documentation conducted and sign-in sheet for staff attendance.

Allegation investigated: Staff did not dispense medications as prescribed.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced subsequent complaint visit to deliver findings regarding the above-mentioned allegation. LPA met with Rosalie Sandoval, Director and the reason for the visit was explained. On 2/17/2026, LPA Cota visited the facility to initiate the investigation and conducted the following: LPA obtained copies of staff and resident rosters, toured the common areas of the facility with a focus on inspecting the medication room, reviewed medication for (7) residents, and obtained copies of January 2026 Medication Sheet for Resident 1 (R1), and February 2026 Medication Sheets for Resident 4 – Resident 6 (R4-R6). Interviews were also conducted with Staff 1 – Staff 4 (S1-S4). During today’s visit, LPA Cota conducted interviews with Resident 2 – Resident 7 (R2-R7) and interviewed Staff 5 (S5) during the span of the investigation. LPA attempted to conduct interviews with Resident 1 (R1); however, R1 did not return calls from LPA after leaving messages at the day program R1 attends and the facility they currently reside in. Substantiated The investigation revealed the following: Regarding: Staff did not dispense medications as prescribed. It is alleged that the facility is not properly administering medication to resident during the 4:00 p.m. and 7:00 p.m. shifts by missing doses for days in a row. Interviews with S1-S5 indicated that medication is dispensed as prescribed to residents in care. Interviews with S1 and S5 revealed that physician orders are followed to properly administer medication to residents; however, medication for R1 had not been administered as prescribed due to R1 seeming intoxicated particularly during the P.M. medication pass. S5, who works during the P.M. shift, indicated that S5 had not been giving R1 their medication which was scheduled to be given to R1 with dinner which takes place around 4:30 p.m. S5 stated that S5 did not give R1 their medication because R1 would be observed drinking alcohol down the street outside of the building and R1 seemed intoxicated when returning to the facility. S5 further indicated that the medication which was not given to R1 was the P.M. set. S5 stated that they could not recall how long R1 has gone without their P.M medication, but although it wasn’t a daily occurrence, it was missed several times a week for the past few months (exact dates could not be recalled by S5). Interview with S1 revealed that S5 acknowledged not dispensing R1’s mediation as prescribed due to R1 “being drunk.” During record review, the facility could not provide LPA with missed medication documentation, contact with physician regarding R1 missing doses or new physician orders indicating changes to current medication or discontinue orders for R1. Review of R1’s January 2026 medication sheet revealed that R1 should have been receiving (5) mediations which include medication to manage their glucose level and control their blood pressure. LPA reviewed medication for (7) residents and observed that R4 has a NovoLog Flex Pen (insulin injection)/100 units Sub-Q to be administered before meals and at bedtime per sliding scale received by the facility from the pharmacy on 1/30/2026. Review of R4’s medication revealed that R4’s insulin injections have not been dispensed to R4 by staff. LPA observed that the box in which the injection pen was sent out by the pharmacy was sealed and unused. Interview with S2 indicated that R4 has not received any injections from this prescribed pen since it was sent out by the pharmacy on 1/30/2026. S1 and S3 further indicated that R4’s insulin injections are to be administered on a “sliding scale” which means R4’s glucose level must be measured before their meals to determine if insulin is needed. However, the facility could not provide the Daily Blood Sugar Readings log for R4 which the facility uses to track resident's blood sugar checks and the levels before administering insulin. ***Continues on LIC 9099-C Interviews with (7) out (8) residents indicated that their medication is dispensed as prescribed and have no concerns with their medication needs. Interviews with staff, observations and record review corroborate the allegation that staff did not dispense medications are prescribed. The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided. Exit interview was conducted with Rosalie Sandova, Director, and a copy of this report, LIC 9099D and Appeal Rights was provided.the state’s words, verbatim · CDSS document, Mar 23, 2026 · control 28-AS-20260212100512

From the deficiency page — Deficiency type: Type A · Section cited: CCR 874659(a)(4) · Plan of correction due date: Mar 23, 2026

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: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Per interviews with S1 and S5, R1 did not receive their P.M. medication as prescribed several time a week. Review of records and medication by LPA found that R4 has not received their insulin injections as prescribed and facility could not provide the Daily Blood Sugar Readings log for R4 which the facility uses to track resident's blood sugar checks and levels before administering insulin.the state’s words, verbatim · CDSS document, Mar 23, 2026

Plan of correction: Citation cleared during today's visit. Director provided LPA with copies of In-Service Training regarding: Safe Medication Management and Documentation conducted on 2/12/2026 and sign-in sheet for staff attendance.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Mayra Cota, conducted a Case Management (CM) – Deficiencies visit during delivery of findings for a complaint investigation today. LPA met with Rosalie Sandoval, Director and the reason for this CM visit was explained. During review for Resident 1’s (R1’s), medication documentation on 2/17/2026, staff were unable to provide LPA with Medication Sheets prior to January 2026 and PRN Medication Log prior to 10/8/2024, even though R1 had been living in the facility since 10/11/2018. Interview with S2 and S3 indicated that R1 is no longer living in the facility as of 2/2/2026 but could not locate R1’s medication records. During today’s visit, a deficiency was noted and a citation was issued. A copy of this report, LIC 809-D and Appeal Rights was issued. Exit interview conducted with Rosalie Sandoval, Director.the state’s words, verbatim · CDSS document, Mar 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(3) · Plan of correction due date: Mar 23, 2026

Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by: staff were unable to provide LPA with Medication Sheets prior to January 2026 and PRN Medication Log prior to 10/8/2024, even though R1 had been living in the facility since 10/11/2018. Staff were unable to locate R1's medication records.the state’s words, verbatim · CDSS document, Mar 23, 2026

Plan of correction: Citation claered during today's visit. Director provided LPA with copies of In-Service Training regarding: Safe Medication Management and Documentation conducted on 2/12/2026 and sign-in sheet for staff attendance.

Allegation investigated: Staff did not ensure that the facility is kept free of bed bugs. Staff did not provide shower assistance to resident in care. Staff left resident in care in a soiled diaper for an extended period of time. Staff did not provide feeding assistance to resident in care in a timely manner. Staff did not safeguard resident's personal items.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 03/03/2026 regarding the above allegations. On 11/18/2025, LPA Ramirez conducted an initial complaint investigation visit and a need further investigation was documented. During today’s visit LPA Ramirez was greeted by Administrator Rosalie Sandoval and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster (LIC 500), Staff#1-4 (R1-R4) interviews, Resident#1-8 (R1-R8) interviews, copy of pest control service agreement and technician notes, copies of R5's: physician's report, Appraisal/Needs and services plan, client/resident personal property and valuables log (LIC 621), copies of R2's : Hospice care plan, physician's report, Appraisal/Needs and services plan, copy of R6's physician's report, copy of facility Resident Theft and loss record, copy of facility plan of operation, and physical plant tour. SEE 9099-C Unsubstantiated The investigation revealed the following: regarding the allegation “Staff did not ensure that the facility is kept free of bed bugs.” It is alleged the facility is not kept free from bed bugs. Two (2) out of the eight (8) residents interviewed corroborated this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. During record review, LPA observed a pest control service agreement effective from 10/21/2025 through 10/21/2026. This agreement revealed that pest control services will be provided once a month. Service report dated 11/2025, and 12/2025 revealed that no live insects were witnessed in any rooms during treatment. On 11/18/2025, LPA Ramirez inspected eight (8) resident rooms at random and did not observe insects in these rooms. 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. “Staff did not provide shower assistance to resident in care.” It is alleged the staff are providing R6 with shower assistance. Eight (8) out of the eight (8) residents interviewed denied this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. Interview with R6 revealed that staff does assist them with bathing at R6’s request and when R6 chooses to bathe. Staff interviews revealed that all residents have a shower schedule and staff maintain a shower log. Staff revealed that whenever a resident refuses to shower, staff will document the refusal and try at a later time to encourage the resident to shower. 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. “Staff left resident in care in a soiled diaper for an extended period of time.” It is alleged that staff left a resident soiled in a diaper for an extended period of time. Three (3) out of eight (8) residents interviewed corroborated this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. During resident interviews, LPA observed residents to be groomed and did not observe residents to be malodorous. During resident rooms tour, LPA observed unsoiled disposable underpads on top of resident mattresses for residents with incontinence care. LPA observed extra adult diaper supply in staff office. 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. SEE 9099-C “Staff did not provide feeding assistance to resident in care in a timely manner.” It is alleged that staff do not provide R2 with feeding assistance. Eight (8) out of eight (8) residents interviewed denied this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. Interview with R2 revealed that staff do provide them with feeding assistance. Review of R2’s physician report revealed that R2 is able to self-feed themself. 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. “Staff did not safeguard resident's personal items.” It is alleged that staff did not safeguard R5’s personal belongings. One (1) out of eight (8) residents interviewed corroborated this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. Interview with R5 revealed that several articles of clothing and food items went missing. R5 revealed they told staff about the missing clothing and food, but staff did nothing to locate the items. Staff interviews revealed that R5 has a history of storing expired fresh food items in their room which causes insects and odors in R5’s room. Staff interviews and records reviewed revealed that on 01/13/2023, R5 and the facility signed an agreement in which R5 agreed to allow staff to enter R5’s rooms to discard rotted food. Staff interviews revealed that they have never discarded R5’s clothing or any valuables. LPA observed documentation dated 10/27/2025, which revealed staff threw away rotted cheese in R5’s room. Review of R5’s client/resident personal property and valuables log (LIC 621) revealed several personal belongings of R5’s logged with dates from 2018 through 2024. 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. No deficiencies were cited. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 3, 2026 · control 28-AS-20251114145415

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA), Mayra Cota, conducted a Case Management (CM) – Deficiencies visit during a complaint investigation conducted today. LPA met with Rosalie Sandoval, Director and the reason for this CM visit was explained. During today’s visit, LPA conducted an audit of Resident 5 and Resident 6 (R5 and R6) routine and PRN medication and observed expired bubble packs as follows: R4 current medication: Acetaminophen 325 mg. tablets to be taken every (4) hours or as needed expired on 10/14/2025. Guaifenesin-DM100-10 mg to be taken every (6) hours or as needed expired on 11/22/2025. R5 current medication: Ibuprofen 400 mg tablets to be taken every (8) hours or as needed expired on 12/27/2025. Acetaminophen 325 mg tablets (2) tablets to be taken (=650 mg) every (4) hours or as needed expired on 12/27/2025. Lorazepam 1 mg tablet to be taken twice a day or as needed expired on 12/14/2025. During today’s visit, a deficiency was noted and a citation was issued. A copy of this report, LIC 809-D and Appeal Rights was issued. Exit interview conducted with Rosalie Sandoval, Director.the state’s words, verbatim · CDSS document, Feb 17, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Feb 17, 2026

Incidental Medical and Dental Care (i)Prescription medications which are... not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed... shall be destroyed in the facility by the facility administrator and one other adult who is not a resident... This requirement is not met as evidence by: Based on observation licensee did not ensure that expired medication for R5 and R6 was properly destroyed, which poses a potential risk to the persons health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Feb 17, 2026

Plan of correction: Licensee has cleared the citation during today's visit. Director provided Medication Distuction Records for R5 and R6 expired medication, Discontinued Medication documents and Discontinue Orders from physician for R5 and R6. Director provided proof of pharmacy medication expiration pick up to be conducted during their quarterly collection. Licensee has locked up expired medication in a separate cabinet pending pick up by pharmacy.

Allegation investigated: Staff do not ensure that resident has clean bedding

***This report supersedes report dated 11/22/2025. The purpose of this report is to correct the citation that was issued 11/22/2025 from 87303(3)(C) to 87307 (a)(3)(C) all other findings remain the same. *** Licensing Program Analyst met with Rosalie Sandoval and explained the purpose of this visit. Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Residential Aide Andrea Flores who assisted with today’s visit. The investigation consisted of the following: During the initial visit conducted on 11/06/2025, LPA obtained copies of the following documents: Staff roster, resident roster, and conducted a room check for R1.On 11/18/2025, LPA’s Gutierrez and Castro interviewed Administrator, staff 1- staff 5 (S1-S5) resident 1 (R1) by telephone, residents 2-residents 7 (R2-R7) and room checks. LPA obtained copies of the following documents: R1’s physicians reports, identification information (LIC 601), appraisal needs and service, facility resident council meeting notes, Orkin Pest Control, and Squash Pest Control invoices. During today’s visit LPA Gutierrez delivered findings. Substantiated In regard to the allegation” Staff do not ensure that resident has clean bedding”, It is alleged that R1’s bedding had urine on it and staff refused to change bedding. During interview with Administrator, and staff six (6) out of six (6) stated that bedding is cleaned once a week or as needed. During initial visit on 11/06/2025 LPA observed R1’s bedding stained with urine. R1 stated to Administrator that he/she had asked the night before for linen to be changed and Administrator stated staff would be there today at 3:00 PM to change it. During visit on 11/18/2025 LPA observed room 9 and room 17 to have urine-stained bedding. Interviews with residents, four (4) out of seven (7) stated that they have had urine-stained bedding or witnessed other residents with soiled linen. R1 stated that they are supposed to change bedding weekly but get too busy to do it. R7 stated one time they had an accident and when staff was asked to change sheets, they stated that it’s not my job wait till another staff gets here, forcing S7 to wait till the next day. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was given to Andrea Flores.the state’s words, verbatim · CDSS document, Jan 16, 2026 · control 28-AS-20251029154058

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a)(3)(C) · Plan of correction due date: Jan 17, 2026

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. Based on observations and interviews licensee did not ensure, residents were provided clean linen free of urine stains which poses an immediate risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2026

Plan of correction: Administrator will insure bedding is free from urine stains and have staff check residents bedding more often. Administrator will go over section 87303(a)(3)(C) training with staff and submit to LPA by POC due date.

Allegation investigated: Staff do not ensure that resident has clean bedding Staff interacts with residents in an inappropriate manner

Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Residential Aide Andrea Flores who assisted with today’s visit. The investigation consisted of the following: During the initial visit conducted on 11/06/2025, LPA obtained copies of the following documents: Staff roster, resident roster, and conducted a room check for R1.On 11/18/2025, LPA’s Gutierrez and Castro interviewed Administrator, staff 1- staff 5 (S1-S5) resident 1 (R1) by telephone, residents 2-residents 7 (R2-R7) and room checks. LPA obtained copies of the following documents: R1’s physicians reports, identification information (LIC 601), appraisal needs and service, facility resident council meeting notes, Orkin Pest Control, and Squash Pest Control invoices. During today’s visit LPA Gutierrez delivered findings. SEE LIC 9099C Substantiated In regard to the allegation” Staff do not ensure that resident has clean bedding”, It is alleged that R1’s bedding had urine on it and staff refused to change bedding. During interview with Administrator, and staff six (6) out of six (6) stated that bedding is cleaned once a week or as needed. During initial visit on 11/06/2025 LPA observed R1’s bedding stained with urine. R1 stated to Administrator that he/she had asked the night before for linen to be changed and Administrator stated staff would be there today at 3:00 PM to change it. During visit on 11/18/2025 LPA observed room 9 and room 17 to have urine-stained bedding. Interviews with residents, four (4) out of seven (7) stated that they have had urine-stained bedding or witnessed other residents with soiled linen. R1 stated that they are supposed to change bedding weekly but get too busy to do it. R7 stated one time they had an accident and when staff was asked to change sheets, they stated that it’s not my job wait till another staff gets here, forcing S7 to wait till the next day. In regard to the allegation” Staff interacts with residents in an inappropriate manner”, It is alleged that staff (S6) refuses food and or snacks and is rude to residents. During interview with Administrator, and staff six (6) out of six (6) stated that they have never interacted with a resident in an inappropriate manner nor ever witnessed another staff treating residents inappropriately. Administrator stated that a complaint was made about S6, and he/she was spoken to but later that day witnessed the resident shaking hands with that staff. During interviews with residents five (5) out of seven (7) stated that S6 denies them food by telling them kitchen is closed. R1 stated that S6 is rude and calls him/her names. R7 stated that S6 tosses plates at them when serving food, is rude, and has denied them food. Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was given to Andrea Flores. In regard to the allegation” Staff speaks inappropriately to resident”, It is alleged that S6 calls residents out of name. During interview with Administrator, and staff six (6) out of six (6) stated that staff has never called a resident out of their name. S6 stated that with difficult residents another staff will usually assist so they can take care of residents together. During Interviews with residents five (5) out of seven (7) stated that staff has called them out of their name. R1 stated that staff is rude and calls me names. In regard to the allegation” Staff do not ensure the facility is free of insects”, It is alleged that facility has bugs in the bedrooms. During interview with Administrator, and staff six (6) out of six (6) stated in the past they have had issues with bugs but have been spraying the facility and working with Orkin. Staff stated that the insects’ problems have gotten better. During interviews with residents five (5) out of seven (7) stated that they have seen bugs in the past but that they are taking care of the problem by spaying the rooms. LPA obtained copies of invoices from Orkin pest control that showed monthly services are being conducted however Administrator stated something else was needed to treat the bug issues and has set up service with a new provider Squash Pest Control Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Rosalie Sandoval, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 22, 2025 · control 28-AS-20251029154058

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(3)(C) · Plan of correction due date: Nov 23, 2025

87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. Based on observations and interviews licensee did not ensure, residents were provided clean linen free of urine stains which poses an immediate risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Nov 22, 2025

Plan of correction: Administrator will insure bedding is free from urine stains and have staff check residents bedding more often. Administrator will go over section 87307 training with staff and submit to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Nov 23, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (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. Based on observations and interviews licensee did not ensure, residents were being free from intimidation, ,or other actions of a punitive nature by staff which poses an immediate risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Nov 22, 2025

Plan of correction: Administrator will give training to all staff on personal rights of the residnets 87468.1(a)(3) with all staff and send log to LPA by PO due date.

Allegation investigated: Staff does not ensure residents' diapering needs are being met. Staff does not ensure to keep up with residents' housekeeping needs.

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced 10-day complaint investigation visit in response to the above-mentioned allegations. LPA, met with Rosalie Sandoval, Executive Director, and the reason for the visit was explained. Today’s visit was facilitated by Naylet Velazquez, Designated Sub., due to Executive Director having to step away from the facility for a prior engagement. The investigation consisted of the following: During today’s visit, LPA obtained copies of staff and resident rosters, toured the facility, inspected (11) resident rooms, and inspected the incontinence supply room and cleaning supply closet. LPA conducted interviews with Staff 1 – Staff 5 (S1-S5) and Resident 1 – Resident 10 (R1-R10) and conducted a record review of staff 24-hour logbook for 11/7/25 through 11/13/25 entries of which copies were also obtained. The investigation revealed the following: ***Continues on LIC 9099-C Unsubstantiated Regarding: Staff does not ensure resident’s diapering needs are being met. It is alleged that staff only change resident’s diaper three times a day in a 24-hour period. It is also alleged that families have complained that resident’s diaper should be changed more than three times a day. Staff deny the allegation. Interviews with (5) out of (5) staff revealed that residents’ incontinence care (diapering) is being conducted more than three times a day in a 24-hour period. Staff indicated that every staff shift begins with rounds which consist of providing incontinence care for residents. Staff indicated that incontinence care is done every one to two hours and when needed in between scheduled checks. Staff also indicated that staff ensure that residents that require a higher level of care are checked and changed more frequently, and that independent residents who can do their own incontinence care are observed and assisted if requested. Staff further stated that they have not received any complaints from family members of residents regarding incontinence care. Four (4) out of (5) staff stated that they check the resident logbook during their shift to check notes documented by staff who previously cared for residents to continue meeting diapering needs appropriately throughout the day. Record review indicated that staff document incontinence care after it is conducted by indicating the date and time of the event, and the name of the resident and the staff who performed the task. Records also indicated that no more than two hours pass between diapering and other personal hygiene tasks. LPA inspected the incontinence storage room and observed sufficient supplies of incontinence care items for residents. Interviews with (8) out of (10) residents revealed that their incontinence needs are being met appropriately and that staff check in on them often throughout the day. Two (2) out of (10) residents indicated that they do not need help from staff to conduct their “diapering;” however, staff provide them with the supplies they need to conduct their personal hygiene. Staff and resident interviews, record review and observations do not corroborate the allegation that staff are not ensuring that diapering needs are not being. ***Continues on LIC 9099-C page 2 Regarding: Staff does not ensure to keep up with residents' housekeeping needs. It is alleged that facility has only one housekeeper and that housekeeping has not been keeping up with sweeping and mopping residents’ rooms. It is also alleged that staff are not taking out the trash in residents’ rooms. Staff deny the allegation. Interviews with (5) out of (5) staff revealed that facility is not short of housekeeping staff and that all staff contribute to maintaining the facility clean during their shifts. Staff indicated that sweeping and mopping starts at 6:00 a.m. which is done by the night shift staff. Staff indicated that sweeping and mopping continues throughout the day after breakfast, lunch, dinner and as needed. Staff stated that resident rooms are mopped every other day; however, spills and accidents due to incontinence are cleaned up immediately. Staff further indicated that trash bags are taken out of the residents’ rooms daily, especially after “diapering” soiled items have been removed from residents and disposed of in the trash cans. Staff stated the cleanliness of the whole facility, including residents’ rooms, is not just the responsibility of the housekeeping staff, but of all staff in general. Interview with (1) out of (10) residents indicated that sometimes resident has to take out their own trash bag; however, for the most part, staff clean resident’s room often. Interviews with (9) out of (10) residents indicated that staff are sweeping and mopping their rooms and taking out their trash bags often and have no concerns about staff not cleaning their rooms. LPA inspected (11) resident rooms and observed the floors to be clean and trash bins to contain clean liners. Inspection of the cleaning supply room indicated that the facility has sufficient cleaning supplies readily available for use. Staff and resident interviews and observations do not corroborate the allegation that staff are not keeping up with residents’ housekeeping needs. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Rosalie Sandoval, Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 28-AS-20251106110826

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Case Management Visit-Incident on 8/28/25, stemming from incident report received on 8/1/25. LPA was greeted by Elizabeth Sandoval, Medication Aide, and the purpose of the visit was explained. Naylet Velazquez, Medication Aide/Second Designee, arrived shortly after to assist with the visit. Rosalie Sandoval, Executive Director, was contacted telephonically and was also informed about the reason for the visit. According to Unusual Incident Report (SIR) received on 8/1/2025, licensee self-reported that a resident was having sexual contact with another resident in the facility which was witnessed by a staff member who then reported the incident to the director. The incident happened on 7/24/25 in the evening. According to SIR, the incident took place at the facility between Resident 1 and Resident 2 (R1-R2). R1, indicated to staff, R2 is their friend but felt pressured by R2 to receive sexual advances which made R1 feel uncomfortable. LPA conducted interviews with Staff 1 – Staff 4 and obtained the following information: administrative staff have talked to R2 regarding the inappropriateness of their behavior toward R1. Staff are taking extra measures to supervise the interactions between R1 and R2. Staff are also conducting more frequent checks on R1 in their room and while spending time in the common areas of the facility to ensure R1's safety. Staff further indicated, R1 is safe and well taken care of by staff and no other incident has been witnessed or reported. Telephone interview with Ombudsman indicated that they came out to the facility to do a wellness check on R1 after the incident. Ombudsman indicated that the facility did everything they are supposed to do in this type of situation. Facility notified Ombudsman, licensing and R1’s conservator/responsible party about the incident. ***Continues on LIC 809-C Ombudsman further indicated that R1 did not express concern regarding the incident and appeared to be in good physical and emotional state when they interviewed R1 during their visit. Ombudsman further stated, “I don’t have any concern for R1’s safety. Director is in constant communication with conservator about R1, which I was able to confirm, via phone call with them.” Ombudsman also indicated that the conservator will continue to be in communication with the facility to get wellness updates on R1. No other incident has been reported to the Ombudsman. R1 was also interviewed during today’s visit and acknowledged the incident between R1 and R2. R1 stated, R2 is their friend, but they don’t want R2 to do this again. R1 indicated, no other incident has taken place and R2 is keeping their distance. R1 further indicated, they feel safe at the facility and feel they are being cared for by the staff. R1 stated they know they can report to staff if R1 feels they are in danger. LPA was unable to conduct interview with R2 due to R2 being away at the time of visit. LPA did not observe any immediate health and safety risks during visit. No further action is required at this time. No deficiencies were cited during this visit. Exit interview was conducted with Naylet Velazquez, Medication Aide/Second Designee. A copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Sanjay Vaid and Elena Mallet conducted the annual inspection. LPAs arrived unannounced and met with Staff, Naylet Velazquez and Administrator, Rosalie Sandoval, assisted with physical tour. The purpose for the visit was explained. The facility is licensed to serve non-ambulatory residents ages 60 and over. There is a hospice waiver approved for 5 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Operational Requirements: The facility does not accept or retain residents with dementia. There are currently 34 residents residing at the facility. The facility has the sufficient amount of liability insurance covering injury to residents. Physical Plant & Environment Safety: The facility has 30 resident rooms and shared bathrooms. There are no swimming pool or bodies of water at the premises. LPAs selected 3 random rooms to inspect #6A,28A, 32B. The bedrooms have the required furniture and sufficient lighting. The hot water temperature was measured in each of the bedroom's sink and shared shower rooms. They were all within the required range of 105-120 degrees F. The smoke detector is interconnected and there is an operable carbon monoxide detector, inspection is serviced by fire service company. The facility does not have a kitchen on site. Foods are cooked at the sister facility next door and is brought over during mealtime. Fire extinguishers inspected 06/19/25. Residents with Special Health Needs: The facility has some residents who use oxygen. The residents who receive insulin injections can administer themselves. Continued on 809C.............. Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are continuing to clean/disinfect every 2 hours as documented. Facility has sufficient PPE supplies and has an Infection Control Plan. They are continuing to follow the strictest guidance for any infectious outbreaks. Staffing: There is sufficient staffing at the facility. The administrator's (Rosalie Sandoval) certificate expires on 1/24/26. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR or first aid training and sufficient on-going training that meets the annual requirement. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal, and Resident rights. Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. Food Service: LPA observed sufficient food supplies of 2-day perishable and a week of non-perishable items at the sister location next door. The facility stores the emergency food supplies on site. Incidental Medical & Dental: The medications are centrally stored and in their original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. During the visit today, LPA reviewed 4 residents' medication, and they are being administered as prescribed by the physician. Disaster Preparedness: The facility has the updated Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Last fire inspections were conducted on 4/24/25. Last fire drill was conducted on 4/25/25, earthquake drill was conducted on 05/24/25. Medication room was observed inaccessible to the residents. Medication was reviewed for 4 residents. LPA reviewed 4 resident/staff files and interviewed 3 residents and 4 staff. Liability Insurance policy expires 05/08/2026. No deficiencies were issued today. An exit interview was held and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Jul 10, 2025

Allegation investigated: Resident sustained injury while in care.

Licensing Program Analyst (LPA) Sanjay Vaid conducted a initial 10 day complaint visit to investigate the above allegation. Upon arrival LPA met Naylet Velasquez, Direct Staff/Designated Sub and Administrator Rosalie Sandoval and explained the reason for the visit. During the initial visit LPA conducted a tour of the facility with the Administrator. LPA also interviewed the Administrator and a total of two (2) staff, who shall be referred to as Staff#1-3 (S1-S3). LPA Vaid interviewed a total of five (5) residents, who shall be referred to as Resident #1- 5 (R1-R5). LPA interviewed Resident#1 (R1) via phone. LPA Vaid obtained staff and resident roster from Garfield Terrace and Garfield Villas. The investigation reveals the following: Regarding the allegation: Resident sustained injury while in care. It is alleged that a resident had an unwitnessed fall in their room at the Garfield Terrace facility, when staff found them, they cleaned up the residents’ face and called the ambulance transport for the resident. Continued on 9099C.... Unfounded Resident was transferred to Los Angeles Community Hospital. From there resident was sent to a skilled nursing facility for physical therapy and rehabilitation. Three (3) out of three (3) staff interviewed denied the allegations, the resident (R1) did not experience a fall at the Garfield Terrace facility. The resident (R1) does not reside at the Garfield Terrace facility. Resident roosters shows the resident (R1) not residing at Garfield Terrace. Four (4) out of four (4) residents interviewed could not corroborate the allegation. Five residents interviewed stated that R1 resides and lives not at the Garfield Terrace facility. This agency has investigated the complaint alleging: Resident sustained injury while in care. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. Exit interview conducted with the Administrator Rosalie Sandoval and a copy of this record provided.the state’s words, verbatim · CDSS document, Mar 11, 2025 · control 28-AS-20250304112323

Allegation investigated: Facility is unsanitary. Facility retaining bedridden residents without approved fire clearance. Facility staff not equipped to care for residents.

Licensee Program Analysts (LPAs) Alberto Lopez, Luis De Leon, and Myra Cota made an unannounced compliant visit to investigate the above allegations. LPAs met with Naylet Velazquez, Medication Aide and Administrator Rosalie Sandoval arrived a short time later and assisted with the visit. The investigation consisted of LPAs interviewing four (4) staff (S#1-S#4), and seven (7) residents (R#1-#7), reviewing and obtaining staff and resident rosters, medical documentation for R2-R7. Allegation: Facility is unsanitary. It is alleged that there is feces in R4 bed. The investigation revealed: LPAs interviewed four (4) staff and four (4) of four (4) staff denied the allegation. LPAs interviewed seven (7) residents and seven (7) of seven (7) residents could not corroborate the allegation. LPAs took tour of the facility and random rooms and all were observed to be clean. (Continued on 9099C) Unsubstantiated One (1) staff stated that R4 is known to make a mess when they use the bathroom, however, staff promptly clean R4 room as much as necessary. LPAs did not observe any feces anywhere in R4 room during the entire visit nor any of the others rooms inspected. There is no evidence to support this allegation. Allegation: Facility retaining bedridden residents without approved fire clearance. It is alleged that the facility is accepting and retaining bedridden residents without fire clearance. LPAs interviewed four (4) staff and all four (4) staff stated they have no bedridden residents at the facility at this time. LPAs interviewed seven (7) residents including the four (4) mentioned in the allegations and seven (7) of seven (7) residents were unable to corroborate the allegations. All seven (7) residents stated they are able to get in and out of bed on their own. Medical documentation for the four (4) residents alleged to be bedridden showed that they are all non-ambulatory. LPAs observation did not observe a health or safety hazard for the residents at the time of visit. There is not enough evidence to substantiate this allegation. Allegation: Facility staff not equipped to care for residents. It is alleged that facility staff are not properly equipped to assist in lifting residents. LPAs interviewed four (4) staff and all four (4) staff denied the allegation. Administrator stated that the facility is not required to have a Hoyer Lift or back brace support for staff because they don't do any lifting of any of the residents. All they do is assist in changing the residents and assist with transferring. Administrator stated they do not lift any resident. LPAs interviewed seven (7) residents and four (4) our of seven (7) could not corroborate the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted and copy of report was left with the Administrator.the state’s words, verbatim · CDSS document, Nov 4, 2024 · control 28-AS-20241031145838

Allegation investigated: Staff are retaining residents that require a higher level of care

Licensing Program Analyst (LPA) Vaid conducted an unannounced subsequent complaint visit regarding the above allegation. LPA met Naylet Velasquez (Med-Aide/ Direct Staff/ Designated SUB) and explained the reason for the visit, Administrator Rosalie Sandoval arrived shortly after. Conducted physical plant tour with N Velasquez and did not observe any health and safety issues or concerns. Observed staff assisting residents. The facility is licensed to serve 60 non-ambulatory residents ages 60 and over. There is a hospice waiver approved for 5 residents. The facility currently has 3 hospice residents. LPA Vaid requested, received, obtained and reviewed residents medical assessment/ care and service plan, physicians report for residential care facilities, copy of facility admission agreement, Hospice and palliative care plan. Staff and client rosters, staff in service training; skills and knowledge to provide necessary resident care and supervision dated 03/10/2023 and staff duties for new admitted residents dated 09/10/24. Continued on 9099 C...... Unsubstantiated Regarding the allegation: Staff are retaining residents that require a higher level of care. It is alleged that the facility staff are not reporting health changes for certain residents that receive hospice care at the facility, the allegation further claims facility staff has not employed CNA (Certified Nurse Assistant) to assist the residents who are on hospice. The facility is an Assisted Living provider, the facility is not required to employ a Certified Nurse Assistant, as per regulations. Three (3) out of three (3) staff interviewed deny the allegation. Three (3) out of three (3) residents interviewed could not corroborate the allegation. LPA interviewed Hospice care residents. According to the physicians reports and hospice assessments, the staff caregivers and Home Health Hospice agencies are communicating residents’ health and forwarding health concerns and issues to the primary physician who determines whether higher level of care is further required. Hospice agencies assigned to the residents come three time per week to assist with showering and incontinent needs, the facility staff assists residents with other grooming and daily living needs. LPA observed home health agencies assisting other residents at the facility. LPA observed facility staff caregivers working with Hospice home care to ensure that hospice residents are comfortable with their needs and services. LPA reviewed Restricted Health Conditions/ Allowable Health Conditions folder, containing residents on hospice, special diets, treatment of healing wounds, residents using insulin, residents using ear and eyes drops, catheters and home health services received by residents and trace logged by the staff. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and copy of report was left with the Administrator.the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 28-AS-20240925140307

Allegation investigated: Staff does not ensure sliding glass door closes/locks properly.

Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation for the allegation listed above. LPA arrived unannounced and met with Administrator, Rosalie Sandoval. The purpose of the visit was explained. LPA obtained copies of the staff and resident rosters, toured the facility, and conducted interviews. For allegation - Staff does not ensure sliding glass door closes/locks properly. LPA interviewed Administrator and staff who acknowledge the sliding door is heavy and can be difficult for some residents to open and close. However, the door can be closed and locked properly. Administrator stated that they have sprayed lubricant on the bottom of the sliding door to make it easier to slide. They remind residents to close it and staff will also check to ensure the door is closed. LPA interviewed 4 residents. 3 out of the 4 residents indicated the door is heavy and choose not to use it. They use the other door in the dining room to go in and out instead. One uses the sliding door often and has no issues with it. Unsubstantiated They do not feel that the sliding door poses a safety concern. During the tour, LPA observed the sliding door in the dining room to be working properly. The door requires a little more force to open and close due to its heaviness, but it is not in disrepair. There is another door in the dining room to access the courtyard. LPA observed 2 individuals utilizing the sliding door without any problems. 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 with the administrator. A copy of this report along with the appeal rights was provided.the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 28-AS-20240906094743

Allegation investigated: Staff do not properly maintain the facility

Licensing Program Analyst (LPA) S Vaid conducted an unannounced initial 10 day complaint visit regarding the above allegation. LPA met Naylet Velasquez (Med Aide, Direct Staff, Designated Substitute) and explained the reason for the visit. Administrator Rosalie Sandoval arrived shortly after. During today's visit, LPA reviewed and obtained client and staff roster, LPA toured the physical plant with Designated Sub Naylet Velasquez and did not observe any deficiencies or health and safety concerns. LPA Vaid interviewed Staff 1-3 (S1-S3). LPA interviewed clients 1-4 (C1-C4). Regarding the allegation: Staff do not properly maintain the facility. It is alleged that the facility is not maintaining the facility and allows foul smell of urine, feces, and mildew to remain within the common restrooms and community showers. Three (3) out of (3) staff deny this allegation. Four (4) out of (4) clients interviewed have no knowledge of the allegation, clients interviewed say that the facility is always cleaning, and staff keeps the facility safe for them. CONTINUED on 809C....... Unsubstantiated LPA Vaid toured the facility and observed all three community showers and clients personal restrooms (rooms, 31, 13 and 34 were observed to be near the community restrooms) to be clean and without mal odor. LPA did not observe exposed wiring in any the community restrooms, nor the common restroom used by the staff and visitors. Based on observations made, and interviews conducted. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was held and copy of this report was given to Administrator Rosalie Sandoval.the state’s words, verbatim · CDSS document, Sep 3, 2024 · control 28-AS-20240829151957

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Sanjay Vaid conducted a subsquential visit to complete the annual inspection at 1:30PM. LPA arrived unannounced and met with Staff, Naylet Velazquez and Administrator, Rosalie Sandoval, assisted with the visit. The purpose for the visit was explained. The facility is licensed to serve 60 non-ambulatory residents ages 60 and over. There is a hospice waiver approved for 5 residents. The facility currently has 2 hospice residents. The facility is licensed to serve 40 non-ambulatory residents ages 60 and over with an approved hospice waiver for 5 residents. The facility is a 1 story building located in a residential area, it has 20 shared rooms, an activity room, a dining room with kitchenette, a medication room, and a back outdoor area. Facility does not have a kitchen and per the plan of operation they receive food prepared in their sister facility for all resident meals. On 05/30/24 LPA reviewed 3 domains of the CARE Tools: operational requirements, physical plant and environment and residents with special health needs. On todays visit LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. Staff are continuing to clean/disinfect every 2 hours as documented. Facility has sufficient PPE supplies and has an Infection Control Plan. They are continuing to follow the strictest guidance for any infectious outbreaks. Staffing: There is sufficient staffing at the facility. The administrator's (Rosalie Sandoval) certificate expires on 1/24/24. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR or first aid training and sufficient on-going training that meets the annual requirement. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Physician's Report, Pre-admission appraisal, and Resident rights. Continued on 809 C.... Resident Rights-Information: The Complaint poster, Local Ombudsman, and Residents personal rights are posted. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. Food Service: LPA observed sufficient food supplies of 2-day perishable and a week of non-perishable items at the sister location next door. The facility stores the emergency food supplies on site. Incidental Medical & Dental: The medications are centrally stored and in their original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. During the visit today, LPA reviewed 4 residents' medication and they are being administered as prescribed by the physician. Disaster Preparedness: The facility has the updated Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Last fire inspections was conducted on 4/24/24. Last fire drill was conducted on 4/10/23, earthquake drill was conducted on 04/25/24. Medication room was observed inaccessible to the residents. Medication was reviewed for 4 residents. LPA reviewed 4 resident/staff files and interviewed 4 residents and 4 staff. Administrators certificate #6012456740 is in process of renewal, post mark for renewal sent is 12/14/23. Liability Insurance policy expires 05/08/2025. Surety bond insures $8000.00 per incident dated 01/15/2016. No deficiencies were issued today. An exit interview was held and a copy of this report was given to the administrator.the state’s words, verbatim · CDSS document, Jun 12, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sanjay Vaid conducted the annual inspection. LPA arrived unannounced and met with Staff, Naylet Velazquez and Administrator, Rosalie Sandoval, assisted with physical tour. The purpose for the visit was explained. The facility is licensed to serve 60 non-ambulatory residents ages 60 and over. There is a hospice waiver approved for 5 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Operational Requirements: The facility does not accept or retain residents with dementia. There are currently 31 residents residing at the facility. The facility has the sufficient amount of liability insurance covering injury to residents. Physical Plant & Environment Safety: The facility has 30 resident rooms and shared bathrooms. There are no swimming pool or bodies of water at the premises. LPA selected 3 random rooms to inspect #4, #27, #30. The bedrooms have the required furniture and sufficient lighting. The hot water temperature was measured in each of the bedroom's sink and shared shower rooms west, south, north. They were all within the required range of 105-120 degrees F. The smoke detector is interconnected and there is an operable carbon monoxide detector. The facility does not have a kitchen on site. Foods are cooked at the sister facility next door and is brought over during meal time. Residents with Special Health Needs: The facility has some residents who use oxygen. The residents who receive insulin injections are able to administer themselves. Due to shortage of time, the staff and residents were not interviewed. The following Care Tools were completed: Operational requirements, physical plant and environment, and residents with special health needs. No deficiencies were noted on today’s visit. Exit interview was conducted with Rosalie Sandoval administrator and a copy of this report, were provided.the state’s words, verbatim · CDSS document, May 30, 2024

Allegation investigated: Staff threatened resident

On 05/14/2024 at 09:27 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted a subsequent complaint visit to investigate the above allegation. Upon arrival LPA met the Administrator Rosalie Sandoval and explained the reason for the visit. During the initial visit LPA conducted a tour of the facility with the Administrator. LPA also interviewed the Administrator and a total of two (2) staff, who shall be referred to as Staff#1-2 (S1-S2). LPA Baptiste interviewed a total of four (4) residents, who shall be referred to as Resident #2- 5 (R2-R5). LPA interviewed Resident#1 (R1) via phone. LPA Baptiste obtained staff and resident roster and conducted file review for S1 and R1's file. Report Continued on 9099c Unsubstantiated The investigation reveals the following: Regarding “Staff threaten resident”. It is alleged that the staff threaten the residents. The Administrator denied the allegation stating they have never threatened the residents. 2 out of 2 staff denied the allegations stating they have never threatened the residents. 5 out of 5 residents denied the allegation stating staff has never threaten them or they have never witness other residents being threatened by staff. Based on LPA's interviews, investigation revealed: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with the Administrator Rosalie Sandoval and a copy of this record provided. The investigation reveals the following: Regarding “Staff punched resident”. It is alleged that staff#1(S1) punched resident#6(R6). The Administrator denied the allegation stating R6 is not a resident at the facility and confirmed that none of the staff have ever physically assaulted a resident. 2 out of 2 staff denied the allegations stating they have never physically assaulted the residents. 5 out of 5 residents denied the allegation stating they were never assaulted or witness other residents being assaulted by staff. LPA reviewed resident roster and observed R6 do not live at the facility. LPA also reviewed S1’s files and did not observe disciplinary actions. Based on the information gathered during this visit, the allegation is deemed UNFOUNDED. A finding of UNFOUNDED means that the allegation is either false, could not have happened, and/or is without a reasonable basis. Exit interview conducted with the Administrator Rosalie Sandoval and a copy of this record provided.the state’s words, verbatim · CDSS document, May 14, 2024 · control 28-AS-20240502104510

Allegation investigated: Facility does not have a qualified administrator. Facility staff failed to give resident P&I funds. Facility administrator does not allow resident to file complaint to public agencies. Facility staff are not properly trained.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Naylet Velazquez and explained the reason for the visit. The investigation consisted of the following: LPA requested a copy of staff and resident roster. LPA toured common areas, reviewed 5 staff files, and interviewed 4 staff and 5 residents. LPA requested copies of administrator’s certificate renewal documents, administrator’s personnel record, staff’s personnel records, initial training and 2022- 2023 – 20 hours of training for each staff, trust bank statement - May 2024 for P&I funds, petty cash request form for May 2024, and 5 residents record of resident’s safeguarded cash resources. The investigation revealed the following: Regarding allegation: Facility does not have a qualified administrator. It is alleged there is not an administrator who is qualified at the facility. (CONTINUED ON LIC 9099C) Unsubstantiated Interview conducted with administrator revealed administrator has been in the field as an administrator since 1990. Documents reviewed revealed facility’s assigned administrator Rosalie Sandoval, has an administrator certificate #6012456740 with expiration date 1/24/24 and renewal documents were mailed out to the department on 12/14/23. Administrator’s personnel record dated 6/9/16 lists education and previous employment. Administrator meets the requirements for education and experience per Title 22 Regulations for a facility of capacity of 50 residents and over. 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. Regarding allegation: Facility staff failed to give resident P&I funds. It is alleged most of the residents don't receive their P&I money. Interviews conducted with residents revealed 3 out of 5 residents stated to receive P&I funds once a month on the first day of the month or the Friday before the first of the month. They stated to not be denied their funds at any time. 1 out of 5 residents stated to handle own funds and 1 out of 5 residents was not able to provide an answer due to cognitive skills. Interviews conducted with staff revealed residents received P&I funds and they have not complaint that their money is being denied. Per staff there is only one resident who may state funds are not being provided. However, this resident no longer receives P&I funds due to funding source change. Facility keeps a trust bank account in which P&I funds for the residents, a balance was observed. A check request form was observed for the facility for the month of May 2024 with petty cash provided to the facility for the amount of $4000.00 from which P&I funds were provided to the residents. Each resident who receives P&I funds has a safeguarded cash resources form and the amounts withdrawn and balance is noted in each form with staff and residents' signatures. 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. Regarding allegation: Facility administrator does not allow resident to file complaint to public agencies. It is alleged “executive director is untouchable, so no one can complaint to the Licensing and Ombudsman” agencies. LPA toured the common areas and observed Complaint Hotline for Department of Social Service poster posted outside the medication room and Local Ombudsman poster in the hallway across the dining room and in the entrance of the facility. (CONTINUED ON LIC 9099C) Interviews conducted with residents revealed 3 out of 5 residents are aware of the name of the agencies to call to complaint 2 out of the 3 residents are aware were to find the phone numbers. 1 out of 5 residents was not aware of the complaint phone numbers or agencies to complaint and 1 out of 5 residents was unable to answer due to cognitive skills. Interviews with staff revealed residents know were to complaint and the staff point to the posters when they inquire about where to complaint. 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. Regarding allegation: Facility staff are not properly trained. It is alleged that staff are not trained properly to meet the needs of the residents. Interviews conducted with residents revealed 3 out of 5 residents feel staff are knowledgeable of their responsibilities. 2 out of 5 residents were unable to provide an answer due to cognitive skills. Interviews with staff revealed staff received training consistently throughout the year, each training provided is for an hour, and staff received initial training when hired. Documents reviewed reveal staff have received 40 hours of initial training and 20 hours of training on Documentation, Monitoring Residents, Emergency Procedures, Incident Reports, Medical Emergencies, Personal Care, Personal Rights, Medications, Hospice, Dementia, Activities of Daily Living, Recreation, End of Life Care, Food Services, Basic Care, Resident Care and Supervision. Personnel Record for each staff list staff’s education and experience and each staff is over 18 years old. 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 was conducted with Rosalie Sandoval and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 7, 2024 · control 28-AS-20240503143132

Allegation investigated: Facility staff takes resident's personal belongings. Facility staff interfering with resident's right to have visitors. Facility staff speak inappropriately to residents. Facility staff allow resident to drink from a cup with a roach in it. Facility staff left resident on the floor for several hours.

Licensing Program Analyst(LPA) Nicol Wesley conducted an unannounced 10 day complaint visit at the facility and met with Executive Director Rosalie Sandoval to discuss the purpose for todays visit. During the visit, LPA Wesley requested a copy of the staff and resident roster, observed exterminator invoices, toured random resident rooms, dining room, kitchen, interviewed the residents, interviewed the executive directtor and the staff #1. Resident #1 and Resident #2 was not present in the facilty. Regarding allegation: Facility staff takes resident's personal belongings. LPA interviewed 6 residents who indicated that the staff does not take their personal belongings. In regards to resident #1 staff indicated that resident #1 doesn't have a TV, he is blind and the radio that he had in his room belonged to staff #1. Continued on LIC 9099C. Unsubstantiated Regarding allegation: Facility staff interfering with resident's right to have visitors. LPA Wesley interviewed 6 residents who indicated that the staff never interferes with their visitors if they were to visit. In regards to resident #1 he had a visitor that came to the facility drunk and aggressive towards staff and residents, they asked him to leave because he was posing a risk to residents in the RCFE, Other than that, the staff have never interfered with the residents rights to have visitors. Regarding allegation: Facility staff speak inappropriately to residents. LPA Wesley interviewed 6 residents who said the staff does not speak to them inappropriately. LPA Wesley interviewed the staff and they said they never speak inappropriately to residents. Regarding allegation: Facility staff allow resident to drink from a cup with a roach in it. LPA Wesley interviewed 6 residents who said they have never received food or drink with a roach in it. One resident said he have never seen a roach in the facility. The Executive director said the facility receives extermination from an outside source and from the facility maintenance person, and they have never served anyone a drink or food with a roach in it. Regarding allegation: Facility staff left resident on the floor for several hours. LPA interviewed 6 residents who said the staff never left them unattended or on the floor for several hours. One of the residents said he is a fall risk and they have never left him unattended on the floor for several hours. In regards to resident #2 he had fallen at 3:30 am and called for staff and they came to got him off the floor. He is high functioning and can be heard if he screamed for help, resident #2 also has a cellphone and calls 911 when he needs immediate medical attention that the facility can't provide. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. A copy of the LIC 9099, LIC 9099C was given during the exit interview.the state’s words, verbatim · CDSS document, May 2, 2024 · control 28-AS-20240426095643

Allegation investigated: Facility manager does not allow staff to assist a resident in care. Facility manager confiscated resident's personal belongings.

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Naylet Velazquez and explained the reason for the visit. The investigation consisted of the following: LPA requested copies of staff/resident roster. LPA conducted interviews with 4 residents and 4 staff. LPA requested a copy of resident #1’s (R1) personal property and values form, physician’s report, admission agreement and last staff in-service on resident care and supervision. LPA conducted a tour of R1’s room. The investigation revealed the following: Regarding allegation: Facility manager does not allow staff to assist a resident in care. It is alleged the manager does not allow the staff to assist a resident who cannot see. Interviews with residents revealed staff assist and provide care to residents as needed. Overall all staff are good with residents. Administrator ensures that residents are provided assistance in all their needs. (CONTINUED ON LIC 9099C) Unsubstantiated Interviews with staff revealed staff are aware that they must assist residents. Administrator has not told any of the staff to not assist a resident in need. Facility provided an in-service to staff on 3/8/24 on Resident Care and Supervision. 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. Regarding allegation: Facility manager confiscated resident's personal belongings. It is alleged that when manager has an issue with the resident confiscates the resident's personal items such as radio and tv. Interviews with residents revealed 3 out of 4 residents stated to have all their belongings and administrator will not confiscate items as retaliation. 1 out of 4 residents stated recently the room was fumigated and upon returning the TV and radio provided by case manager were gone and a new one has not been provided. Resident stated to not have issues with staff. Interviews with staff revealed facility staff/administrator have not removed any items from the residents as retaliation. All resident items are not touch. Documents review revealed R1 does not have listed a TV or radio in the personal property and valuables. 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 was conducted with Rosalie Sandoval Administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 26, 2024 · control 28-AS-20240318102723