Glen Park at Glendale - Boynton St

Allegation investigated: Facility Staff did not provide resident with their medical device.

This report supercedes the report dated July 10, 2026. Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegation. LPA met with Susan Park and explained the reason for the visit. --- Facility Staff did not provide resident with their medical device. It was alleged that facility is not giving Resident #1 (R1) their sleep apnea machine which they have a prescription for. To investigate the allegation, on June 12, 2025, LPA Melissa Spaeth interviewed three (03) staff and seven (07) residents from around 11:20a.m. to 1:15p.m. LPA was unable to interview R1. To further investigate the allegation, on November 13, 2025, LPA contacted Local Ombudsman office. On April 10, 2026, LPA requested additional documents. On June 26, 2026, LPA requested additional documents at around 12:45p.m. and interviewed one (01) additional staff. (CONT. on LIC9099-C) Substantiated During interviews, all staff stated that R1 does not know how to operate the Continuous Positive Airflow Pressure (CPAP) machine so R1 does not use it. S1 and Staff #2 (S2) added that R1 has memory issues and cannot follow directions to use the CPAP. Staff #3 (S3) added they made multiple attempts to discuss the CPAP machine usage with the RP verbally and by email. During interviews with residents, all interviewed residents confirmed they do not use such medical devices. A review of Physician’s Report states R1 has a primary diagnosis of Dementia. R1 had no known allergies, confused/disoriented, sundowning behavior, able to follow instructions and communicate their needs. R1 is not able to administer own medications, administer own oxygen or store own medications. A review of documents provided indicate that a CPAP machine was prescribed on May 28, 2025, with instructions and signed and dated on the bottom May 30, 2025, and another document with similar information dated June 12, 2025, acknowledging receipt informing facility of need for CPAP. A review of the email correspondence provided is dated June 30, 2025, explaining the facility does not have skilled professionals available at night. The Local Ombudsman stated they were not given authorization to release the information to the LPA. Based on interviews and record review, there is enough information to verify the allegation, therefore, the allegation will remain SUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Aug 12, 2026 · control 31-AS-20250606101944

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87619(b)(1)(2) · Plan of correction due date: Aug 12, 2026

87619 Intermittent Positive Pressure Breathing (IPPB) Machine (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (1)Monitoring of the resident's ongoing ability to operate the equipment in accordance with the physician's orders. (2)Ensuring that the procedure is administered by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidenced by; Based on interviews, all staff stated R1 does not know how to operate the CPAP so R1 is not using it. S1 and Staff #2 (S2) added that R1 has memory issues and cannot follow directions to use the CPAP which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2026

Plan of correction: A new POC was not issued as the Administrator has submitted a written letter stating they have reviewed regulation CCR Title 22 87619 and will adhere to it.

Allegation investigated: Staff did not ensure resident was allowed to be readmitted to the facility Staff do not ensure resident receives assistance with using the bathroom Staff do not ensure resident receives adeqaute food portions Staff do not ensure resident is spoken to in an appropriate manner

On 06/23/26, at 8:15am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Susan Park, Administrator. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 05/30/25, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted the initial complaint visit, conducted a physical tour and received documentation. On 06/23/26, at 8:50am, LPA Saucedo conducted another physical tour, interviewed additional staff and residents and received additional documentation. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not ensure resident was allowed to be readmitted to the facility. It is alleged that resident #1 (R1) was not allowed back to the facility on 05/29/25. During LPA’s interview with staff #1 (S1), Responsible Party picked up R1 from hospital on 05/29/25 and brought R1 back to the facility without providing a discharge report from the hospital. S1 continued by saying R1 was sent to the hospital on 05/28/25 for a psychological evaluation. Furthermore, S1 confirmed that they had advised R1’s Responsible Party that R1 needed higher level of care and/or adjustment of medication because of all the behaviors R1 was exhibiting and R1 was also using a CPAP- Continuous Positive Airway Pressure machine nightly machine in the facility that required a skilled professional to provide to R1 and it was brought into the facility by R1’s daughter/responsible party without the facility’s knowledge. Although, R1’s daughter Responsible Party did not listen to S1 and their concern or R1’s higher level of care, R1 was still allowed back to the facility and R1 did not leave the facility again until 07/22/25 when R1’s daughter took R1 back to the hospital for having a fever and R1 never returned back to the facility. During LPA's interview with R1's daughter/responsible party, they confirmed that R1 was readmitted to the facility on 05/29/25 but they also brought R1 back from the hospital because they disagreed on R1 being at the hospital. LPA did obtain the Unusual/Incident/Injury report for 05/28/25 that was sent to Community Care Licensing Department. Therefore, based on the interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not ensure the resident receives assistance with using the bathroom. It is alleged that Resident #1 (R1) requires assistance with urinating every hour per doctor's orders. During LPA's file review, LPA obtained the doctor's order from 05/09/25, where it asks if R1's caregiver can assist with bladder training, visits to the restroom every hour. Let it be noted that R1's daughter/responsible party opted out of optional services, such as a one-to-one supervision program for R1, in the Admission Agreement. During LPA's interview with Staff #1 (S1) and S2, both staff stated that R1's daughter responsible party did not want R1 to wear any diapers or pull-ups and was demanding that facility staff attend to R1's bathroom needs by taking R1 to the restroom every hour, despite having the opportunity to pay for one-to-one supervision. S1 further stated that there are sixty (60) other residents in the facility who require care, some of whom receive one-to-one supervision, and that staff were doing their best to remind R1 to urinate as regularly as possible. During LPA's interview with R1's daughter/responsible party, did confirm that they did not want R1 to wear any diapers/pull-ups. Therefore, based on the interviews conducted the allegation is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff do not ensure resident receives adequate food portions. It is alleged that resident #1 (R1) did not get a larger portion size of food that was an order from the doctor. During LPA’s file review, LPA obtained the prescription of the doctor dated 05/09/25 that confirms that a daily additional meal with protein was supposed to be provided to R1. On 05/28/25, there was another doctor’s order for R1’s daughter/responsible behavior to provide protein shakes to R1. During LPA’s interview with staff #1 (S1) confirmed R1, R1 was provided extra snacks by the facility and by R1’s daughter/responsible party. Furthermore, S1 confirmed that they spoke to R1’s daughter/responsible party about the order from the doctor and told R1’s daughter/responsible party that the admission agreement under food services states: Three nutritious meals daily with snacks…which is part of their basic services and R1’s daughter/responsible party would have to pay for the any extra meals outside of that agreement instead they only brought snacks for R1. R1’s daughter/responsible party never bought the protein shakes for R1 only the doctor’s prescription. During LPA’s interview with R1’s daughter/responsible party, they confirmed they bought snacks for R1 but not protein shakes and did not pay the facility for extra meals. Although, R1’s medical assessment, preplacement appraisal resident appraisal and functional capability assessment did not indicate R1 was on a special diet and/or needed other portions of food S1 stated we tried our best to accommodate the eating habits of R1 we provided extra yogurt, sandwiches. Therefore, based on the interviews and file review of R1 conducted the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff do not ensure resident is spoken to in an appropriate manner. It is alleged that resident #1 (R1) was yelled at because they were trying to exit the front door. During LPA’s interview with staff #1 (S1) and S2, both confirmed that R1 would walk around the facility a lot and on multiple occasions R1 would try to exit the front door when they would see others exiting and/or entering the facility. S1 stated, “we were trying to redirect R1 not yell at them." S2 also stated, "R1 needed a lot of redirection." During LPA’s interview with R1’s daughter/responsible party, they confirmed that they were not at the facility when this happened, but they were on the phone and heard them redirecting R1. LPA obtained R1's Preplacement Appraisal and Resident Appraisal that confirms R1 needed constant redirection. Therefore, based on the interviews and file review of R1 conducted the allegation(s) is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jun 23, 2026 · control 31-AS-20250529103419

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced Annual/Required visit to this facility today. LPA met with Administrator Susan Park and explain the reason for the visit. The facility has a fire clearance for 98 non-ambulatory residents,15 of which may be bedridden. Hospice Waiver for ten (10) residents. No one is receiving Hospice Care at this time. The facility is also fire cleared for delayed egress. The facility had submitted and approved Mitigation and Infection plan. The facility is a single storey building located in a residential neighborhood consisting of 81 rooms. There is one (1) large activity room/living room, room designated for arts and crafts, large and small dining room, beauty salon, medication room and a basement parking and two (2) laundry room located in the mid section of the building. At 9:12 AM, LPA conducted physical plant tour of the facility with the Administrator. Facility currently has 32 residents on the Assisted Living Waiver (ALW) program. Common areas, including the living room, activity room and dining room appeared to be clean and properly furnished. The kitchen was clean and the appliances and fixtures are functional. Refrigerated and frozen foods were stored at proper temperatures and properly packed and stored. There was a sufficient amount of perishable and non-perishable food at the facility. Residents do not have access to the kitchen; dangerous items are stored and inaccessible to residents. The facility menu appears to meet the daily dietary needs of the residents. There were no pesticides or poisons observed near any food areas. Entry/exits passages were free of obstruction. The outdoor area was clean and free of hazards. The patios and balconies have proper furnishings. (continued from LIC 809) The medications were locked in the medication carts in the medication room, properly labeled and stored. Medication documentation and implementation appeared to be complete. Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Hot water temperature in random resident bathrooms were checked at a range of 113.4°F to 118.6°F and within the required range. First aid kits are located in the medication room. Fire alarms are hardwired throughout the facility. Fire extinguishers located in the hallways throughout the facility were checked, extinguishers were observed to be fully charged and last inspected on 10/30/25. Smoke detectors are hardwired and are observed to be operational. The facility is equipped sprinkler system and pull system. An annual inspection of the automatic sprinkler system was last completed on 03/26/26. LPA checked alarms on all direct exit doors to ensure they are operational as required, alarms were functional. LPA observed video cameras throughout the facility in the common areas with a non-audio monitoring system in place. Facility emergency disaster plan was reviewed. Facility disaster drills are conducted monthly and was last conducted on 05/30/26. In addition to the physical plant inspection, resident and staff records were reviewed. The facility handles cash for the residents. Therefore, current surety bond was checked and observed to be current. LPA reviewed five (5) of randomly selected residents. Files included signed admission agreements, current appraisals, current medical assessments, physician orders for medications and centrally stored medication logs. Medications appeared to be given as prescribed. Staff present records were also reviewed and observed to be complete and updated. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Jun 14, 2026

Allegation investigated: Staff use inappropriate restraints on residents. Staff do not treat residents with dignity and respect. Staff mismanage residents medication.

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced subsequent visit for the above allegation. LPA met with the executive director (S1), Susan Park, and explained the reason for the visit. On 08/18/25 LPA Abgan conducted an initial investigation visit. On 5.13.2026, LPA toured the physical plant at 10:40 AM. At 10:45 AM, LPA interviewed the executive director (S1) and five (5) staff. At 11:45 AM, LPA interviewed and reviewed medication for six (6) residents. At 12:00 PM, LPA conducted a records review as well as other relevant documents, including the physician's report, LIC 500 (staff roster), resident roster, appraisal needs and service plan (LIC 625), medication administration record (MAR), centrally stored medication and destruction record (CSMDR), and other pertinent documents. Allegation: Staff use inappropriate restraints on residents. Continue to LIC 9099-C Unsubstantiated It was alleged that staff are restraining resident#1-#2(R1-R2) physically or by removing the wheelchair to prevent them from being disruptive and residents are being chemically restrained with over-the-counter (PRN) medications. LPA record review today revealed a physician's order for a wheelchair for R1 and R2. LPA interview with staff revealed they never restrain residents, and R1/R2 were free to roam around the facility. Interview with residents revealed that they are not restrained and residents are assisted immediately when requested. R1 was not interviewed as they are no longer in the facility. During the physical plant tour of the facility conducted on 5.13.2026, LPA did not observe any residents being restrained chemically or physically and were happy roaming freely around the facility. Medications were stored centrally stored and medication review did not reveal PRN for restraining purposes. Based on interviews, observation, and record reviews, there is no sufficient information to verify the allegation. Therefore, the allegation is unsubstantiated at this time. Allegation: Staff do not treat residents with dignity and respect. Regarding the above allegation, it is alleged that the facility staff slammed a resident into the bed and held the resident there. Interviews with residents revealed that they are happy with the care provided and have not experienced such treatment from staff. R1 was not interviews as they are no longer at the facility. Interviews with staff revealed that they treat all their residents with dignity and respect. Upon review of facility records, there was no information to support the allegation. LPA reviewed last personal rights training given to staff on 2.3.2026. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation: Staff mismanage residents medication. It was alleged that facility staff mismanage residents' medication by missing dosages and not giving the residents their medication in a timely manner. To investigate this investigation, LPA reviewed the Centrally Store Medication and Destruction Record (CSMDR) and Medication Administration Record (MAR) for 6 residents and did not observed discrepancies. Continue to LIC 9099-C LPA reviewed the Medication Administration Record (MAR) for R1 and observed that from June 1, 2025, to November 2025, the resident's medication was given in a timely manner. All staff stated that residents always received their medication as prescribed by their physician. R1 would sometimes refuse to take their medication, but staff would try again later, and R1 would cooperate. Interview with residents revealed that they always get their medication as prescribed by their physician and that the staff gives it to them at the correct times. Residents have not been given medication to make them sleepy or keep them restrain. Based on the information received and record review, this allegation is Unsubstantiated this time. No health and safety issues were noted at the time of this visit. An exit interview was conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 13, 2026 · control 31-AS-20250811124846

Allegation investigated: Staff did not prevent a verbal altercation between residents Staff did not prevent a phyiscal altercation between residents resulting in injury

On 05/13/26, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial visit was greeted by Susan Parks, Executive Director. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 05/13/26, LPA Saucedo asked for the census, staff, and resident rosters. On 05/13/26, at 9:45am, LPA Saucedo conducted a physical tour, interviewed both residents and staff. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not prevent a verbal altercation between residents. It is being alleged that resident #1 (R1) and resident #2 (R2) began to argue at the front desk because both residents wanted to talk to the receptionist. During LPA's physical tour, LPA reviewed the facility cameras and R1 was seen arguing with the receptionist at the front desk, before R2 arrived at the front desk. R1 and R2 were then seen talking to each other for a bit. LPA conducted five (5) resident interviews. Out of the five (5) residents, three (3) resident interviews were attempted but to no avail were the residents understanding what the LPA was asking including R1 and R2. Furthermore, R1 and R2 did not remember the incident. Let it be noted R1 and R2 are diagnosed with dementia. In addition, LPA interviewed three (3) staff that confirmed R1 and R2 were not arguing it was R1 arguing with the staff member. LPA also received the Unusual Incident/Injury Report and SOC 341 which was reported to Community Care Licensing Department, the Police Department and the Ombudsman. Therefore, based on the LPA's observations, staff and resident interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not prevent a physical altercation between residents resulting in injury. It is being alleged that resident #1 (R1) stabbed resident #2 (R2) with a pen and staff did not prevent it. During LPA's physical tour, LPA reviewed the facility cameras and R2 was seen pushing their walker into R1 when R1 suddenly hit R2 with a pen which they already had in their hand. The cameras show that two (2) staff immediately responded to the incident. Let it be noted, R1 and R2 were not arguing before the incident. R2 was standing behind R1 when R1 got hit by R2 using their walker. LPA conducted five (5) resident interviews. Out of the five (5) residents, three (3) resident interviews were attempted but to no avail were the residents understanding what the LPA was asking including R1 and R2. Furthermore, R1 and R2 did not remember the incident. Let it be noted R1 and R2 are diagnosed with dementia. In addition, LPA interviewed three (3) staff that confirmed R1 and R2 are friends and are always together talking and walking around the facility. LPA also received the Unusual Incident/Injury Report and SOC 341 which was reported to Community Care Licensing Department, the Police Department and the Ombudsman. Therefore, based on the LPA's observations, staff and resident interviews conducted, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, May 13, 2026 · control 31-AS-20260511145120

Allegation investigated: Staff are not following physician’s order for resident’s medical needs.

On 5/13/2026 at approximately 9:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit to the facility. LPA was greeted by the Administrator, Susan Park and stated the reason for their visit. To investigate the allegation(s), at approximately 10:00 AM, LPA conducted a physical plant tour. By 11:00 AM, LPA requested relevant documentation such as but not limited to: Physician’s Reports, Needs/Services, and Physician’s Orders. From 11:30 AM to 2:30 PM, LPA attempted to interview one (1) resident (R1), two (2) staff members (S1-S2) and conducted record review. (Continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff are not following physician’s order for resident’s medical needs. It was alleged staff did not follow R1’s physician’s orders pertaining to their walker. To investigate the allegation, LPA attempted to interview one (1) resident and two (2) staff members. LPA attempted to interview R1, but they no longer reside at the facility. LPA’s interview with S1 revealed R1 moved out of the facility into a smaller facility due to them needing a higher level of care. S1 stated, R1’s representative did not choose to pay for optional services such as one (1) to one (1) Supervision Program. Per S1, R1’s cognitive impairments had resulted in an increase in falls and although they had a walker they would forget to use it. LPA’s interview with S2 correlated with S1’s interview. S2 stated they self-reported R1’s falls on an Unusual Incident/Injury Reports (SIRs). LPA conducted a record review of R1’s file. LPA’s record review of R1’s Physicians Visit dated 3/24/2026 confirmed R1 to need their walker. R1’s initial Needs and Services Plan dated 8/29/2022 documented R1 as ambulatory without needing assistance. However, R1’s Needs and Services Plan dated 4/12/2026, documented their change of condition to reflect their need of a walker and in need of supervision due to their inability to follow instructions. R1’s Physician’s Report dated 2/18/2026 confirmed R1 could not follow directions/instructions due to their diagnosis. LPA’s record review confirmed the facility did report R1’s falls to the appropriate reporting parties including Community Care Licensing Division (CCLD). Additionally, LPA’s review of R1’s Admission Agreement confirmed they did not have Optional Items and Services to be notated. Further record review of R1’s Notice of Resident Moving Out dated 4/15/2026 documented their reason of moving as, “Higher level of care”. During LPA’s physical plant tour, LPA observed a variety of residents to be using assistances devices to ambulate such as walkers. Additionally, LPA observed a variety of staff members assisting residents to the common areas, food preparation and medication. Based on interviews, record review and observations there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No immediate health and safety issues observed during the day of the visit. Exit interview was conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, May 13, 2026 · control 31-AS-20260326152151

Allegation investigated: Facility Staff did not provide resident with their medical device.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with Susan Park and explained the reason for the visit. --- Facility Staff did not provide resident with their medical device. It was alleged that facility is not giving Resident #1 (R1) their sleep apnea machine which they have a prescription for. To investigate the allegation, To investigate the allegation, on June 12, 2025, LPA Melissa Spaeth interviewed three (03) staff and seven (07) residents from around 11:20a.m. to 1:15p.m. LPA was unable to interview R1. To further investigate the allegation, on November 13, 2025, LPA contacted Local Ombudsman office. On April 10, 2026, LPA requested additional documents. (CONT on LIC9099-C), Executive Director did not agree with statement and does not wish to sign. Substantiated During interviews, all staff stated R1 does not know how to operate the Continuous Positive Airflow Pressure (CPAP) machine so R1 is not using it. S1 and Staff #2 (S2) added that R1 has memory issues and cannot follow directions to use the CPAP. During interviews with residents, all interviewed residents confirmed they do not use such medical devices. A review of Physician’s Report states R1 has a primary diagnosis of Dementia. R1 had no known allergies, confused/disoriented, sundowning behavior, able to follow instructions and communicate their needs. R1 is not able to administer own medications, administer own oxygen or store own medications. The Local Ombudsman stated they were not given authorization to release the information to the LPA. Based on interviews, there is enough information to verify the allegation, therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued. Executive Director did not agree with statement and does not wish to sign. LPA was unable to interview R1. To further investigate the allegation, on November 13, 2025, LPA contacted Local Ombudsman office. On April 10, 2026, LPA requested additional documents. During interviews, all staff stated all medications are given as prescribed by the physician and all residents have signed consent. During interviews, all residents stated staff have never given them medication that was not prescribed to them. A review of the Medication Administration Records indicates during the time in question resident was taking Levetiracetam/Keppra twice daily for seizures. The Medication Administration Records did not indicate R1 was taking Depakote/Divalproex Sodium/Valproate Sodium or any other medication for seizures. A review of the Centrally Stored Medication and Destruction Record does not show R1 had the alleged Depakote/ Divalproex Sodium/Valproate Sodium centrally stored with the facility. A review of R1’s records shows R1 or their responsible party signed the Consent to a Medical Examination, Consent for Emergency Medical Treatment, and Release of Client/Resident Medical Information forms. The Local Ombudsman stated they were not given authorization to release the information to the LPA. Based on interviews and record review, there is not enough information to verify the allegation, therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Apr 10, 2026 · control 31-AS-20250606101944

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87619(b)(1)(2) · Plan of correction due date: Apr 13, 2026

87619 Intermittent Positive Pressure Breathing (IPPB) Machine (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (1)Monitoring of the resident's ongoing ability to operate the equipment in accordance with the physician's orders. (2)Ensuring that the procedure is administered by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidenced by; Based on interviews, all staff stated R1 does not know how to operate the CPAP so R1 is not using it. S1 and Staff #2 (S2) added that R1 has memory issues and cannot follow directions to use the CPAP which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 10, 2026

Plan of correction: Licensee will review regulation CCR Title 22 87619 and submit a written letter stating they have reviewed the regulation and going forward will adhere to it by the POC due date.

Allegation investigated: Staff does not ensure infection control guidelines are being followed

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced complaint visit, to investigate the allegation mentioned above. LPA met with the front receptionist and Administrator Susan Park and informed them the reason of the visit. The following information was obtained: To investigate the allegation, on the date of the visit, from 9:30 a.m. to 10:00 a.m., (LPA) conducted a physical plant inspection of the facility. Review of the complaint indicated that facility staff were placing PPE carts outside the rooms of infected residents. It was also reported that staff working at the facility had tested positive for COVID19 and that visitors were not notified. From 10:30 a.m. to 12:30 p.m., LPA conducted interviews with seven (7) staff and six (6) out of six (6) residents. During the physical plant inspection, upon entry into the facility, LPA observed no posted signage regarding COVID-19 or infectious diseases throughout the facility. (Cont'd LIC9099C) Unsubstantiated However, such signage is not currently required based on guidance from the local health department, public health orders, or other government reporting entities, including Licensing. LPA observed infection control measures in place, including identification of COVID-19 positive residents through postings on resident doors, PPE supply storage drawers, and covered trash bins located outside the affected residents’ rooms. The Administrator reported that staff follow the facility’s infection control plan and implement appropriate infection prevention procedures. LPA interviewed staff who were providing care to COVID-19 positive residents. Staff explained their procedures for donning and doffing PPE before entering and after exiting resident rooms. The procedures described by staff were consistent with the facility’s infection control plan. Additionally, LPA was informed that only one (1) staff member had tested positive for COVID-19, and that staff member was not currently working at the facility. Residents reported that they were notified of positive COVID-19 cases within the facility. LPA observed multiple residents and staff wearing masks during the visit. Based on observations, physical plant inspection, and interviews conducted, there is insufficient evidence to support the allegation that staff do not ensure infection control guidelines are being followed. Therefore, the allegation is determined to be Unsubstantiated. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Feb 26, 2026 · control 31-AS-20260223090016

Allegation investigated: Staff refused to accept resident back to the facility

On 02/03/2026 at approximately 1:15pm, Licensing Program Analyst (LPA) Nadia Shahbazian arrived at the facility to conduct an unannounced, subsequent complaint visit. LPA was greeted by Susan Park - Executive Director and explained the purpose of this visit. On 08/26/2025, LPA Shahbazian conducted the initial complaint visit. On 08/26/25, LPA Shahbazian had interviewed staff and gathered pertinent documents regarding the investigation. On 02/03/2026, at 1:30pm, LPA Shahbazian conducted a physical tour to ensure safety, no immediate health issues were observed. Continued on 9099-C Unsubstantiated Regarding the allegation: Staff refused to accept resident back to the facility. It is being alleged that Resident #1 (R1) was not being accepted back to the facility. R1 was admitted to the facility with diagnosis of dementia and required Assistance of Daily Activities (ADLs). LPA was provided copies of several Unusual Incident/Injury Reports from 04/21/2025-05/28/2025, where R1 was involved in physical altercations with staff and residents, which presented health and safety threats. On 02/10/25 R1 was diagnosed with a condition requiring use of Continuous Positive Airway Pressure (CPAP) machine nightly. Administrator informed LPA that sometime in late April 2025 POA brought in a CPAP machine, without notifying the Administrator. POA trained a former Med Tech how to put on the mask on R1 and asked the staff to monitor R1 every two hours to ensure the mask is properly placed. In May 2025 Administrator had a Care and Service Meeting with POA. Additionally, Administrator informed POA that breathing machines are considered Restricted health conditions, which are against facility’s plan of operation. Administrator informed POA that R1 might perhaps need a higher level of care. On several occasions R1 was hospitalized. On one occasion, on 05/28/2025, POA discharged R1 from hospital, without approval from facility administrator and without providing discharge report. Facility served a 30 day eviction notice on 06/17/2025, with move out date of 07/17/2025, but R1 was not evicted. Administrator informed LPA that on 07/22/2025 POA took R1 to hospital due to fever and R1 was hospitalized. Facility staff visited R1 in the hospital on 08/19/2025 and evaluated R1. It was observed that R1 is using CPAP machine in the hospital. Additionally, hospital report obtained, also states that resident has sleep apnea and requires continued use of CPAP machine at nights. Based on interviews and record review, it was determined that POA was informed of R1’s possible need for higher level of care due to behavioral issues and CPAP machine. R1 was served 30 day eviction notice on 06/17/2025. Due to higher level of care, facility is unable to provide such care, therefore the allegation is UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 31-AS-20250821090734

Allegation investigated: Staff handled resident in a rough manner.

Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with the administrator Susan Park who granted access. Shortly after LPA met with the Assistant Administrator, Christopher Redmond, and explained the reason for the visit. Allegation: Staff handled resident in a rough manner. It was alleged that on 01/25/2026, Resident #1 (R1) struck a staff member on the face and staff retaliated by aggressively grabbing and shaking R1's arm, then throwing a blanket over the resident’s face and body. To investigate the allegation, on 02/02/2026, LPA obtained copies of the Personnel Report (LIC 500) and the Client Roster. At 11:05 a.m., LPA initiated a physical plant tour of the facility to ensure the health and safety of residents in care. Between 11:15 a.m. and 2:00 p.m., LPA conducted interviews with seven (7) residents, of which two (2) did not respond to LPA’s questions, as well as interviews with three (3) staff members and the assistant administrator. At 12:15 p.m., LPA reviewed and obtained a copy of the video footage related to the incident. (Continue to LIC9099-C) Substantiated (Continued from LIC9099) At approximately 2:25 p.m., LPA reviewed and obtained copies of the following documents, including but not limited to: R1’s Physician’s Report, R1’s Appraisal, Staff #1’s (S1) job application, S1’s training records, and the Unusual Incident Report and SOC 341 the facility submitted to Community Care Licensing. R1 was not at the facility during todays visit. LPA's interviews with five (5) residents denied they had been treated roughly by staff members. LPA's interview with Staff #3 (S3) revealed R1 reported the incident to them. S3 then reviewed the video from that day and reported the incident to the assistant administrator. During LPA's interview with Staff #2 (S2) they stated they were asked to assist S1 with transferring R1 from the couch to a wheelchair, but did not witness, "R1 hit S1 or S1 hit R1 back" they maintained they did not witness either interaction and if S1 grabbed R1 it was without intention and without pressure. LPA's interview with S1 denies they handled R1 in a rough manner. According to S1 they held R1's arm down to prevent R1 from hitting staff or the other resident and they meant to "toss" the blanket to couch behind the client. LPA’s review of the video shows S1 and S2 struggling to assist R1 from the couch to a wheelchair, attempting at least three times before successfully placing R1 in the wheelchair. R1 is seen striking S1 in the face, after which S1 approaches R1 and grabs R1 by the right arm, because another resident stands in front of S1 and R1, LPA could observe R1’s head from side to side and part of R1's arm movement. S2 then tosses a blanket to R1, and R1 throws the blanket to the floor. S1 picks up the blanket from the floor and throws it over R1’s head and body before walking out of the room. R1 removes the blanket, and another resident is seen grabbing the blanket and shoving it onto R1’s face. S2 stops the interaction between R1 and the other resident, and then wheels R1 out of the room. According to the assistant administrator S1 was placed on Administrative leave pending an investigation and has been terminated as of 02/02/2026. Based on interviews conducted and video observed, this allegation is deemed SUBSTANTIATED at this time. Deficiency cited (refer to LIC9099-D). Exit interview conducted. Appeal Rights provided. A copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 2, 2026 · control 31-AS-20260129081307

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Feb 3, 2026

(a)...residential care facilities for the elderly shall have all of the following personal rights: (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 conducted and video reviewed by LPA, R1 was handled in a rough manner by S1 which posed an immediate health and safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Feb 2, 2026

Plan of correction: S1 was terminated as of 02/02/2026. Administrator will start in service training for all staff regarding residents rights and mandated reporting. Administrator will provide a copy of the material and sign in sheet to LPA by POC date 02/03/2026.

Allegation investigated: Staff did not ensure that resident was provided a safe environment.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with Assistant Administrator, Christopher Redmond, and explained the reason for the visit. --- Staff did not ensure that resident was provided a safe environment. It was alleged that Resident #1 (R1) was pushed and pulled to the ground on multiple occasions by two former roommates approximately one month ago. To investigate the allegation, on January 21, 2026, LPA requested documents at 9:30am and interviewed three staff and six residents from 10:00a.m. – 1:00p.m. A review of facility schedule shows there are five caregivers and one MedTech during the morning and afternoon shifts and three caregivers for the overnight shift. A review of the Department’s records shows that R1 had two fall incidents during the period in question. (CONT. on LIC9099-C) Unsubstantiated During interviews with residents, R1 stated on two separate occasions, Resident #2 (R2) pushed them to the floor and Resident #3 (R3) pulled them to the bed. R1 could not recall when. R1 added there were no witnesses during both alleged incidents. During the interview, R1 stated, “I think that happened, I may have imagined it.” LPA was unable to interview R2 and R3 due to current health conditions. During interviews, all staff stated they did not witness the alleged incident or know of any witnesses. Staff added residents are checked on at least every hour or more frequently if needed. Staff #1 (S1) stated R1 was evaluated, did not have visible injuries but was sent to the hospital as a precaution. On both alleged incidents, the hospital returned R1 with no injury. S1 stated as an additional precautionary measure, R1 was moved to another room on both alleged occurrences. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 31-AS-20260114125531

Allegation investigated: Factility staff are not releasing resident's records to legal representative

On 01/12/26, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Christopher Redmond-Assistant Administrator. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 01/12/26, LPA Saucedo asked for the census, staff, and resident rosters. On 01/12/26, at 9:55am, LPA Saucedo conducted a physical tour. On 01/12/26, at 10:15am, LPA Saucedo started to conduct resident and staff interviews. LIC 9099C-continued Unsubstantiated Regarding the allegation: Facility staff are not releasing resident's records to legal representative. It is being alleged that Resident #1 (R1)’s entire file has been requested, there have been six (6) attempts and there has been no release of R1’s records to legal representatives. During LPA’s pre-investigation, LPA received a HIPPA-(Health Insurance Portability and Accountability Act) Compliant Medical Authorization signed and dated by R1's son on 06/16/23 with no notarization and an Advanced Health Care Directive stating R1's son is Power or Attorney for Health Care signed and dated and notarized on May 04, 2017, including R1's signature in 2016. The Advanced Health Care Directive lists two (2) other of R1's sons for Power of Attorney but it does not list any legal representatives as Power of Attorney to receive records. There have been no documents provided to show any type of consent-(form LIC 605A) for the Release of Client/Resident Medical Information to legal representatives besides the Power of Attorney. LPA did speak to R1's Power of Attorney and they did state, "that no paperwork has been updated to show records can be released to others." The LIC 605A was signed on 10/26/23 by R1's son for the Release of Client/Resident Medical Information. LPA attempted to interview R1 but to no avail was R1 responding to LPA's question. Let it be noted, R1 is currently diagnosed with Dementia per their Physician's report and Resident Appraisal. LPA interviewed two (2) staff that confirmed they did receive information from legal representatives to receive R1's file but R1's Power or Attorney for medical records never requested such information and never updated the LIC 605A form to let anyone else receive R1's records. In addition, the person's that were requesting R1's records are not listed on R1's Identification and Emergency Information. LPA reviewed and obtained the following documents regarding R1-Physician's report and Resident Appraisal, LIC 605A, Identification and Emergency Information, Admission Agreement, Personal Rights all signed by R1's son-Power of Attorney. Therefore, based on the record reviews and interviews conducted, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Assistant Administrator.the state’s words, verbatim · CDSS document, Jan 12, 2026 · control 31-AS-20260107164256

Allegation investigated: Staff refused to accept resident back to the facility Staff did not inform authorized representative of incidents

On 12/16/25, at 9:25am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent visit was greeted by Assistant Administrator, Christopher Redmond. LPA explained the purpose of this visit was to gather additional information, interview staff and residents and deliver findings for this complaint. On 11/26/25, LPA Saucedo conducted the initial visit. On 11/26/25, LPA Saucedo asked for the census, staff, and resident rosters. On 11/26/25, LPA Saucedo conducted a physical tour and obtained the following documents regarding resident #1 (R1)’s-Pre-placement, Resident Appraisal, Functional Capability Assessment, Physician's Report and Appraisal/Needs and Services Plan. On 12/16/25, at 9:55am, LPA Gina Saucedo conducted another physical tour, interviewed additional staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff refused to accept resident back to the facility. It is being alleged that resident #1 (R1) was not being accepted back to the facility. LPA received all unusual/incident reports that were sent to CCLD-Community Care Licensing Department in regards to R1’s falls and/or hospitalization. LPA interviewed three (3) staff that confirmed R1 returned to the facility more than once from the hospital. They have not refused R1 back into the facility at any time. One (1) staff did confirm that they spoke to someone at the hospital telling them that R1 will need a higher level of care because of the repetition of their falls and their concern for R1's safety. LPA also spoke to R1’s POA-Power of Attorney and the POA did confirm that the facility did mention a higher level of care because of R1’s falls and asked if R1 can have a 1:1 staff with them because R1 is now a fall risk and also confirmed with LPA that R1 was accepted back to the facility with no issues. During LPA’s physical tour on 11/26/25, R1 was at the facility and had just returned from the hospital a few days prior. LPA attempted to interview six (6) residents including R1 but to no avail none of the residents could understand what the LPA was asking and/or answer LPA's questions. Therefore, based on the LPA's record reviews, staff, resident and POA interviews conducted, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not inform authorized representative of incidents. It is being alleged that resident #1 (R1)’s power of attorney (POA) was not informed of R1’s incidents. LPA interviewed four (4) staff that confirmed that since R1’s admission to the facility was in October of 2025, R1 has fallen multiple times and has gone to the hospital twice. Four (4) staff confirmed that for every incident they have informed R1’s POA and doctor. LPA reviewed all unusual/incident reports that were sent to CCLD-Community Care Licensing Department in regards to R1’s falls and/or hospitalization and it shows POA and doctor were informed. LPA called R1’s POA to confirm if they were aware of R1’s incidents and R1’s POA confirmed that they were aware of R1’s incidents and hospitalization because the facility let them know and they also had visited R1 at the hospital. Furthermore, R1's POA also confirmed that the hospital called them since they were on R1's emergency paperwork to let them know R1 was at the hospital. LPA obtained R1's Identification and Emergency Information showing who is R1's guardianship. LPA attempted to interview six (6) residents including R1 but to no avail none of the residents could understand what the LPA was asking and/or answer LPA's questions. Therefore, based on the LPA's record reviews, staff, resident and POA interviews conducted, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Dec 16, 2025 · control 31-AS-20251120120416

Allegation investigated: Licensee changed resident's Insurance without the resident or their responsible party's authorization. Staff did not assist resident with their medication. Medication staff not properly trained. Licensee retaliates against the resident.

On 12/11/2025 at approximately 9:45 AM, Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced subsequent complaint visit to the facility to conclude the investigation regarding the above allegations. Upon arrival, LPA was greeted by Christopher Redmond-Assistant Administrator and Executive Director-Susan Park and advised of the complaint. To investigate the above allegations, on 12/09/2025 at approximately 10:00 AM, Licensing Program Manager (LPM) Troy Agard and Licensing Program Analyst (LPA) Nadia Shahbazian had conducted an unannounced initial complaint visit to the facility and requested relevant documentation. From 10:30 AM to 1:30 PM, LPA/LPM conducted a record review and interviews with residents and staff. on 12/09/2025 at 1:20 PM, LPA/LPM conducted a physical plant tour. Continued on 9099-C Unsubstantiated Regarding the Allegation: Licensee changed a resident’s insurance without the resident’s or responsible party’s authorization. It was alleged that a facility staff member modified the resident’s health insurance without consent from the resident or their responsible party. LPA and LPM interviewed five staff members out of a total of 45. Interviews indicated that any changes to a resident’s health insurance must be initiated by the resident and/or their responsible party. During an interview with Staff 1 (S1) stated they were unaware of who made the changes to the medication portion of R1’s health insurance and explained that such modifications are typically handled between R1’s Power of Attorney (POA) and the pharmacy. Interviews with W1 and W2 did not confirm who made the changes to R1’s medical insurance; however, both stated that the facility was not responsible for the alteration. Interviews with the resident were not able to confirm this allegation. Regarding the Allegation: Staff did not assist the resident with their medication. It was alleged that staff failed to package a one-day supply of R1’s medications, resulting in a shortage, particularly at the end of the month. It was further alleged that the facility refused to transport medication to address the shortage. LPA and LPM interviewed five staff members and residents. Interviews confirmed that the pharmacy provides medications in blister packs covering an entire month, and refills are typically ordered one week in advance to prevent any interruption in the medication supply. It was determined that R1 went on a home visit during the middle of a medication cycle, and the POA had been informed that the medication for the upcoming month was not yet available due to the holiday week. During an interview with S1, S1 stated they did not transport the medication because no authorized individual was available to deliver it, that such transport is not standard practice unless the facility is at fault for a medication error, and that they were not comfortable with the request to send the medication via “Uber” while R1 was on a home visit. Interviews with the resident were not able to confirm this allegation. Continued on 9099-C Regarding the Allegation: Medication staff not properly trained. It was alleged that a Medication Technician (Med Tech) was not properly trained in preparing medications for residents who leave the facility for outings. Staff interviews indicated that Med Techs receive training from both a virtual Registered Nurse (RN) and an onsite Licensed Vocational Nurse (LVN). Training includes medication administration procedures and certification requirements. During an interview with S1, it was reported that the facility recently implemented a new system intended to reduce medication-related issues for residents who go on home visits. A review of training records confirmed that Med Techs receive three to six weeks of training, including shadowing. Interviews with the resident were not able to confirm this allegation. Regarding the Allegation: Licensee retaliates against the resident. It was alleged that the facility retaliated against the resident. Interviews with R1, residents and staff unanimously denied this allegation. Based on interviews, record review, and all information gathered, the above allegation(s) are determined to be UNSUBSTANTIATED. Exit interview was conducted, and a copy of this report was provided to the Assistant Administrator.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 31-AS-20251201113926

Allegation investigated: Facility staff did not follow reporting requirements

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with Chris Redmond and explained the reason for the visit. ---Facility staff did not follow reporting requirements It was alleged that facility has multiple unreported incidents involving Resident #1 (R1). To investigate the allegation, on 06/12/2025 LPA Melissa Spaeth interviewed three (03) staff from around 11:20a.m. to 1:15p.m. On 06/16/2025, LPA Spaeth interviewed other parties. To further investigate the allegation, on 11/13/2025, LPA contacted Local Ombudsman office and reviewed the Community Care Licensing Department’s records. (CONT. on LIC9099-C) Substantiated During interviews with staff, all staff stated they follow all reporting requirements. During interviews with Staff #1 (S1), they stated facility has had multiple incidents involving staff and other residents. S1 also stated that R1 had an incident on 05/28/2025 involving a physical altercation between R1 and another resident. During interviews with other parties, they stated facility did not notify the Responsible Party until the following day that an incident had occurred. The Local Ombudsman stated they were not given authorization to release the information to the LPA. Although facility notified the Responsible Party within 24 hours, a review of the Department’s records revealed that facility did not notify the department of the alleged incidents between R1 and staff, and R1 and resident(s). Based on interviews and record reviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued. During interviews with staff, all staff stated they do not retaliate against residents and have never witnessed S1 retaliating against R1. During interviews with residents, all residents stated they have never experienced any retaliation from S1. S1 stated R1 has had multiple altercations between staff and residents and that a 30-day eviction was issued for the health and safety of other residents, staff and R1. The Local Ombudsman stated they were not given authorization to release the information to the LPA. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 31-AS-20250606101944

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 17, 2025

Reporting Requirements(a)(1)A written report shall be submitted to the... agency.. within seven days…(D)Any incident which threatens the welfare, safety or health of any resident,... by staff or other residents,...This requirement is not met as evidenced by; Based on interviews & record review, Licensee did not submit to the licensing agency...within 7 days an incident that threatened the welfare, safety or health of a residents which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2025

Plan of correction: Licensee will review the CCR Title 22 87211 and submit a written letter stating they have reviewed the regulation and going forward will ensure to adhere to the regulation by the POC due date.

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: Staff did not provide resident medication as prescribed

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to conclude the investigation regarding the above allegation. LPA met with the assistant administrator, Edwin Sanchez and advised him of the complaint. Today’s investigation consisted of interviews with the administrator and staff. LPA also conducted a record review and a physical plant inspection. In regards to the allegation, it’s being reported that on or around 09/26/25, Resident 1 (R1) was packed another resident’s (Resident 2 (R2)) medication for R1’s outing. Both resident’s take Memantine. R1’s dosage for the Memantine is 5mgs, but instead of packing R1’s Memantine for 5mgs, R1 was packed R2’s Memantine for 10mgs. In addition, R1 was packed several of R2’s other medications, which were Atorvastatin, Donepezil, and Tamsulosin. Pictures of this medication error was included as proof R1 was packed the wrong medication for their outing. It was also identified that this packing of medication error, Substantiated between both these two residents, has occurred by the same staff, Staff 1 (S1) in the past. S1 was trained and instructed to review and differentiate both these residents medications when packing, but S1 made the same mistake. Interviews with both administrator and one (1) of one staff were held between 9:15am-10:15am to discuss the package, preparation and distribution of resident medications during outings. At around 10:15am - 12:15pm, LPA conducted a physical plant inspection of the medication room to observe and review centrally stored medication and medication documentation. LPA attempted to interview six (6) of six residents between 12:15pm to 1:00pm, but due to the diagnoses of these residents, LPA was unable to get a consistent interview. Although corrections are in place to address this medication error, based on the information obtained, the allegation of staff providing or packing the wrong medication for R1 is Substantiated. Citation issued on the 9099D. Administrator advised and a copy of this report issued.the state’s words, verbatim · CDSS document, Oct 9, 2025 · control 31-AS-20250929135423

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(4) · Plan of correction due date: Oct 16, 2025

Personnel Requirements: All personnel shall be given on the job training or have related experience with knowledge required to safely assist with prescribed medications. This requirement was not met as evidenced by: on or around 09/26/25, R1 was packed R2's medication in error, for R1's outing. This posed a potential health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Oct 9, 2025

Plan of correction: As POC, S1, will receive on the job training to address this section of the regulation. As proof training is held, licensee will submit attendance log with training topic, addressing section 87411(d)(4) to CCL by 10/16/25

Allegation investigated: Resident sustained multiple injuries while in care. Staff did not prevent inappropriate interactions between residents in care. Staff did not accord resident dignity while in care.

In conjunction to complaint control # 31-AS-20250929135423, Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegations. The initial visit was made by Licensing Program Analyst (LPA) Mariana Agban on 06/26/25. During this visit, LPA met with the assistant administrator, Edwin Sanchez, and advised him of the complaint. LPA’s investigation consisted of interviews with staff and residents, a physical plant inspection, and record review. Resident sustained multiple injuries while in care: In regards to the allegation, it’s being reported that due to a lack of supervision, Resident 1 (R1) sustained unexplained injuries, presumably caused by another resident or staff. There were no witnesses identified to confirm this allegation. Moreover, R1 is diagnosed with a disease that makes them unable to provide an explanation of what happened to cause the injury. Unsubstantiated At approximately 11:45am to 12:30pm LPA conducted interviews with six (6) of six staff, who were unable to confirm the allegation. From 12:30pm to 1:30pm LPA conducted interviews with six (6) of six residents. Due to the diagnosis of these residents, they were unable to confirm if the facility provides adequate supervision. From 1:30pm to 2:15pm, a physical plant inspection was conducted. There are surveillance cameras observed in common areas of the facility, which is a one story building, licensed to serve a capacity of 98 non-ambulatory residents. The facility also has an approved delayed egress. During the physical plant inspection, LPA observed six staff on duty, which include LVN, Residential Care Specialists, Office Manager, House Keeping and Kitchen staff. Based on the information obtained, there wasn’t enough evidence to prove a resident’s injury was a result of a lack of supervision. Therefore, the allegation is deemed Unsubstantiated at this time. Staff did not prevent inappropriate interactions between residents in care: In regards to the allegation, it’s being reported that on or around April 2024, because of inadequate staffing at the facility, Resident 2 (R2) struck and attacked R1. Law enforcement was notified and responded to a report describing battery. Their report gave no indication or conclusive evidence that there was a lack of supervision. Surveillance video was reviewed and it was observed that Staff 1 (S1) intervened immediately to redirect both residents. At approximately 11:45am to 12:30pm LPA conducted interviews with six (6) of six staff, who were unable to confirm the allegation. From 12:30pm to 1:30pm LPA conducted interviews with six (6) of six residents. Due to the diagnosis of these residents, they were unable to confirm if the facility provides adequate supervision. From 1:30pm to 2:15pm, a physical plant inspection was conducted. There are surveillance cameras observed in common areas of the facility, which is a one story building, licensed to serve a capacity of 98 non-ambulatory residents. The facility also has an approved delayed egress. During the physical plant inspection, LPA observed six staff on duty, which include LVN, Residential Care Specialists, Office Manager, House Keeping and Kitchen staff. Although the police report showed evidence of R2 attacking R1, there was insufficient evidence to conclude that this was a lack of supervision on the day this incident occurred as S1 was shown to intervene immediately to redirect both residents. Moreover, interviews made with both staff and residents do not corroborate with the allegation. Therefore investigation is Unsubstantiated at this time. Staff did not accord resident dignity while in care. In regards to the allegation, it’s being reported that on or around 04/26/25, there was a male individual, verbally abusing R1. There was no indication if this individual was a staff or resident. There also was no witnesses identified to corroborate with the allegation. At approximately 11:45am to 12:30pm LPA conducted interviews with six (6) of six staff, who were unable to confirm the allegation. From 12:30pm to 1:30pm LPA conducted interviews with six (6) of six residents. Due to the diagnosis of these residents, they were unable to confirm any personal rights violation. During the physical plant inspection, LPA observed six staff on duty, which include LVN, Residential Care Specialists, Office Manager, House Keeping and Kitchen staff. LPA did not observe any personal rights violation during this walk through of the facility. Based on the information obtained, it could not be proven that staff do not accord the resident’s dignity while in care. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 31-AS-20250620115653

Allegation investigated: Staff did not provide resident medication as prescribed

Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegation. The 10 day visit was made bye LPA Mariana Agban on 06/26/25. Today, LPA met with the assistant administrator, Edwin Sanchez and advised him of the complaint. The administrator, Susan Park, was advised of the complaint and joined shortly after. Today's investigation consisted of a physical plant inspection (between 11:00am-12:00pm), Record review (between 12:00pm-1:00pm), and interviews with staff and residents (between 1:00pm-2:00pm). In regards to the above allegation, it's reported that Resident 1's (R1) medication for Keppra was stopped being administered by facility staff without the doctor's orders. Prescription for Keppra, should have decreaed, but not stopped entirely. Facility staff did not follow R1's prescription orders as prescrbied. As a result of the stoppage, or discontinued use of Keppra, R1 experienced a seizure. Unsubstantiated Interviews with the facility administration and Staff 1 (S1) deny the allegation. According to administration and staff, R1's Keppra was ordered to be given on or off by R1's physician or the pharmacy. Nonetheless, Keppra was being administered as prescribed. Review of facility records and documentation of R1's orders for Keppra reveal the follwing: 06/09/25- Order for Keppra was stopped 06/15/25- Order for Keppra is to start, one (1) tablet, two (2) times daily for thirty (30) days 06/28/25- Order for Keppra was changed to take one (1) tablet, once a day Copy of R1's Medication Administration Record (MAR) for June and July 2025 obtained to insure R1's Keppra was given as ordered. No discrepancy observed through July 22, 2025, when R1 was sent to the hospital. R1 has been in the hospital since July 22, 2025. Discharge unknown at this time. In addition, interview with ten (10) of then residents made. These interviews are inconsistent and do not corroborate with the allegation of staff not giving the resident's medications as prescribed. Based on the information obtained, there wasn't enough evidence to prove the allegation of staff not providing resident medications as prescribed. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 31-AS-20250626110852

Allegation investigated: Staff did not provide adequate supervision resulting in resident sexually abusing another resident.

On 08/25/25, at 9:20am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Administrator, Susan Park. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 08/25/25, at 9:45am, LPA Saucedo asked for the census, staff, and resident rosters. At 10:15am, LPA Saucedo conducted a physical tour, interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff did not provide adequate supervision resulting in resident sexually abusing another resident. It is being alleged that resident #1 (R1) has dementia with wandering behavior and can be confused/disoriented and might not have the capacity to consent to potential sexual interactions. During LPA's physical tour, LPA reviewed the facility cameras on 08/16/25, where it shows that R1 entered resident #2 (R2)'s room with their walker willingly. R2 was behind R1 walking normally. Let it be noted, R1 in non-ambulatory and R2 is ambulatory. About twenty-five to thirty minutes later, R1 was seen exiting R2's room. Both R1 and R2 continued to look outside of the room on their left and right side to check if anyone was coming in both directions. R1 proceeded to step out of R2's room and R2 came out right behind R1. LPA spoke to R1's daughter via telephone to check if the facility had contacted them and the daughter stated, "yes, they contacted me and stated R1 has the right to do what they want, I cannot stop them and R1 is happy and has not reported anything inappropriate them." LPA also spoke to four (4) staff that confirmed that R1 is always talking to R2 and two (2) staff confirmed that R1 has been seen with R2 on multiple occasions. Two (2) staff also confirmed that they saw R1 on the day of the incident where R1 came into the dining hall with messy hair and R1 seemed happy and did not report anything to them. LPA also interviewed R1 and R2 and they both stated that they are friends and they are both happy. Both also confirmed that they have not been sexually and/or physically abused by anyone. Let it be noted, both R1 and R2 are diagnosed with dementia. Both R1 and R2's Physician Report was obtained. LPA attempted to interview four (4) other residents but they did not understand what the LPA was asking. LPA also obtained the Unusual Incident/Injury Report regarding R1 and R2. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Aug 25, 2025 · control 31-AS-20250821130800

Type of visit: Case Management - Deficiencies

In conjunction to the complaint number 31-AS-20250811124846 Licensing Program Analysts (LPA) Mariana Agban conducted a case management- Deficiencies visit. During the complaint investigation, LPA reviewed Internal Resident's Incident Report and observed that on 7/10/25 R2 was R2 was bleeding with a lot of bruises. LPA later confirmed that Administrator failed to submit a Special Incident Report for Resident 2(R2) to CCL. LPA conducted a file review and didn't observe Special Incident Report (SIR) on file for R2. Deficiencies Cited. Exit Interview Conducted. Report Issuedthe state’s words, verbatim · CDSS document, Aug 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80061(b) · Plan of correction due date: Aug 25, 2025

80061(b) Reporting Requirements. Upon the occurrence…a report shall be made to the licensing agency..., a written report ...within seven days following the occurrence of such event. This requirement was not met as evidence by Based on file document review, the Licensee did not comply with the section cited above. Administrator didn't submit a SIR for R2 regarding his/her injuries on 07/10/25. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: The Administrator will conduct in service training reviewing the regulation section about reporting requirements. The Administrator will provide all training materials and signatures of all staff that have attended the training by the POC due date. Licensee will also submit a SIR for R2.

Allegation investigated: Licensee does not ensure enough staff to meet the needs of residents

On 08/05/25, at 8:55am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Administrator, Susan Park. LPA explained the purpose of this visit was to gather information, interview staff and residents and deliver findings for this complaint. On 08/05/25, at 9:35am, LPA Saucedo asked for the census, staff, and resident rosters. At 10:20am, LPA Saucedo conducted a physical tour, interviewed staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Licensee does not ensure enough staff to meet the needs of residents. It is being alleged that the above facility has limited staff and therefore resident #1 (R1)’s needs are not being met. LPA interviewed five (5) staff that confirmed there are five (5) caregivers working the morning shift, afternoon shift and three (3) caregivers on the night shift. In addition, there are four (4) one-on-one staff providing 24 hour care to four (4) residents. LPA interviewed two (2) residents that confirmed their needs are being met by staff. LPA attempted to interview four (4) other residents but they did not understand and/or were able to answer LPA's questions. Let it be noted, these residents are diagnosed with dementia. LPA obtained the caregivers schedules that confirm there are five (5) caregivers in the morning and afternoon shift, three (3) caregivers at night and four (4) staff providing one-on-one care. During LPA's physical tour, LPA observed five (5) caregivers, the Activities Director, two (2) medical technicians, the administrator and assistant administrator and front desk staff. Therefore, based on the LPA's observations, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the Administrator. Regarding the allegation: Staff did not seek timely medical attention for resident in care. It is being alleged that because resident #1 (R1) did not receive medical attention on a timely basis, R1 got an infection and needed surgery. During LPA's record review regarding R1, LPA observed the R1 receives ALW-Assisted Living Waiver and is under Tier 4. The assisted living waiver states R1 needs extensive assistance with ADL's-Activities of Daily living. Some of the activities of daily living that R1 needs help with is incontinence care and bathing. ALW documentation shows that R1 needs total dependence of toilet use and bathing. In addition, its shows rashes and itchiness to be a problem. Furthermore, the Appraisal/Needs and Services Plan shows that R1 needs assistance with bladder incontinence; therefore, using pull-ups and/or diapers. R1's Physican's report shows that R1 has a history of skin conditions or breakdown. R1's resident appraisal and Functional Capability Assessment shows R1 needs help with toileting and bathing. LPA interviewed four (4) staff that confirmed R1 needs help with toileting and bathing. One (1) out of the four (4) staff confirmed that R1 had pimples and rashes in their private area and noticed it while showering R1. Another staff confirmed that R1 would always be scratching and noticed rashes in their hand area but also confirmed that they heard other staff saying R1 had rashes in their private area. R1 was taken to the Glendale Memorial Hospital on 07/22/25 by their daughter because of fever and chills and it was determined by medical records that R1 had scrotal cellulitis/scrotal abscess and needed a immediate surgery to avoid sepsis. LPA requested medical records from Glendale Memorial Hospital and they were received on 08/04/25 confirming that R1 needed immediate medical attention. Therefore, based on the LPA's observations of the medical records, ALW documents, physicians report, resident appraisal, functional capabilities and needs and services plan, and staff interviews the above allegation(s) above is SUBSTANTIATED at this time. An exit interview was conducted, citation(s) were issued, appeal rights and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 31-AS-20250730155846

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Aug 6, 2025

§1569.269 Enumerated rights; severability(a) Residents of residential care facilities for the elderly shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs... This requirement is not met by: Based on the LPA's record review and staff Interviews the licensee/administrator failed to ensure the care, supervision and services of resident #1 (R1) while in the facility. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Licensee/Administrator will provide training to all staff on the care, supervision and services to all residents. POC Due Date: 08/06/25

Allegation investigated: Communications from residents' representatives are not being answered

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit to investigate the above allegation. LPA arrived and was greeted by the receptionist. LPA met with the Assisted Administrator Edwin Sanchez and Administrator Susan Park, explaining the reason for the visit. LPA requested copies of pertinent information, which includes LIC 500 and the Resident Roster. LPA conducted a physical plan tour to ensure the health and safety of the residents are protected and are in compliance with Title 22 Regulations. Allegation: Communications from residents' representatives are not being answered It was alleged that the facility had a new phone service that made communications from residents' representatives unanswerable. An interview with the Administrator denied the allegation. The Administrator stated that the new phone service had been installed by the facility corporation to assist all Glen Park residents and their representatives. (Continue on 809C) Unsubstantiated Interviews with 7 out of 67 residents and 3 staff members did not corroborate the allegation. LPA conducted random test calls to the facility’s main number and verified that the phone line functions properly, with calls answered after 1-2 rings. Interviews with Staff#2 (S2) and Staff#3 (S3) confirmed that calls from residents' representatives are being answered around the clock. S1 and S2 also mentioned that, in addition to the facility's phone, the Administrator and Assistant Administrator are on call 24/7 for emergencies. Based on information obtained the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jul 14, 2025 · control 31-AS-20250707094244

Allegation investigated: Staff neglect resulted in a resident's death

Licensing Program Analyst, Abeye Duguma, (LPA) conducted an unannounced subsequent complaint visit to the facility. Upon arrival, LPA met with Susan Park and explained the reason for the visit. ---Staff neglect resulted in a resident's death It was alleged that Resident #1 (R1) may have been dead for a number of hours before being found because no staff member had checked on R1 that day until the afternoon. To investigate the allegation, on 11/22/2024, Licensing Program Analyst Gary Tan conducted an unannounced initial complaint visit, conducted physical plant tour at 9:50a.m., requested copies of facility documents relevant to the investigation at 10:08a.m. and interviewed staff and residents between 10:30a.m. to 11: 45 a.m. (CONT. on LIC 9099-C) Unsubstantiated To further investigate the allegation, Investigator Jose Santana (SI) requested additional records and conducted additional interviews. The interviews with staff revealed safety checks were conducted on residents at minimum of every two (02) hours. The review of the facility records revealed the last documented safety check completed by staff was at 2:00p.m. The interview of the staff assigned to R1 revealed they confirmed checks were completed on R1 throughout the shift and no change in condition was observed. The interview of former staff, S1, revealed they were prompted to go to R1’s room because R1 was not present for the 2:00p.m. scheduled medication distribution in the common area (living room). S1 stated they subsequently went to R1’s room to administer the missed medication, found R1 unresponsive in the bathtub and immediately called 911. The review of the EMS/911 audio records revealed at 3:21p.m., staff requested emergency medical services for R1 who was found unconscious and unresponsive, and EMS personnel determined R1 was dead on arrival due to apneic, pulseless, and without pupillary response state. The review of the death certificate revealed R1’s time of death was noted as 3:29p.m. and the cause of death was listed as acute myocardial infarction (heart attack) within minutes. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Jun 25, 2025 · control 31-AS-20241121093525

Type of visit: Required - 1 Year

At 9:47 AM, Licensing Program Analysts (LPAs) Huma Rahimi and Leslie Ngo-Castaneda conducted an unannounced annual inspection to the above facility. LPAs were greeted at the front desk and met with the Administrator Susan Park. LPAs explained the reason for the visit. LPAs and the Administrator toured the facility inside and out and observed the following: The Administrator had to leave and the General Manager Brenda Chacon was designated to sign today's report. The facility is a single story building with private and shared bedrooms, private bathrooms, kitchen, dining room, recreation room, common area, patios, and outdoor areas. The facility is licensed for 98 residents ages 60 and over. The fire clearance is approved for 98 non- ambulatory residents of which 15 can be . There is a hospice waiver approved for 10 residents. Bedrooms: LPAs and Administrator toured vacant and occupied bedrooms. Rooms # 46, 50, 80, 47 28, 38, and 22 were inspected. LPAs observed lamps, nightstands, beds, linens, and private bathrooms with liquid soap, hand towels, and trash cans. Bathrooms: The facility currently has two common restrooms. Additionally, staff has their own private bathrooms. The bathroom was sanitary with liquid soap, paper towels, handwashing instruction sign, and a trash can with a tight-fitting lid. At 9:55 AM, LPAs measured the hot water temperature of a private resident bathroom in room #46 to be 106.3F. Common Areas: All floors, walls, and ceilings were clean. Furniture in the dining room, lounges, living room, and activity room were clean and in good repair. At 10:00 AM LPAs measured the room temperature to be 72 F. Continue on LIC 809C Outdoor Space: LPAs and Administrator toured the outside space. LPAs observed two shaded areas with enough outdoor furniture which was observed in a good condition. LPAs tested the facility's emergency exit doors and observed that the emergency exit requires an access code to exit out to the back of the facility. Both exit doors were functional and operational. LPAs also observed two main exits in the back of the facility to be free of any obstruction and hazard. Laundry: LPAs observed a laundry room to be locked and inaccessible to residents in care. All detergents were locked inside the laundry room. LPAs observed the washer and dryer actively working and in a good working condition. Medication Room: LPAs observed a locked Medication Room where all the residents medication were kept and supervised by a Med Tech. LPAs reviewed random residents medication and did not observe any discrepancies. Storage: LPAs observed a storage room in the basement which has an access through the facility kitchen. LPAs observed that the storage room to be locked and inaccessible to residents in care. Additional emergency supplies and kitchen supplies closets were observed in the hallway by room #50. They were also observed locked and inaccessible to residents in care. Kitchen: LPAs observed menus outside of the kitchen in the dining room. Menus applied to typical and diabetic diets. The kitchen floors and surfaces were clean, and all food was sealed and labeled. The dining room contained tables with designated seating for the residents. Fire Safety: LPAs observed that the facility has fire extinguishers in every wing of the facility and were last serviced on 08/15/2024. All fire extinguishers were fully charged. At 2:05 PM, LPAs reviewed the most recent fire safety report from Atlantic Electric Company conducted on 03/17/2025. All systems were functional and passed inspection. At 11:10 AM LPAs tested the call system in Room #55 to be functional. Staff responded to the call within eight and half minutes. Between 11:30 AM to 2:00 PM, LPAs reviewed records of eight (8) residents and four (4) staff. Resident and staff records appeared to be complete and updated. No deficiency cited during today’s visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jun 17, 2025

Allegation investigated: Staff are monitoring resident's visits. Staff are not allowing resident to have visits for a reasonable amount of time.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with Susan Park and explained the reason for the visit. --- Staff are monitoring resident's visits. --- Staff are not allowing resident to have visits for a reasonable amount of time. It was alleged that facility is supervising other party’s (OP) visits and are not allowing OP to visit alone with Resident #1 (R1) and only allows thirty (30) minutes supervised. To investigate the allegation, requested documents at 11:45a.m., interviewed two (02) staff from 12:00p.m. to 12:40p.m. (CONT. on LIC9099-C) Unsubstantiated A review of Physician’s Report indicates Resident #1 (R1) has a diagnosis of dementia, is confused/disoriented, wanders and unable to leave the community unassisted, manage resources, manage medications or perform activities of daily living. During interviews with staff, all staff stated they are only acting in the best interest of R1, to protect their health and safety. Staff added in the past they have had a number of incidents involving OP, such as barricading the door to keep staff out, found nude in bed with R1, used condoms in found on the pillow, and inappropriate touching such as having R1 sit on OP’s lap and kissing on the lips. Staff also stated Adult Protective Services has an on-going investigation and recommended supervised visitations for no longer than thirty (30) minutes. Staff #1 (S1) stated resident is allowed to visit for an extended time and unsupervised so long as there is a trusted third person, such as a close family member, in the room with OP at all times. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jun 12, 2025 · control 31-AS-20250325144144

Allegation investigated: Staff mismanages resident's medications. Staff cannot communicate due to language barrier.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Susan Park and explained the reason for the visit. ---Staff mismanages resident's medications. It was alleged that staff did not provide medications for 02/28/2025 and are not giving medications as prescribed. To investigate the allegation, LPA requested documents at 11:45a.m., interviewed three (03) staff from 12:00p.m. to 1:00p.m. and seven (07) residents from around 1:00p.m. to 2:30p.m. A review of Resident #1’s (R1) Medication Administration Records shows that R1 was given their medications as prescribed. (CONT. on LIC9099-C) Unsubstantiated It also shows that on 02/28/2025 morning medications were given in the facility and R1 was sent with the evening medications for an overnight stay. During interviews with staff, all staff stated all medications are given as prescribed. During interviews with resident, all interviewed residents stated they are given their medications as prescribed. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff cannot communicate due to language barrier. It was alleged that staff do not follow orders because they do not speak English. To investigate the allegation, LPA requested documents at 11:45a.m., interviewed three (03) staff from 12:00p.m. to 1:00p.m. and seven (07) residents from around 1:00p.m. to 2:30p.m. A review of staff records revealed that all housekeepers have completed all necessary training. During interviews with staff, all staff stated although the English language is a second language for most staff, they are able to communicate effectively with residents and get the job done. If by any chance there is a miscommunication or barrier, we have plenty of other staff that speak all the languages that our residents speak. During interviews with resident, all interviewed residents stated they are able to communicate effectively with staff and they are able to meet all of their needs. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jun 6, 2025 · control 31-AS-20250325084258

Allegation investigated: Staff retain residents with prohibited health conditions

This report is an addendum of the previous Licensing report delivered on 11/06/24. Upon further review of medical records provided by the facility as well as from 3rd party medical providers involved in resident #1’s (R1’s) incidental medical care, the Department concluded that the allegation “Staff retain residents with prohibited health conditions” required further investigation to address additional information that previously was not available. At 2:30 p.m. on 05/20/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit. To investigate the allegation above, LPA conducted an initial visit on 10/29/24 and interviewed staff and residents between 10:30 a.m. and 12:00 p.m., toured the facility inside and out at 10:45 a.m., and conducted a record review of pertinent records, including but not limited to staff and client rosters at 2:15 p.m. Substantiated On 11/06/24 LPA toured the facility at 1:30 p.m., conducted a medication review at 1:35 p.m., interviewed a former staff member, Staff #1 (S1) at 1:45 p.m., and conducted a record review of pertinent records, including but not limited to wound care notes and cash ledgers at 2:00 p.m. LPA Reed requested additional records for review. Prior to this visit on 02/04/2025, 03/20/24 and 04/06/3025, LPA Reed reviewed all documents received from the facility and other medical providers and conducted interview with the representatives from the health care agencies assisting R1. It was alleged the facility retained resident(s) with severe pressure injuries. Interview with the administrator and other staff revealed that currently no residents have prohibited health conditions. Administrator verified that between June 2024 and September 2024, while under hospice care Resident #1 (R1) developed Stage 3 and/or Unstageable Pressure Injuries, and the care was provided by the hospice agency. Interviews with seven (07) other residents revealed no issues with pressure injuries. A review of records revealed that R1 started receiving Hospice services as of 06/11/2024 for other health conditions. As per hospice records the Pressure Injuries noted on R1s skin were staged as Stage 2. Although, the hospice records did not disclose any changes of R1s pressure injuries, on 06/26/24, the wound care specialists attended R1 and they identify Sacrococcygeal pressure injury at Stage 3 and an Unstageable pressure injury on left heel. Wound care specialists provided wound care between 06/26/24 and 09/11/24 and condition of Sacrococcygeal Pressure Injury was not improved. On 09/11/24, while R1 continued to retain at the facility, R1’s hospice services and wound care assistance were interrupted. Between on 09/17/24 and 09/27/24 R1 was attended by the home health nurse, to provide a wound care. A treatment was unsuccessful and on 09/27/25, R1 was sent to the hospital due to infected wound. The information revealed from interviews and record review verified that the facility continued to retain R1 with prohibited health condition upon interruption of Hospice services. Therefore, the allegation is SUBSTANTIATED at this time. Although the allegation is substantiated, no citation will be issued as the facility was cited on 03/20/25, while LPA addressed other issues unrelated to the complaint. Exit interview conducted. Copy of report provided. Interviews with seven (07) out of seven (07) residents revealed no occurrences of physical abuse or rough handling by staff. Interviews with staff and the administrator revealed no staff handle residents roughly or abuse residents. During a facility tour on 11/06/24, LPA observed staff handling residents gently and with respect. Based on interviews and observations, there was no evidence corroborating the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff steal residents’ medications" it was alleged staff steal bottles of resident medication. Interviews with seven (07) out of seven (07) residents revealed no occurrences of missing or stolen medications. Residents confirmed they receive all medications in the right doses. Interviews with staff and the administrator revealed no staff steal medications and no residents are missing any medications. Medication review revealed three (03) out of three (03) residents’ medications were accounted for. None were missing or stolen. Based on medication review and interviews, staff do not steal residents’ medications. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff steal residents money" it was alleged staff members steal residents’ monthly income. Interviews with seven (07) out of seven (07) residents revealed no occurrences of stolen or missing money. Residents interviewed who receive P&I money had no problems with accessing their money. Interviews with staff revealed no reports of staff stealing resident money. Interview with the administrator revealed all resident money is recorded on the internal P&I ledger. Review of P&I ledgers on 11/06/24 at 2:00 p.m. revealed resident money was accounted for and none was missing or stolen. Based on record review and interviews, staff do not steal residents’ money. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff sexually abused residents in care" it was alleged that S1 sexually abused Resident #1 (R1) and Resident #2 (R2). Record review of the resident list revealed R1 and R2 were not currently residents. Interview with S1 revealed they have never abused R1 or R2 and had good relationships with both. R1 and R2 were all unavailable for interviews. Interviews with seven (07) out of seven (07) residents revealed no occurrences of sexual abuse by staff. Residents interviewed stated staff were fine. Interviews with staff and the administrator revealed no evidence of sexual abuse. Based on interviews, no residents were sexually abused by staff. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 20, 2025 · control 31-AS-20241023131909

Allegation investigated: Illegal eviction. Staff did not notify resident's responsible party of incident. Staff did not take appropriate steps to assist resident(s) with rashes.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent visit for the above noted allegations. LPA met with Susan Park and explained the reason for the visit. ---Illegal eviction. It was alleged that Resident #1 (R1) would not be accepted back into the facility. To investigate the allegation, on 09/16/2024, LPA Rosaura Valenzuela requested pertinent documents at around 3:30p.m. and interviewed one (01) staff from 4:00p.m. to 4:30p.m. To further investigate the allegation, on 04/19/2025, LPA interviewed one (01) additional staff from 9:30a.m. to 10: 00a.m. and requested additional documents. A review of the Incident Report log indicates that R1 has multiple incidents of physical altercations with staff and other residents. (CONT. on LIC9099-C) Unsubstantiated R1’s most recent incident resulted in the hospitalization of another resident. During interviews with staff, all staff stated resident was placed on a 5150 hold and determine for the safety of R1, staff and other residents, that R1 needed a higher level of care and supervision. Based on interviews and records review there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not notify resident's responsible party of incident. It was alleged that Responsible Party (RP) was not aware R1 was placed in the hospital or moved to another location. To investigate the allegation, on 09/16/2024, LPA Rosaura Valenzuela requested pertinent documents at around 3:30p.m. and interviewed one (01) staff from 4:00p.m. to 4:30p.m. To further investigate the allegation, on 04/19/2025, LPA interviewed one (01) additional staff from 9:30a.m. to 10:00a.m. and requested additional documents. A review of the incident report states that facility notified them of the incident and status of the resident immediately. During interviews with staff, all staff stated they did inform the RP and explained to them that R1 would not be returning to the facility due to requiring a higher level of care and supervision. Based on interviews and records review there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not take appropriate steps to assist resident(s) with rashes. It was alleged that R1 has been dealing with rashes or scabies for the past four months and it has spread to other residents. To investigate the allegation, on 09/16/2024, LPA Rosaura Valenzuela requested pertinent documents at around 3:30p.m. and interviewed one (01) staff from 4:00p.m. to 4:30p.m. To further investigate the allegation, on 04/19/2025, LPA interviewed one (01) additional staff from 9:30a.m. to 10:00a.m. and requested additional documents. A review of the Physician’s Report does not indicate that R1 had scabies. The Medication Administration Record indicates that resident is using ointment but does not indicate that R1 has scabies rather it states it is for rash/eczema. A review of the Incident Report records do not show any signs of a scabies outbreak during the time in question. (CONT. on LIC9099-C) During interviews with staff, all staff stated they are not aware of any scabies outbreak. Based on interviews and records review there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 19, 2025 · control 31-AS-20240912154746

Allegation investigated: Staff did not prevent resident from being sexually abused

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent visit for the above allegation. LPA met with Executive Director, Susan Park, and explained the reason for the visit. --- Staff did not prevent resident from being sexually abused. It was alleged that Resident #1’s (R1) son was kissing R1 using his tongue, "French kissing" and cuddling with the resident naked. To investigate the allegation, on 09/12/2024, LPA requested pertinent documents at 2:30p.m. and interviewed one (01) staff from 2:30p.m. to 3:00p.m. On 09/13/2024, IB Investigator Lorraine Patterson (IB) received a police report from the Glendale Police Department. On 10/15/2024, IB requested and reviewed additional documents. On 10/21/2024 IB interviewed R1 and requested additional documents. (CONT on LIC9099-C) Unsubstantiated On 10/31/2024, at approximately 9:30a.m., IB visited the facility and obtained a printed copy of Incident Reports. A review of the Unusual Incident Report dated 03/04/2024 states, on 01/28/2024, R1’s son brought CBD oil, unknown supplements, and three condoms to the facility, all of which were confiscated and brought to the office. The report also states, on 03/04/2024 R1’s son was not wearing anything below the waist but using separate blankets. Staff reported it to the Long-Term Care Ombudsman (LTCO). Staff #1 (S1) stated they would partner with the LTCO and the Regional Office (RO) to develop a plan of action that preserves R1’s relationship with their son. The report also states that on 09/10/2024, Staff #2 (S2) reported the incident to Adult Protective Services (APS) by phone and fax that R1’s son was receiving R1’s Social Security income but was not paying R1’s rent putting R1 in danger of eviction. Additionally, S2 added R1’s son stays at the facility and sleeps in the same bed as R1, that the bed is a twin size and is too small to accommodate two (02) people. The Glendale Police Department's report states that Officer Ryan Varela #28091 responded to the facility at 8:00p.m. on 9/11/2024 because of a report alleging R1’s son sleeps “half nude” with R1, is not paying R1’s rent, and interferes with R1’s medication administration. Staff #3 (S3) asked to speak with Off. Varela in private and stated that R1’s son stays beyond visiting hours and is sometimes there for days at a time. The facility administrator has been reluctant to trespass R1’s son because they hold R1’s power of attorney (POA). S3 told Off. Varela that Staff #4 (S4) submitted an internal report about a year ago after observing inappropriate kissing. The report adds upon entering R1’s room, off. Varela observed R1’s son sleeping at the foot of R1’s bed, with R1 sleeping in the bed. R1’s son initially did not want to provide a statement, so off. Varela attempted to interview R1, but it was apparent that R1 did not have the capacity to provide a coherent statement. R1 stated they were fine and happy but then said they were scared, needed help, and did not know what was going on. When R1’s son later agreed to answer questions, he said he never touched R1 in a sexual way, kissed R1 inappropriately, or has been naked in front of R1. Concerning the door being blocked with a chair, R1’s son stated he was moving furniture and unintentionally left a night stand in front of the door. Based on the questionable behavior reported by facility staff and the facility’s unwillingness to trespass R1's son, off. Varela decided to obtain an emergency protective order (EPO) on R1’s behalf. (CONT on LIC9099-C) The EPO was granted by Judge Knight and took effect immediately, through 9/18/2024. Off. Varela personally served the EPO and escorted R1’s son off the property. R1’s Physician’s Report confirms that R1 has Dementia, Bi-polar disorder, Anxiety disorder, confused, disoriented and wandering behavior. During interviews with staff, all staff stated R1’s son kisses and touches R1 inappropriately using their tongue when kissing and sleeps in bed nude with R1. Staff #5 added they witnessed open condoms in the During interviews with residents, R1 stated they do not feel uncomfortable with their son’s visits and feels agitated, but when asked how they engage during their visits, R1 raised their voice, and told IB they no longer wanted to answer questions. Based on interviews and records review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 12, 2025 · control 31-AS-20240912122906

Allegation investigated: Facility staff did not administer resident's medication as prescribed. Facility staff did not provide adequate food service to resident in care. Facility is operating without a certified administrator. Staff did not ensure that residents are provided activities while in care. Facility staff did not prevent resident from engaging in a physical altercation.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent visit for the above noted allegations. LPA met with Susan Park and explained the reason for the visit. --- Facility staff did not administer resident's medication as prescribed. It was reported that facility staff did not administer Resident #1 (R1's) medication as prescribed. To investigate the allegation, on 05/01/2024, LPA Abeye Duguma conducted a physical plant tour at around 10:30 AM, requested pertinent documents at 11:00 AM and interviewed one (01) staff from 12:15 PM to 12:35 PM., On 10/02/2024, between 11:45am and 1:00pm, LPA Valenzuela conducted an interview with staff and reviewed facility records between 1:00pm and 2:00pm. To further investigate the allegation, on 04/05/2025, LPA Duguma interviewed six (06) residents and two (02) additional staff from 1:30p.m. – 3:30p.m. (CONT on LIC9099-C) Unsubstantiated A review of the Medication Administration Record revealed that R1 does receive their medication as prescribed by a physician. During interviews with staff and residents, all stated medications are given as prescribed. LPA Duguma was unable to interview R1 due to current health condition. Based on interviews and records review there is not enough information to verify the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time. --- Facility staff did not provide adequate food service to resident in care. It was alleged that facility staff did not provide adequate food service to a resident in care. It was reported that facility does not provide snacks to R1, in between meals. To investigate the allegation, on 05/01/2024, LPA Abeye Duguma conducted a physical plant tour at around 10:30 AM, requested pertinent documents at 11:00 AM and interviewed one (01) staff from 12:15 PM to 12:35 PM., On 10/02/2024, between 11:45am and 1:00pm, LPA Valenzuela conducted an interview with staff and reviewed facility records between 1:00pm and 2:00pm. To further investigate the allegation, on 04/05/2025, LPA Duguma interviewed six (06) residents and two (02) additional staff from 1:30p.m. – 3:30p.m. During the physical plant tour, LPA Valenzuela observed staff pushing a cart and offering snacks to residents. A review of the facility’s menu shows that residents are served well-balanced meals with desserts and snacks available. During interviews with residents and staff, all stated snacks are available upon request and that food service is adequate. Based on interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time. --- Facility is operating without a certified administrator. It was alleged that facility is operating without a certified administrator. To investigate the allegation, on 05/01/2024, LPA Abeye Duguma requested pertinent documents at 11:00 AM and interviewed one (01) staff from 12:15 PM to 12:35 PM., On 10/02/2024, between 11:45am and 1:00pm, LPA Valenzuela conducted an interview with staff and reviewed facility records between 1:00pm and 2:00pm. To further investigate the allegation, on 04/05/2025, LPA requested for a copy of the Administrator’s certificate. (CONT on LIC9099-C) During the initial visit, LPA was greeted by then Administrator Rafael Silva who was able to produce his Administrator’s Certificate. A review of the facility’s records confirms that facility had a certified Administrator during the time in question. During interviews with staff, all staff stated facility has always had a certified administrator but acknowledged that there have been changes in staffing. This year the facility has had four different administrators. Based on interviews, record review and observations, there is not enough information to verify the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time. --- Staff did not ensure that residents are provided activities while in care. It was alleged that staff did not ensure that residents are provided activities while in care. To investigate the allegation, on 05/01/2024, LPA Abeye Duguma conducted a physical plant tour at around 10:30 AM, requested pertinent documents at 11:00 AM and interviewed one (01) staff from 12:15 PM to 12:35 PM., On 10/02/2024, between 11:45am and 1:00pm, LPA Valenzuela conducted an interview with staff and reviewed facility records between 1:00pm and 2:00pm. To further investigate the allegation, on 04/05/2025, LPA Duguma interviewed six (06) residents and two (02) additional staff from 1:30p.m. – 3:30p.m. During the physical plant tour, LPA Valenzuela observed the activities calendar for month inside the arts and crafts room. During interviews with staff and residents, all stated facility has always had activities available for residents to participate in. Based on interviews and observation, there is not enough information to verify the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time. ---Facility staff did not prevent resident from engaging in a physical altercation. It was alleged that staff did not prevent Resident #2 (R2) from engaging in a physical altercation with R1. R2 pushed hard R1, causing them to fall and hit their head. To investigate the allegation, on 05/01/2024, LPA Abeye Duguma interviewed one (01) staff from 12:15 PM to 12:35 PM. On 10/02/2024, between 11:45am and 1:00pm, LPA Valenzuela conducted an interview with staff. (CONT. on LIC9099-C) To further investigate the allegation, on 04/05/2025, LPA Duguma two (02) additional staff from 1:30p.m. – 3:30p.m. LPA was unable to interview R1 due to current health condition. During interviews with staff, staff stated they immediately had R1 accessed and transported to the hospital for further evaluation. Staff also notified R1's responsible party of the incident. R2 was placed on a 5150 and assured everyone that they would not be returning to the community, due to being a danger to others. Staff told LPA that R2 had been placed on 5150 several times and would return to the community after 72 hours. After this incident, facility refused to accept back R2, due to a series of violent incidents. LPA Valenzuela reviewed incident reports and confirmed what staff had told LPA. Based on interviews and records review, there is not sufficient information to support the allegation. Therefore, the allegation will remain UNSUBSTANTIATED at this time. No health and safety hazards noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 5, 2025 · control 31-AS-20240425103743

Allegation investigated: Staff does not ensure Med Tech is properly trained. Staff does not ensure resident's medical needs are being met. Staff does not safeguard resident's personal belongings.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with Susan Park and explained the reason for the visit. --- Staff does not ensure Med Tech is properly trained. It was alleged that Staff #2 (S2) is not a trained MedTech. To investigate the allegation, LPA requested documents at 11:45a.m., interviewed three (03) staff from 12:00p.m. to 1:00p.m. and seven (07) residents from around 1:00p.m. to 2:30p.m. A review of S2’s records shows that S2 successfully completed the medication training courses. During interviews with staff, all staff stated they are all properly trained. (CONT. LIC9099-C) Unsubstantiated During interviews with residents, all interviewed residents stated they felt staff were competent. LPA was unable to interview R1. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff does not ensure resident's medical needs are being met. It was alleged that R1's blood pressure is not taken by facility staff. To investigate the allegation, LPA interviewed three (03) staff from 12:00p.m. to 1:00p.m. and seven (07) residents from around 1:00p.m. to 2:30p.m. During interviews with staff, all staff stated facility staff are not skilled trained medical professionals and are not expected to take residents’ blood pressure. During interviews with resident, all interviewed residents stated they feel all their medical needs are being met. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff does not safeguard resident's personal belongings. It was alleged that facility dryer is damaging residents’ bedsheets. To investigate the allegation, on 03/26/2025 LPA conducted a physical plant tour at around 10:30a.m., interviewed three (03) staff from 12:00p.m. to 1:00p.m. and seven (07) residents from around 1:00p.m. to 2:30p.m. During the physical plant tour, LPA inspected seven (07) rooms at random and did not observe damaged bedsheets. During interviews with staff, all staff stated there is no issue with the dryer and that R1 only has a few bedsheets to rotate that they have had for an extended time and any signs of it being worn is normal wear and tear from usage and repeated wash cycles. During interviews with resident, all interviewed residents stated they don’t feel the dryer damages their property. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Mar 26, 2025 · control 31-AS-20250325084258

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 interfered with resident's visitation

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with Dora Chacon and explained the reason for the visit. ---Staff interfered with resident's visitation It was alleged that facility is refusing visitation without supervision and for no longer than 30 minutes. On 12/18/2024, LPA requested pertinent documents at around 2:30 PM and interviewed one (01) staff from 2:30 PM to 3:00 PM. On 03/23/2025, LPA interviewed one (01) additional staff. A review of Physician’s Report indicates Resident #1 (R1) has a diagnosis of dementia, is confused/disoriented, wanders and unable to leave the community unassisted, manage resources, manage medications or perform activities of daily living. (CONT on LIC9099-C) Unsubstantiated During interviews with staff, all staff stated they have had disturbing incidents with one of R1’s visitors, that Adult Protective Services recommended supervised visitations for no longer than thirty (30) minutes and witnessed resident staying overnight multiple nights in a row. Staff added that they found this individual in bed with R1, kissing R1 on the lips and having them sit on visitor’s lap. Staff stated visitor also barricades R1’s door with a dresser blocking staff access to care for and supervise R1. LPA was unable to interview Resident #1 due to current health condition. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Mar 23, 2025 · control 31-AS-20241210153519

Type of visit: Case Management - Other

At 11:00 a.m. on 03/20/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and later the administrator and disclosed the reason for the visit. Today’s case management visit was conducted after review of the complaint #31-AS-20241023131909 revealed the facility did not apply for an exception for a resident with a worsening prohibited health condition. To investigate complaint #31-AS-20241023131909, LPA conducted an initial visit on 10/29/24 and interviewed staff and residents between 10:30 a.m. and 12:00 p.m., toured the facility inside and out at 10:45 a.m., and conducted a record review of pertinent records, including but not limited to staff and client rosters at 2:15 p.m. LPA conducted a subsequent visit on 11/06/24 and toured the facility at 1:30 p.m. and conducted a record review of pertinent records, including but not limited to wound care notes at 2:00 p.m. Today, LPA conducted a record review at 10:00 a.m. of additional wound care notes and hospice records of Resident #1 (R1) and toured the facility at 11:15 a.m. Interview with the administrator at 10:35 a.m. on 10/29/24 revealed no residents currently have prohibited health conditions. There is one (01) resident, R1, who has a Stage 1 pressure injury, which is a restricted but allowable condition in this facility. Record review today of R3’s hospice records and wound care notes from June 2024 to September 2024 revealed that R3 enrolled into hospice services for “other frontotemporal degeneration”. R3’s wound care notes showed they were visited by hospice nurses about twice a week and by wound care specialists about once a week between July 2024 and September 2024. R3 was diagnosed with a Stage 3 sacrococcygeal pressure injury on 06/26/24 and a stage 3 pressure injury on their left heel on 07/03/24. R3’s pressure injury on their heel healed over time and was fully healed by 09/11/24. R3’s sacrococcygeal pressure injury was smaller in size each week except from 08/07/24 to 08/14/24 when the wound increased from 1.9 centimeters (cm) long x .6 cm wide x .1 cm deep to 3.5 cm long x 1.1 cm wide x .5 cm deep. The wound had grown in size and was not healing during that period of time. A file review at 11:30 a.m. today of an incident report submitted the facility revealed that on 09/17/24, R3 was hospitalized due to needing a higher level of care from their Stage 3 pressure injury which measured approximately .75 inches long (about 1.9cm). Interview with the administrator today at 11:50 a.m. revealed R3’s hospice services expired that day. Therefore, R3 was eventually hospitalized with the prohibited health condition. Based on interviews and record reviews, when wound care specialists measured R3’s sacrococcygeal pressure injury on 08/14/24 to be larger than the previous week, the facility should have either sent R1 to a facility which could provide a higher level of care or applied for an exception to retain R1 at the facility and continue all services to support R1. The facility did not hospitalize R3 or apply for an exception, and therefore a deficiency is issued on the corresponding LIC809-D page. Due to disagreeing with today's findings, the licensee and administrator declined to sign this document. Exit interview conducted. Appeal rights discussed. Copy of report provided.the state’s words, verbatim · CDSS document, Mar 20, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.73(b) · Plan of correction due date: Mar 31, 2025

§1569.73 Terminally ill residents... (b) At any time that… the facility... determines that the resident's condition has changed ... the facility may initiate procedures for a transfer. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by retaining Resident #1 (R1) with a worsening prohibited health condition and not applying for an exception which posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 20, 2025

Allegation investigated: Staff did not provide resident’s records to resident’s authorized representative.

On 1/23/2025 at 11:00am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an unannounced initial ten-day visit to investigate the above allegation. Upon arrival, LPA met with Brenda Chucon – the office manager (OM), introduced herself by showing her badge and explained the reason for the visit. Facility Administrator Susan Park arrived shortly after and helped with the investigation process. At 11:15am, LPA requested resident and staff rosters, copies of pertinent information which include, but not limited to Policy and Procedures for processing Subpoenas/Record requests., and other relevant documents to support the investigation. LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. During course of the investigation, interviews and record review were made. Between 11:25am – 12:45pm, LPA conducted interviews with the Administrator, Office manager (OM), and (QA) Quality Assurance representative Rafael Silva. Continue on LIC9099-C Substantiated Allegation: Staff did not provide resident’s records to resident’s authorized representative. It was reported that agency submitted initial record request on October 30th, 2024, to receive copies of complete files on behalf of R1 and R2. LPA requested documentation and observed that agency requested the facility to submit copy of complete files within five (5) business days. After several attempts made by the agency, S1 provided partial documents to the agency on December 13th, 2024, via email. Agency submitted another request on December 19th, 2024, to receive the documents not provided by the facility. After no response and failing to submit requested copy of complete file, the agency submitted another request on January 6th, 2025, via mail and email. Interview with witness from the agency revealed that facility did not provide full requested documents until January 22, 2025 which confirms facility did not comply Title 22 Code of Regulations and agency's request. Therefore, based on records review and interviews, this allegation is deemed Substantiated. Exit interview conducted and copies of this report delivered.the state’s words, verbatim · CDSS document, Jan 23, 2025 · control 31-AS-20250114084446

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Jan 23, 2025

Personal Rights...(19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This requirement is not met as evidenced by: Based on record review and interview the licensee did not provide the records of R1 and R2 to the authorized representative in a timely manner which poses a potential personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Jan 23, 2025

Plan of correction: LPA cleared during the visit. The facility had already provided the requested documents on 01/22/2025.

Type of visit: Case Management - Other

At approximately 12:00 p.m. on 01/14/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and later the administrator and disclosed the reason for the visit. Today’s case management visit was conducted to ensure the safety and welfare of evacuees from the Eaton Fire who were relocated temporarily to the facility. LPA interviewed the administrator at 12:15 p.m., toured the facility at 12:30 p.m., and interviewed residents between 12:40 p.m. and 1:00 p.m. Currently, three (03) residents from Casa de Madera (197610118) and six (06) residents from an adult residential facility are present. LPA interviewed seven (07) out of nine (09) relocated residents. All residents were in good condition and felt safe. No immediate health or safety hazards were observed during today’s visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 14, 2025

Allegation investigated: Staff handle residents roughly Staff steal residents medications Staff steal residents money Staff sexually abused residents in care Staff retain residents with prohibited health conditions

At 1:15 p.m. on 11/06/24 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and later the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA conducted an initial visit on 10/29/24 and interviewed staff and residents between 10:30 a.m. and 12:00 p.m., toured the facility inside and out at 10:45 a.m., and conducted a record review of pertinent records, including but not limited to staff and client rosters at 2:15 p.m. Today, LPA toured the facility at 1:30 p.m., conducted a medication review at 1:35 p.m., interviewed a former staff member, Staff #1 (S1) at 1:45 p.m., and conducted a record review of pertinent records, including but not limited to wound care notes and cash ledgers at 2:00 p.m. Regarding the allegation "Staff handle residents roughly" it was alleged staff “slam” and abuse residents. Unsubstantiated Interviews with seven (07) out of seven (07) residents revealed no occurrences of physical abuse or rough handling by staff. Interviews with staff and the administrator revealed no staff handle residents roughly or abuse residents. During a facility tour today, LPA observed staff handling residents gently and with respect. Based on interviews and observations, there was no evidence corroborating the allegation. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff steal residents’ medications" it was alleged staff steal bottles of resident medication. Interviews with seven (07) out of seven (07) residents revealed no occurrences of missing or stolen medications. Residents confirmed they receive all medications in the right doses. Interviews with staff and the administrator revealed no staff steal medications and no residents are missing any medications. Medication review revealed three (03) out of three (03) residents’ medications were accounted for. None were missing or stolen. Based on medication review and interviews, staff do not steal residents’ medications. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff steal residents money" it was alleged staff members steal residents’ monthly income. Interviews with seven (07) out of seven (07) residents revealed no occurrences of stolen or missing money. Residents interviewed who receive P&I money had no problems with accessing their money. Interviews with staff revealed no reports of staff stealing resident money. Interview with the administrator revealed all resident money is recorded on the internal P&I ledger. Review of P&I ledgers today at 2:00 p.m. revealed resident money was accounted for and none was missing or stolen. Based on record review and interviews, staff do not steal residents’ money. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff sexually abused residents in care" it was alleged that S1 sexually abused Resident #1 (R1) and Resident #2 (R2). Record review of the resident list revealed R1 and R2 were not currently residents. Interview with S1 revealed they have never abused R1 or R2 and had good relationships with both. R1 and R2 were all unavailable for interviews. Interviews with seven (07) out of seven (07) residents revealed no occurrences of sexual abuse by staff. Residents interviewed stated staff were fine. Interviews with staff and the administrator revealed no evidence of sexual abuse. Based on interviews, no residents were sexually abused by staff. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff retain residents with prohibited health conditions" it was alleged the facility retained residents with severe pressure injuries. Interview with the administrator revealed no residents have prohibited health conditions. There is currently one (01) resident, Resident #3 (R3) with a Stage 1 pressure injury, which is a restricted but allowable condition in this facility. Record review confirmed a wound care specialist was seeing the R3 on a weekly basis and providing proper and adequate care for the wound. Interviews with seven (07) other residents revealed no issues with pressure injuries. Based on record review and interviews, the facility does not retain residents with prohibited conditions. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. No immediate health or safety hazards were observed during today's visit. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 6, 2024 · control 31-AS-20241023131909

Allegation investigated: Staff did not address resident's ringworm infection. Staff did not assist resident with oxygen. Staff providing resident's oxygen to another resident in care. Staff chemically restrained resident.

Licensing Program Analysts (LPA) Abeye Duguma and Angelica Segovia conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with administrator, Susan Park, and explained the reason for the visit. --- Staff did not address resident's ringworm infection. It was alleged that Resident #1 (R1) has ringworms that were not addressed. To investigate the allegation, on 07/24/2024 LPA requested pertinent documents at 11:00 AM and interviewed three (03) staff from around 11:45 AM to 1:00 PM. A review of the facility’s Medication Administration Records revealed that R1 was seen by a physician and given medications as prescribed for the ringworm infection. During interviews with staff, Staff #2 (S2) and Staff #3 (S3) stated that resident was given medications to treat ringworms. All other staff were unaware of the issue. (CONT. on LIC9099-C) Unsubstantiated Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not assist resident with oxygen. It was alleged that staff does not check resident's oxygen. To investigate the allegation, on 07/24/2024 LPA interviewed three (03) staff from around 11:45 AM to 1:00 PM and interviewed seven (07) residents from around 1:00 PM to 3:00 PM. During interviews with staff, all staff stated they check on residents’ oxygen a minimum three (03) times a day. During interviews with residents, all residents stated they are unaware of how often staff check on residents’ oxygen tanks. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff providing resident's oxygen to another resident in care. It was alleged that resident’s oxygen has been used in other residents’ rooms. To investigate the allegation, on 07/24/2024 LPA interviewed three (03) staff from around 11:45 AM to 1:00 PM and interviewed seven (07) residents from around 1:00 PM to 3:00 PM. During interviews with staff, all staff stated that they do not share R1’s oxygen with other residents. During interviews with residents, all residents stated they are not aware of oxygen tanks being shared. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (CONT on LIC9099-C) ---Staff chemically restrained resident. It was alleged that staff admitted to "over medicating" resident. To investigate the allegation, on 07/24/2024 LPA requested pertinent documents at 11:00 AM, interviewed three (03) staff from around 11:45 AM to 1:00 PM and interviewed seven (07) residents from around 1:00 PM to 3:00 PM. A review of the facility’s Medication Administration Records revealed that residents are being given medications as prescribed. During interviews with staff, all staff stated they do not over medicate residents and give residents their medications as prescribed. During interviews with residents, all residents stated they get their medications as prescribed and do not feel over medicated. Based on record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 31, 2024 · control 31-AS-20240722200124

Allegation investigated: Facility staff did not administer resident's medication as prescribed. Facility staff did not provide adequate food service to resident in care. Facility is operating without a certified administrator. Staff did not ensure that residents are provided activities while in care. Facility staff did not prevent resident from engaging in a physical altercation.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced subsequent visit for the above noted allegations. LPA met with Administrator Susan Park and explained the reason for the visit. On 05/01/2024, LPA Abeye Duguma initiated the investigation. At the time of that visit LPA conducted a physical plant tour, requested pertinent documentation and initiated staff interviews. It was reported that facility staff did not administer Resident #1 (R1's) medication as prescribed. To investigate this allegation on 10/02/2024, between 11:45am and 1:00pm, LPA initiated staff interviews. Interviews revealed that R1 has and does receive their medication as prescribed by a physician. Between 1:00pm and 2:00pm, LPA requested and reviewed facility records. Records confirmed what staff told LPA. Based on interviews and records review there is not sufficient information to support this allegation. Thus, Unsubstantiated the allegation is UNSUBSTANTIATED at this time. It was alleged that facility staff did not provide adequate food service to a resident in care. It was reported that facility does not provide snacks to R1, in between meals. To investigate this allegation on 10/02/2024, between 11:45am and 1:00pm, staff interviews were initiated. Interviews revealed that facility does provide snacks to all residents in care. At 2:30pm, LPA observed staff pushing a cart and offering snacks to residents. Based on interviews and observation, there is not sufficient information to support this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. It was reported that facility is operating without a certified administrator. To investigate this allegation on 10/02/2024, between 11:45am and 1:00pm, staff interviews were initiated. Interviews revealed that the facility has always had a certified administrator, but acknowledged that there having been changes in staffing. This year the facility has had four different administrators. Between 1:00pm and 2:00pm, LPA requested and reviewed facility records. Records confirmed what staff told LPA. Based on interviews and records review there is not sufficient information to support this allegation. Thus, the allegation is UNSUBSTANTIATED at this time. It was alleged that staff did not ensure that residents are provided activities while in care. To investigate this allegation on 10/02/2024, between 11:45am and 1:00pm, staff interviews were initiated. Interviews revealed that facility does provide activities for residents in care. In fact, the facility has two activity directors. Between 1:00pm and 2:00pm, LPA requested and reviewed facility records. Records confirmed what staff told LPA. In addition, LPA observed the activities calendar for month inside the arts and crafts room. Based on interviews, records review, and observation, there is not sufficient information to support this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. It was reported that staff did not prevent Resident #2 (R2) from engaging in a physical altercation with R1. R2 pushed hard R1, causing them to fall and hit their head. To investigate this allegation on 10/02/2024, between 11:45am and 1:00pm, LPA initiated staff interviews. Interviews revealed that staff immediately had R1 accessed and transported to the hospital for further evaluation. Staff also notified R1's responsible party of the incident. R2 was placed on a 5150 and assured everyone that they would not be returning to the community, due to being a danger to others. Staff told LPA that R2 had been placed on 5150 several times and would return to the community after 72 hours. After this incident, facility refused to accept back R2, due to a series of violent incidents. Between 1:00pm and 2:00pm, LPA reviewed incident reports and confirmed what staff had told LPA. Based on interviews and records review, there is not sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued. R2 pushed hard R1, causing them to fall and hit their head. To investigate this allegation on 10/02/2024, between 11:45am and 1:00pm, LPA initiated staff interviews. Interviews revealed that staff immediately had R1 accessed and transported to the hospital for further evaluation. Staff also notified R1's responsible party of the incident. R2 was placed on a 5150 and assured everyone that they would not be returning to the community, due to being a danger to others. Staff told LPA that R2 had been placed on 5150 several times and would return to the community after 72 hours. After this incident, facility refused to accept back R2, due to a series of violent incidents. Between 1:00pm and 2:00pm, LPA reviewed incident reports and confirmed what staff had told LPA. Based on interviews and records review, there is not sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 2, 2024 · control 31-AS-20240425103743

Allegation investigated: Staff did not ensure resident was provided with toiletries

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA met with Administrator Susan Park and explained the reason for the visit. LPA conducted physical plant tour at 9:44 AM, requested facility documents relevant to the investigation at 10:13 AM and interviewed residents and staff between 10:40 AM to 1:20 PM. It was alleged that Resident #1 (R1) was told by the staff that R1 had to buy own deodorant and toothpaste. LPA's interview with the administrator and two (2) staff today between 10:40 AM to 1:20 PM revealed that the facility provides toiletries including but not limited to body wash, soap, deodorant, toothpaste, toothbrush, hand and body lotion and shampoo. Further interview with Staff #1 (S1) who was in charge of the toiletries supply at the facility revealed that the care staff are regularly checking residents' toiletries supply and replenish them on a weekly basis. Further interview with the administrator also confirmed that in case a resident needs any toiletries, any resident could inform the office and they will be provided. (continued on LIC 9099) Unsubstantiated (continued from LIC 9099) LPA's interview with R1 today at around 11:40 AM revealed that R1 was provided with all the toiletries R1 needed. LPA's observation during physical plant tour at around 9:50 AM revealed that the facility has sufficient supplies of toiletries in the storage. LPA's interview with six (6) random residents or 10% of current census today revealed that six (6) out of six (6) residents stated that they were regularly provided the toiletries they need. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Oct 1, 2024 · control 31-AS-20240925115531

Allegation investigated: Facility does not provide a safe environment for the residents.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with administrator, Rafael Silva, and explained the reason for the visit. --- Facility does not provide a safe environment for the residents. It was alleged that Resident #1 (R1) had been pushed to the ground by Resident #2 (R2) and R2 also assaulted three (03) staff members prior to the incident. To investigate the allegation, LPA interviewed four (04) staff from 11:00 AM – 1:00 PM and reviewed pertinent documents at 1:30 PM. During interviews, all staff stated R2 was aggressive that day, assaulted three (03) staff. Staff #1 stated R2’s nurse practitioner and physician were alerted about the change in condition, an ambulance was called for a 5150 hold and that paramedics stated they would arrive in a few hours. (CONT. on LIC9099-C) Substantiated All staff added that while R2 was in their room waiting to be transported, R1 was passing by and R2 told R1 to leave the area and raised their arms as though they were about to do something to R1. At that moment Staff #2 (S2) was in the area and shouted out “don’t” but by then it was too late. R2 pushed R1 to the ground. S1 then called 911 again and paramedics took R1 to the hospital and R2 to the 5150 hold. A review of the department’s records confirmed the incident and details. Based on interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued. Staff added that facility has call buttons for immediate attention and caregivers are divided into four (04) zones for supervision with one (01) caregiver that floats throughout the other zones as needed. A review of the facility’s staff roster confirms staffs’ statements regarding scheduling and availability. During interviews with residents, all residents stated that staff are sufficient in numbers, and competent to provide the services necessary to meet their needs. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Physical abuse incident was not reported to required agencies. It was alleged that staff did not notify local law enforcement. To investigate the allegation, LPA interviewed four (04) staff from 11:00 AM – 1:00 PM and requested documents at around 1:30 PM. During interviews, all staff stated that after contacting the paramedics, facility contact the Glendale Police Department, but by the time they arrived, the paramedics left with R2 for the 5150 hold. A review of the facility’s incident report states that law enforcement was contacted after the incident and identifies the officer’s name that took the police report including the department, bureau and contact information. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No other health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Sep 12, 2024 · control 31-AS-20240905124218

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Sep 16, 2024

87468.1 Personal Rights of Residents in All Facilities; (a) Residents in all residential care facilities for the elderly shall have the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by; Based on interviews and record review, the facility did not ensure that the residents treat each other with dignity and respect which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 12, 2024

Plan of correction: The Administrator will provide written information explaining the steps the facility will take to ensure that all residents’ health, safety and personal rights are protected at the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Sep 16, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, residents in privately operated residential care facilities for the elderly shall have all of the following..(8)..free from ...physical...abuse This requirement is not met as evidenced by; Based on interviews and record review, the facility did not ensure that the residents was free from physical abuse which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 12, 2024

Plan of correction: The Administrator will provide written information explaining the steps the facility will take to ensure that all residents’ health, safety and personal rights are protected at the facility.

Allegation investigated: Staff did not provide toilet paper for resident. Staff did not keep the facility clean and sanitary. Staff handled resident in a rough manner.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with Vanessa Ortega and explained the reason for the visit. --- Staff did not provide toilet paper for resident. It was alleged that facility does not provide toilet paper to Resident #1 (R1). To investigate the allegation, LPA conducted a physical plant tour at around 11:00 AM, interviewed three (03) staff from around 11:45 AM to 1:00 PM and interviewed seven (07) residents from around 1:00 PM to 3:00 PM. During the physical plant tour, LPA observed toilet paper in the R1’s room. During interviews with staff, all staff stated that all residents are provided toilet paper and are never without access. (CONT. on LIC 9099-C) Unsubstantiated During interviews with residents, all residents stated they have never been denied access to toilet paper. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not keep the facility clean and sanitary. It was alleged that R1’s room had feces on bathroom walls, feces on R1’s towels and vomit on R1’s bed. To investigate the allegation, LPA conducted a physical plant tour at around 11:00 AM, interviewed three (03) staff from around 11:45 AM to 1:00 PM and interviewed seven (07) residents from around 1:00 PM to 3:00 PM. During the physical plant tour, LPA did not observe any feces on the bathroom walls, feces on towels or vomit on the beds of residents. During interviews with staff, all staff stated they are not aware of residents having feces on the bathroom walls, feces on residents’ towels or vomit on the beds. During interviews with residents, all residents stated they have never witnessed feces on walls, vomit on beds or feces on towels. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff handled resident in a rough manner. It was alleged that staff were observed to be grabbing residents by the arm and yanking them away. To investigate the allegation, LPA interviewed three (03) staff from around 11:45 AM to 1:00 PM and interviewed seven (07) residents from around 1:00 PM to 3:00 PM. During interviews with staff, all staff stated they do not treat residents in a rough manner, have never yanked any resident and are gentle with everyone. During interviews with residents, all residents stated that staff are gentle when handling them. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jul 24, 2024 · control 31-AS-20240722200124

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

Allegation investigated: Facility’s phone is inoperable.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with Office Manager, Brenda Chacon, and explained the reason for the visit. --- Facility’s phone is inoperable. It was alleged that facility phone lines have been down for over five (05) days. To investigate the allegation, LPA conducted a physical plant tour at around 11:00 AM, interviewed five (05) staff from around 11:45 AM to 1:00 PM and interviewed seven (07) residents from around 1:00 PM to 3:00 PM. During the physical plant tour, LPA observed the facility’s telephones to be fully operational. During interviews with staff, all staff stated that facility could not receive incoming calls for two (02) to five (05) days. (CONT. on LIC 9099-C) Substantiated Staff added that the Department and responsible parties were notified of the issue and provided alternate contact numbers and an email address. During interviews with residents, all residents were unaware of the facility having issues with the telephones. Based on interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued. During interviews with staff, five (05) out of six (06) staff stated residents have activities on Sundays and Mondays and are never left without care and supervision. Staff #4 stated they do not know about what takes place on Sundays and Mondays as they do not work as a caregiver during those days. During interviews with residents, all residents stated they have activities on Sundays and Mondays and are not left without care and supervision for an extended time. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff are unable to communicate effectively with resident. It was alleged that staff are unable to communicate with staff due to a language barrier. To investigate the allegation, LPA interviewed five (05) staff from around 11:45 AM to 1:00 PM and interviewed seven (07) residents from around 1:00 PM to 3:00 PM. During interviews with staff, all staff stated all caregivers are able to communicate effectively to meet the needs of the residents. During interviews with residents, all residents stated they can communicate with staff effectively and that they meet all their needs. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff burned resident. It was alleged that staff burned resident in the shower with hot water. To investigate the allegation, LPA conducted a physical plant tour at around 11:00 AM, interviewed five (05) staff from around 11:45 AM to 1:00 PM and interviewed seven (07) residents from around 1:00 PM to 3:00 PM. During the physical plant tour LPA observed average hot water temperature measured at 111.6 degrees Fahrenheit. During interviews with staff, all staff stated they are unaware of any resident being burned with hot water in the shower by staff. During interviews with residents, all residents stated they have never been burned by staff with hot water in the shower. LPA was unable to interview Resident #1 (R1). Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 19, 2024 · control 31-AS-20240612080940

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 19, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by; Based on interviews, the facility was without a fully functional phone for two to five days which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 19, 2024

Plan of correction: Although the facility telephone was not in working order, the facility took measures to have the telephone repaired, therefore, a Plan of Correction will not be issued at this time.

Allegation investigated: Staff handled resident in a rough manner Staff yelled at resident Staff do not have appropriate training Staff did not ensure resident was provided a bed

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation. LPA met with Office Manager, Brenda Chacon, and explained the reason for the visit. --- Staff handled resident in a rough manner. It was alleged that staff are rough with residents. To investigate the allegation, on 05/01/2024, LPA interviewed four (04) staff from around 11:30 AM to 12:15 PM and interviewed ten (10) residents from around 12:15 PM to 2:15 PM. During interviews with staff, all staff, including Staff #2 (S2), stated they are always handling residents gently and are never rough with residents. (CONT. on LIC9099-C) Unsubstantiated During interviews with residents, all residents stated staff are never handling them in a rough manner. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff yelled at resident. It was alleged that staff are yelling at residents. To investigate the allegation, on 05/01/2024, LPA interviewed four (04) staff from around 11:30 AM to 12:15 PM and interviewed ten (10) residents from around 12:15 PM to 2:15 PM. During interviews with staff, all staff, including Staff #2 (S2), stated they never yell at residents and treat all residents with dignity and respect. During interviews with residents, all residents stated staff do not yell at them. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff do not have appropriate training. It was alleged that staff receive no training before they begin working as caregivers. To investigate the allegation, LPA requested staff files at 10:30 AM and, on 05/01/2024, interviewed four (04) staff from around 11:30 AM to 12:15 PM. A review of staff files revealed that all staff have completed all necessary training to provide care and supervision. During interviews with staff, all staff stated that they completed all training prior to starting their work as caregivers. --- Staff did not ensure resident was provided a bed It was alleged that residents are left in their wheelchairs all night because their beds are not ready. To investigate the allegation, on 05/01/2024, LPA interviewed four (04) staff from around 11:30 AM to 12:15 PM and interviewed ten (10) residents from around 12:15 PM to 2:15 PM. (CONT. LIC9099-C) During interviews with staff, all staff stated they have never left a resident in their wheelchair all night due to residents’ beds not being ready. During interviews with residents, all residents stated they have never been without a bed all night due to bed not being ready. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 15, 2024 · control 31-AS-20231027104543

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Rosaura Valenzuela and Abeye Dugumas conducted the required annual inspection. LPAs arrived unannounced and met with Business Manager Brenda Chacon who assisted with the inspection today. The facility is licensed for 98 residents ages 60 and over. The fire clearance is approved for 98 non- ambulatory residents of which 15 can be . There is a hospice waiver approved for 10 residents. Currently there are 74 residents at the facility. 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 gloves while assisting residents with medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance. Operational Requirements: A current Plan of Operation was reviewed. Infection Control Plan was reviewed but not updated. The facility has a Dementia waiver in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 12/05/2024. Surety Bond is valid and in place. The last fire Drill was conducted on 03/15/2024. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the persons with special needs were observed. Physical Plant & Environment Safety: The facility is a single-story building. Common areas, including the living room, activity room and dining room, all appeared clean and were properly furnished. The kitchen appeared clean and the appliances and fixtures functional. Entry/exits were free of obstruction. The medications were locked in the medication room. The following random resident rooms were inspected: #27, 13, 50, 52, #47, 33 and the water temperature measured between 115.7 – 118.7 degrees F which is within range of 105 – 120 degrees F. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Visiting hours were posted during visit. 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: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents. Incidental Medical & Dental: The medications are centrally stored and in their original containers. Disaster Preparedness: The facility has an Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, The facility conducts emergency drill on a quarterly basis for all staff and residents. Residents with Special Health Needs: No residents are receiving home health services. No resident receives hospice care. No residents have prohibited health conditions. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 15, 2024

Allegation investigated: Staff do not assist residents with toileting Staff do not answer residents' call buttons in a timely manner Staff do not assist residents with bathing Staff do not provide resident with drinking water

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation. LPA met with Office Manager, Brenda Chacon, and explained the reason for the visit. --- Staff do not assist residents with toileting. It was alleged that staff are telling residents to relieve themselves in their chairs and leaving them on toilets for an extended time. To investigate the allegation, LPA interviewed four (04) staff from around 11:30 AM to 12:15 PM and interviewed ten (10) residents from around 12:15 PM to 2:15 PM. During interviews with staff, all staff stated they have never told a resident to relieve themselves on their chair or refused toileting assistance. All staff added they do not leave residents on toilets for an extended time. (CONT. on LIC9099-C) Unsubstantiated During interviews with residents, all residents stated they have never been told to relieve themselves in their chair and are not left on toilets for an extended time. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff do not answer residents' call buttons in a timely manner It was alleged that multiple rooms are calling for help at once the caregivers are not able to get to them. To investigate the allegation, LPA conducted a physical plant tour at 10:30AM, interviewed four (04) staff from around 11:30 AM to 12:15 PM and interviewed ten (10) residents from around 12:15 PM to 2:15 PM. During the physical plant tour, LPA selected five (05) rooms at random, pressed the call button and observed an average response time of six (06) minutes. During interviews with staff, all staff stated they respond to call buttons with in five (05) to ten (10) minutes. During interviews with residents, four (04) out of ten (10) residents stated that staff take up to fifteen (15) minutes to respond to the call button while the remaining six (06) out of ten (10) residents stated that staff take no longer than ten (10) minutes to respond to the call button. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff do not assist residents with bathing. It was alleged that residents go a week without getting a shower. To investigate the allegation, LPA interviewed four (04) staff from around 11:30 AM to 12:15 PM and interviewed ten (10) residents from around 12:15 PM to 2:15 PM. During interviews with staff, all staff stated they have a shower schedule for each resident, and they shower between two (02) to three (03) times a week. Staff added they have residents that sometimes refuse to shower but do not have residents that go a whole week without showering. (CONT. LIC9099-C) During interviews with residents, all residents stated they receive shower assistance between two (02) to three (03) times a week. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff do not provide resident with drinking water. It was alleged that residents are not getting enough drinking water. To investigate the allegation, LPA conducted a physical plant tour at 10:30AM, interviewed four (04) staff from around 11:30 AM to 12:15 PM and interviewed ten (10) residents from around 12:15 PM to 2:15 PM. During the physical plant tour, LPA observed two (02) drinking water fountains in the facility. During interviews with staff, all staff stated they offer residents water throughout the day and that the residents have free access to clean drinking water. During interviews with residents, all residents stated they are offered water throughout the day and that they have access to water whenever they want. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, May 1, 2024 · control 31-AS-20231027104543

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

Allegation investigated: Staff are abusing the residents while in care. Staff are inappropriately tying the facility doors at night.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation. LPA met with the Executive Director, Brenda Chacon, and explained the reason for the visit. --- Staff are abusing the residents while in care. It was alleged that staff are abusing seniors. To investigate the allegation, on 04/19/2024 LPA conducted a physical plant tour at 9:30 AM, interviewed seven (07) residents from 10:30 AM to 12:30 PM and interviewed three (03) staff from 12:30 PM to 02:00 PM. During physical plant tour, LPA observed that all residents were clean, well groom and did not have any signs of physical abuse. During interviews with residents, all residents stated that they have never been physically or verbally abused by any staff. (CONT. on LIC9099-C) Unsubstantiated During interviews with staff, all staff stated they have never physically or verbally abused a resident or witnessed staff abusing any resident. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff are inappropriately tying the facility doors at night. It was alleged that staff are tying the doors shut at night. To investigate the allegation, on 04/19/2024 LPA conducted a physical plant tour at 9:30 AM, interviewed seven (07) residents from 10:30 AM to 12:30 PM and interviewed three (03) staff from 12:30 PM to 02:00 PM. During physical plant tour, LPA did not observe at doors tied up or mechanisms that can be used to tie up doors. During interviews with residents, all residents stated that their doors have never been tied up by anyone. During interviews with staff, all staff stated they have never tied up anyone’s door. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Apr 19, 2024 · control 31-AS-20231002125242

Allegation investigated: Staff stole resident's personal property Staff did not ensure resident's dietary needs are met Staff did not ensure resident's toileting needs are met Staff intimidate residents in care

Licensing Program Analyst, Antonia Alvizar-Ettima conducted an unannounced initial complaint visit to this facility at approximately 9:10a.m. LPA met with Receptionist, Iris Ortega and Activity Director(AD), Daysy Regalado at that time LPA request staff and resident rosters. At 9:15a.m. AD and LPA conducted a physical plant tour of the facility. At 9:30a.m. the GM arrived at the facility and explained the reason for this visit. At 9:40a.m. GM provided staff and resident roster to LPA. GM also indicated on roster the residents that are verbal and receive incontinence care. Between 9:45a.m. to 12:00p.m. LPA interviewed seven (07) out of seventy-three (73) residents including resident (R1), GM and three (3) staff that assist R1. LPA asked interview questions relevant to the nature of the complaint. At approximately 10:15a.m LPA requested R1’s Physician's Report, Resident Appraisal, Resident's Personal Property Inventory,Client Notes, Special Dietary List, Nutritionist Menu and Staff Inservice Training. At 1:45p.m. LPA received and reviewed documents related to the allegations above. Unsubstantiated 1)Staff stole resident's personal property It was alleged that staff stole R1’s money and cellphone. Interview with R1 reveal that they thought staff stole money and cellphone when away from the facility for a couple days. R1 indicated that when they returned the money and cellphone was at the facility and locked. Interviews with residents revealed that they have never experienced any of their personal property being stolen. Staff interview revealed that R1 has never reporter money and cellphone being stolen. General Manager(GM), indicated that R1 called from the hospital and informed her that cellphone was left at the facility. GM immediately searched for the cellphone, found it and locked it in the office. When R1’s came back to the facility GM returned the cellphone. GM indicated that R1 never reported staff stealing money. A review of R1’s Personal Property Inventory dated 03/18/2024 does not indicated that R1 has a cellphone or money. Based on interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 2) Staff did not ensure resident's dietary needs are met It was alleged that staff has not fed R1 the appropriate diabetic food. Interview with R1 reveal that staff are providing appropriated diabetic food but they sometimes can not wait for meal time so they order fast food using Uber Eats service. Interviews with residents revealed that they receive appropriate diabetic food. Staff interviews revealed that R1 has been provided appropriate diabetic food. GM indicated that R1 has not request food before or after meal time. Facility staff provides food before or after meal time upon resident's request. A review of facility Resident’s Special Dietary Needs indicated that R1 receives diabetic food. Physician's Report indicated that R1 has an eighteen hundred (1,800) calorie special diet. Facility menu is created and approved by Dietitians of OC monthly. Based on interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 3) Staff did not ensure resident's toileting needs are met It was alleged that at times R1 has woken up on they bodily fluid. Interview with R1 reveal that has not woken up on bodily fluid and does not need any toileting needs. R1 indicated that they can perfectly walk, does not need diapers and is independent. Interviews with residents revealed that staff ensure all their toileting needs are met. Residents did not have any concerns about toileting needs. Staff interviews concede with R1’s response. A review R1’s Physician Report indicated that R1 is able to care for own toileting needs. Based on interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. 1) Staff intimidate residents in care It was alleged that staff intimidate R1 by not allowing they to leave the facility. Interview with R1 reveal that they do not get intimidated by staff and has not want to leave the facility. Interviews with residents did not indicate any concerns about staff intimidating them. Resident (R5) indicated I communicate with staff and they are nice with me. Staff interviews reveal that R1 has not reported feeling intimidated by staff because they wanted to leave the facility. During physical plant tour, LPA did not observe staff intimidating residents in care. A review of facility Inservice Training dated 03/14/2024 indicated that staff received training on "How to Communicate & Positive Approach to Dementia Care Customer Service". R1’s Physician Report indicated that R1 is not able to leave the facility unassisted. Based on interviews, observation and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 5, 2024 · control 31-AS-20240326093807

Allegation investigated: Staff did not provide adequate supervision resulting in residents engaging in a physical altercation.

Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced complaint visit to the facility to investigate the above allegation. LPA met with Executive Director (ED), Chanel Sanchez, and explained the reason for the visit. Allegation #1 Staff did not provide adequate supervision resulting in residents engaging in a physical altercation. It was alleged that on 03/23/2024, Resident #1 (R1) entered Resident #2 (R2)’s room and an altercation began where R1 was pushed by R2 resulting in R1 falling and injuring themselves. To investigate the allegation, on 03/27/2023 LPA conducted physical plant tour at around 10:50 AM, interviewed five (05) staff and ED at 11:30 AM and requested records at 12:30 pm. (CONT. on LIC 9099-C) Substantiated During interviews with staff, staff stated that on 03/23/24 R1 entered R2’s room and they were holding on to each other, when R2 took a step forward R1 was propelled backwards and fell injuring themselves. 911 was then called and police, fire and rescue showed up. Record review revealed R1 requires safety measures to address behaviors such as wandering. Staff were not aware of what was happening until R2’s roommate Resident #3 (R3) went to get staff. Staff were not paying attention to cameras and were not aware of what was happening. Based on interviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Being that this is the second time that this citation is issued in less than 12 months LPA explained to ED that this will be a repeat violation with a civil penalty of $250. Please refer to LIC9099-D. Citation was issued. Appeals rights discussed and provided. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 27, 2024 · control 31-AS-20240325110125

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Mar 29, 2024

87705 Care of Persons with Dementia (b) (2) ...the plan of operation shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering, aggressive behavior...This requirement is not met as evidence by; Facility staff did not ensure that the needs of dementia residents were properly addressed. Based on interviews and observations facility staff failed to ensure R1 was supervised by staff which poses an immediate health, safety and hazard to residents in care.the state’s words, verbatim · CDSS document, Mar 27, 2024

Plan of correction: Administrator agreed to review Dementia plan with proof of acknowledgment, will submit a new LIC500 to reflect enough staff for supervision of residents, and will provide Care and Supervision training for all staff to be given by a vendor, all proof will be emailed to LPA by POC due date.

Type of visit: Case Management - Deficiencies

On 03/27/24 LPA Casillas arrived at facility above to conduct an initial 10-day complaint investigation for complaint # 31-AS-20240325110125. This Case Management is not related to the original complaint visit. During the facility tour LPA observed that cleaning supplies were unlocked and unsupervised. This allowed residents to have access to cleaning supplies. During LPA’s tour with Executive Director (ED), LPA observed that a hallway closet with a sign that read “Cleaning Supplies” was not locked. Upon seeing this ED immediately locked the closet making it inaccessible to residents. LPA explained to ED the importance of locking all closets that store harmful products. LPA explained to ED that a citation would be issued for this deficiency. LPA also advised ED that there would need to be a training of all staff on the importance of keeping harmful items locked for resident safety. ED will email LPA a copy of the training that was provided along with a log of all staff that was in attendance by end of POC date. Citation Issued. Appeal rights discussed and provided. Exit Interview conducted.the state’s words, verbatim · CDSS document, Mar 27, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Mar 29, 2024

87705 Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication,..and toxic substances such... cleaning supplies and disinfectants. This requirement was not met as evidence by: Based observation, staff do not ensure that cleaning supplies were locked and inaccessible to clients, this poses an immediate health and safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 27, 2024

Plan of correction: Hallway closet was locked in LPA’s presence. Executive Director will email LPA a copy of the training that was provided along with a log of all staff that was in attendance by end of POC date.

Allegation investigated: Staff do not safeguard resident's funds. Staff do not ensure that residents are adequately fed. Staff do not treat residents with dignity or respect.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation. LPA met with the, Executive Director, Chanel Sanchez and explained the reason for the visit. --- Staff do not safeguard resident's funds. It was alleged that staff is stealing residents’ money. To investigate the allegation, on 03/14/2024 LPA requested pertinent documents at 9:30 AM, interviewed seven (07) residents from 10:30 PM to 12:30 PM and interviewed three (03) staff from 12:30 PM to 02:00 PM. A review of resident’s P&I documents revealed that facility issues funds to residents that are able to manage it accordingly. All other residents receiving P&I from the regional center are able to request anything they need and the funds are deducted from the trust account. (CONT. LIC9099-C) Unsubstantiated During interviews with residents, all residents stated that they are getting the full P&I money and do not feel that the facility is stealing any of their funds. During interviews with staff, all staff stated they do not steal residents’ money and the P&I is issued in full monthly. Based on record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff do not ensure that residents are adequately fed. It was alleged that residents are denied food. To investigate the allegation, on 03/14/2024 LPA requested facility menu at 9:30 AM, conducted a physical plant tour at 9:45 AM, interviewed seven (07) residents from 10:30 PM to 12:30 PM and interviewed three (03) staff from 12:30 PM to 02:00 PM. During physical plant tour, LPA observed at least two (02) days perishable and seven (07) days non-perishable foods. LPA also observed food being prepared and lunch being served to all residents. A review of facility menu shows that residents are served a variety of nutritious foods for breakfast, lunch and dinner. During interviews with residents, all residents stated that they are not denied food. During interviews with staff, all staff stated that residents are never denied food. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff do not treat residents with dignity or respect. It was alleged that residents are physically abused. To investigate the allegation, on 03/14/2024 LPA conducted a physical plant tour at 9:45 AM, interviewed seven (07) residents from 10:30 PM to 12:30 PM and interviewed three (03) staff from 12:30 PM to 02:00 PM. LPA observed that all residents were clean, well groomed and showed no signs of physical abuse. During interviews with residents, all residents stated that they are not abused by staff. During interviews with staff, all staff stated they have never abused any resident or aware of any resident ever being abused. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Mar 14, 2024 · control 28-AS-20230314164651

Allegation investigated: Staff did not properly assist resident with toileting needs

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation. LPA met with the Executive Director, Chanel Sanchez, and explained the reason for the visit. --- Staff did not properly assist resident with toileting needs It was alleged that staff are rushing and not cleaning residents well after toileting. To investigate the allegation, LPA interviewed four (04) staff from around 11:30 AM to 12:15 PM and interviewed ten (10) resdients from around 12:15 PM to 2:15 PM. During interviews with staff, all staff stated residents are not rushed during incontinent cleaning, that they are cleaned properly and are not aware of any residents complaining about not being cleaned well after toileting. (CONT on LIC9099-C) Unsubstantiated During interviews with residents, all residents, including Resident #1 (R1), stated that they are not rushed and cleaned well by staff after toileting. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 1, 2024 · control 28-AS-20230313141306

Allegation investigated: Staff allow residents with prohibited health conditions. Staff financially abuse residents in care.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation. LPA met with the, Executive Director, Chanel Sanchez and explained the reason for the visit. --- Staff allow residents with prohibited health conditions. It was alleged that the facility allows residents to have bed sores. To investigate the allegation, on 09/25/2023, LPA conducted physical plant tour at around 10:30 AM, requested documents at 11:30 AM, LPA interviewed 04 (four) staff at 11:45 AM. During the physical plant tour, LPA selected fifteen (15) residents’ room at random and did not observe any residents with bed sores or pressure injuries. LPA also randomly selected six (06) residents’ physician’s reports which also did not indicate that any of the residents had bed sores or pressure injuries. (CONT. on LIC 9099-C) Unsubstantiated ***This LIC9099-C page is an amendment to the report completed 02/29/2024 to include that residents are not being financially abused*** During interviews with staff, all staff stated they do not have any bedridden residents or residents with bed sores or pressure injuries. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff financially abuse residents in care. It was alleged that Staff #1 and Staff #2 are physically abusing residents and taking medications and resources from residents. To investigate the allegation, on 09/25/2023, LPA interviewed 04 (four) staff at 11:45 AM and interviewed six (06) residents at 01:00 PM. On 03/14/2024 LPA requested pertinent documents at 9:30 AM, interviewed seven (07) residents from 10:30 PM to 12:30 PM and interviewed three (03) staff from 12:30 PM to 02:00 PM. During interviews with staff, all staff stated they have never physically or verbally abused anyone. Staff added that they have never taken anything from residents or heard anything about Staff #1 or Staff #2 taking anything from resident. All staff stated they do not steal residents’ money and the P&I is issued in full monthly to those that are able to manage it. During interviews with residents, all resident stated they have never been abused by staff and are not missing any medications or belongings. All residents stated that they are getting their P&I money and do not feel that the facility is stealing any of their funds. A review of resident’s P&I documents revealed that facility issues funds to residents that are able to manage it accordingly. All other residents receiving P&I from the regional center are able to request anything they need and the funds are deducted from the trust account. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 31-AS-20230921104845

Allegation investigated: Facility staff is emotionally and mentally abusing residents. Facility staff is physically abusing residents.

Licensing Program Analyst (LPA) Rosaura Valenzula conducted an unannounced subsequent visit for the above noted allegations. LPA met with Administrator Peter Bonilla and explained the reason for the visit. It was reported that facility staff is emotionally and mentally abusing residents. To investigate this allegation, on 2/14/2024, between between 1:00pm and 2:00pm, staff interviews were initiated. Interviews revealed that facility employees are not emotionally and mentally abusing residents. Staff #1 (S1) told LPA that if they were to become aware or see any staff abusing residents in care, that they would be fired immediately. Moreover, the staff that are identified as the abusers are not present or employed at the facility. Between 2:00pm and 2:30pm, LPA reviewed facility records. Records confirmed what staff had told LPA. The alleged abusers are not employed as facility staff. Between 2:30pm and 3:30pm, resident interviews were initiated. Eight residents were interviewed. Interviews revealed that facililty staff is not emotionally and mentally abusing residents. Staff are nice, friendly, and helpful. Continue on 9099-C Unsubstantiated Based on interviews and records review, there is not sufficient information to verify this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. It was alleged that facility staff is physically abusing residents. To investigate this allegation between 1:00pm and 2:00pm, staff interviews were initiated. Interviews revealed that staff is not physically abusing residents. According to S1 if staff were physically abusing staff, that would be grounds for immediate termination. Between 2:00pm and 2:30pm, facility records were reviewed. Records revealed that the staff identified as the abusers are not employed at the facility. Between 2:30pm and 3:30pm, resident interviews were initiated. Eight residents were interviewed. Interviews revealed that facility staff is not physically abusing residents. On the contrary, staff are friendly, polite, and helpful. Based on interviews and records review, there is not sufficient information to support this allegation. Thus, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 14, 2024 · control 28-AS-20230222134544

Allegation investigated: Staff mismanaged resident's medication.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Administrator Peter Bonilla and explained the reason for the visit. It was reported that staff mismange Resident #1 (R1)'s medication. To investigate this allegation on 10/31/2023 between 1:00pm and 2:30pm, facility records were reviewed. Between 3:00pm and 3:30pm, staff interviews were initiated. Staff interviews revealed that approximately six weeks ago a medication error occurred. R1 was given Resident #2 (R2)'s medication and R2 was given R1's medication. The medication was mixed up by a former staff member. Staff #1 (S1) was terminated and no longer works at the facility. Between 3:35pm and 3:50pm, LPA interviewed R2. Interviews confirmed what staff told LPA. R2 stated that their medication was mixed up. Based on interviews there is sufficient information to support this allegation. Therefore, this allegation is SUBSTANTIATED at this time. Substantiatedthe state’s words, verbatim · CDSS document, Oct 31, 2023 · control 31-AS-20231030103931

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Nov 14, 2023

87465-Incidental Medical & Dental Care (c) If the resident 's physician stated in writing that the resident is able to determine his/her own precription medications...the licensee shall be permitted to assist resident with self administration...(2) Once ordered by the physcian the medication is given the physcian the medication is given according to the physician's directions. This requirement was not met as evidenced by...The facility staff mixed up the medication of R1 and R2. Each were given the wrong medication. This poses an immediate and health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: The Licensee shall submitted in writing to the deparment by 11/14/2023, how they will ensure that medication errors do not occur. In addition, the Licensee shall provide medication training to staff and show proof to the Department that training was completed.

Allegation investigated: Staff does not ensure resident's hygiene needs are being met. Staff does not ensure resident's showering needs are being met. Staff does not provide adequate meal service.

Licensing Program Analysts (LPAs) Angela Panushkina and Michael Cava conducted an unannounced subsequent complaint visit to conclude the investigation regarding the above allegations. This initial visit to this complaint was made by LPA Cava on 05/26/23. LPAs met with the Executive Director, Peter Bonilla, and explained the reason for the visit. At approximately 11:30am to 1:00pm, LPAs conducted a physical plant inspection of the facility and conducted interviews with five (5) residents. A record review was also made. Staff does not ensure resident's hygiene needs are being met: In regards to the allegation, it was reported that Resident 1's (R1) hasn't had their nails clipped or cleaned in over two weeks. Also, it was alleged that R1 wasn't getting assistance with their teeth brushed. During the initial visit on 05/26/23, LPA Cava attempted to interview R1, but R1 was non-verbal to the LPA's questions. LPA did assess and observe R1 to be maintained and in good hygiene, and R1's nails to be manicured and kept. During visit on 10/27/23, LPAs were advised R1 is no loger at the Unsubstantiated facility. LPAs conducted interviews with five (5) of five residents, and all five denied the allegation of not getting their hygiene needs met. Therefore, based on the information obtained, the allegation of staff not insuring R1's hygiene needs not being met is deemed Unsubstantiated at this time. Staff does not ensure resident's showering needs are being met: In regards to the allegation, it was alleged that R1 has not been showered or bathed for weeks. During the initial visit on 05/26/23, LPAs reviewed R1's records, and confirmed R1 requires assistance with bathing. Record review also reveal that the facility maintained bathing schedule for R1 and other residents, showing that R1 was provided assistance with bathing two to four times per week. LPA Cava attempted to interview R1 on 05/26/23, but R1 was non-verbal to the LPA's questions. On 10/27/23, LPAs interviewed five of five residents, who all denied the allegation of not getting their bathing/showering needs met. Based on the information obtained, it could not be proven that staff does not ensure R1's showering needs are being met. Therefore, the allegation is deemed Unsubstantiated at this time. Staff does not provide adequate meal service: In regards to the allegation, it was reported that staff had forgotten to provide R1 their meals. No dates were specified on when R1 could have missed their meals. During the initial 10 day visit to investigate this allegation, LPA Cava attempted to interview R1 on 05/26/23, but R1 was non-verbal to the LPA's questions. On 05/27/23, LPAs conducted interviews with five (5) of five residents, and all five denied the allegation of not being provided an adequate meal service. In addition, LPAs conducted a walk through of the dining room area, and observed meals provided to all the residents that were there. Based on the information obtained, it could not be proven that staff does not provide adequate meal service. Therefore, the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Oct 27, 2023 · control 31-AS-20230509133727

Allegation investigated: Resident sustained multiple burns while in care

This is a subsequent visit to previous visit conducted on 3/9/23, with additional deficiencies added to the 9099-D. Licensing Program Analyst (LPA) Angelica Rea met with Office Manager, Brenda Chacon, who assisted with today's visit. Regarding the allegation that Resident #1 sustained multiple burns while in care, the investigation was conducted by the department, which included interviews with staff, residents, and review of resident #1's facility file and hospital records. The investigation revealed that on 1/23/21, resident #1 was found by staff #1, in the bathtub with hot water running. Resident #1 was sent to hospital. It was determined that resident #1 was scalded by hot water and suffered multiple first and second degree burns to the face and body. Substantiated Review of resident #1's file, including needs and services plan dated 6/19/20, indicates that resident #1 had severe cognitive impairment, and a history of wandering throughout the facility. Per documentation and interviews, Resident #1 was often disoriented and confused, and required assistance with completing all activities of daily living. Staff interviewed stated that resident #1 needed a higher level of care, and/or one to one supervision. Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D. An immediate $500 civil penalty was previously issued. The licensee was informed that a civil penalty might be assessed based on health and safety code 1569.49 (e)or (f). Exit interview conducted. Appeal rights explained.the state’s words, verbatim · CDSS document, Oct 11, 2023 · control 28-AS-20210126124057

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(b)(2) · Plan of correction due date: Oct 18, 2023

(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement was not met as evidenced by: Staff interviewed stated that resident #1 had severe cognitive impairment and a history of wandering. The facility did not provide safety measures to address resident #1's wandering behavior, which resulted in resident #1 sustaining multiple 1st and 2nd degree burns.the state’s words, verbatim · CDSS document, Oct 11, 2023

Plan of correction: LIcensee shall follow Title 22 regulations and ensure that the facilty's plan of operation is followed, and the needs to address residents with dementia are followed to ensure the safety of residents in care. Licensee to conduct staff in service on this regulation, and will submit proof of training to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Oct 18, 2023

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by: Staff interviewed stated that resident #1 required one to one supervision, or a higher level of care. Resident #1 was not provided with sufficient supervision which resulted in resident #1 sustaining multiple 1st and 2nd degree burns.the state’s words, verbatim · CDSS document, Oct 11, 2023

Plan of correction: Licensee shall follow Title 22 regulations and ensure that residents with dementia have the adequate number of direct care staff to support their needs. LIcensee to conduct staff inservice on this regulation and will submit proof of training to LPA by POC due date.