Glen Park at Glendale - Mariposa St

Allegation investigated: Staff threatens resident Staff is not providing medical care for resident

On 06/15/26, at 12:05pm, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, subsequent complaint visit and was greeted by Susan Parks, Administrator. LPA explained the purpose of this visit was to gather additional information and deliver findings for this complaint. On 06/01/26, LPA Saucedo conducted the initial complaint visit, conducted a physical tour and interviewed residents and staff. On 06/15/26, at 12:15pm, LPA Saucedo conducted another physical tour, interviewed additional staff and residents. LIC 9099C-continued Unsubstantiated Regarding the allegation: Staff threatens resident. It is being alleged that Resident #1 (R1) was threatened by staff #1 (S1) to be slapped. During LPA’s interview with R1, R1 admitted that S1 never threatened to slap them and has never hit them. R1 also admitted to LPA, that they wrote a letter apologizing to S1. During LPA’s interview with S1 and staff #2 (S2), they both confirmed that R1 wrote S1 a letter apologizing. LPA received a copy of the letter. During LPA’s interview with S1, S1 confirmed that they have never threatened R1 and/or any other resident. During LPA’s interview with S2, S2 confirmed that S1 has never had any issues with any residents. In addition, S2 conducted their own investigation and R1 admitted that they lied about S1. Furthermore, S2 confirmed that the police dismissed the incident because R1 kept changing their story about what happened. LPA interviewed eight (8) other residents that confirmed S1 has never threatened to hit them and/or has ever slapped them. Therefore, based on the staff and resident interviews conducted the allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff is not providing medical care for resident. It is being alleged that Resident #1 (R1) has rashes on their arm and staff #1 (S1) is not providing medical care. During LPA’s interview with R1, R1 admitted that the rashes they had on their arm was from a hygiene bottle they had bought and S1 had been providing a cream on their arms and told them to stop using the hygiene because of the allergic reaction it was causing. During LPA’s interview with S1, S1 confirmed that a prescribed cream was being provided to R1’s arm daily for a rash they had obtained from a hygiene bottle they had and had gotten an allergic reaction. S1 also confirmed that they have never denied any medical care to any of the residents. During LPA’s interview with Staff #2 (S2), S2 confirmed that no residents have complained about S1 not providing care to them and that R1 was currently being provided cream for their rashes. Furthermore, S2 also confirmed when they asked R1 where they received the hygiene bottle R1 confirmed their brother gave it to them. LPA interviewed eight (8) other residents that confirmed S1 has never denied them any medical care. Therefore, based on the staff and resident interviews 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 15, 2026 · control 31-AS-20260529130838

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 120 non-ambulatory residents 29 of which may be bedridden. Hospice Waiver for ten (10) and there is three (3) residents receiving Hospice Care at this time. The facility had submitted and approved Mitigation and Infection plan. The facility is a single storey building located in a residential neighborhood consisting of 98 rooms. There is one (1) large activity room/living room, across the activity room is a separate area for library, activity area, pool table, computer room and a room designated for arts and crafts. It has a large dining room, laundry room, nurse's station, medication room and a basement parking. At 9:12 AM, LPA conducted physical plant tour of the facility with the Administrator. Facility currently has 62 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 appeared 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 on LIC 809-C) (continued from LIC 809) The medications were locked 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 106.7°F to 118.2°F and within the required range. First aid kits are located in the medication carts. 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 03/06/26. Smoke detectors are hardwired and are observed to be operational. The facility is equipped sprinkler system. An annual inspection of the automatic sprinkler system was last completed on 03/06/26. 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 05/21/26. 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 13, 2026

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

At 10:00 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent visit to this facility to deliver the final report. LPA met with the Administrator Susan Park and explained the reason for the visit. On 09/30/2025, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegation, “Staff did not provide adequate supervision resulting in resident sexually touching another resident.” The complaint was referred to Community Care Licensing Division’s Investigations Branch (IB). On 09/30/2025, LPA Rahimi conducted an initial complaint visit. LPA obtained copies resident and staff roster. LPA conducted a physical plant tour and obtained other pertinent information, including but not limited to Physician Report, Admission Agreement, Appraisal Needs and Service Plan, Staff Training, etc., which is relevant to the investigation. Continue on LIC 9099C Substantiated Allegation: Staff did not provide adequate supervision resulting in resident sexually touching another resident. As part of the investigation, the Department requested and reviewed a police report from the Glendale Police Department on 10/06/2025, conducted interviews with the Administrator and Resident #1 (R1) on 10/10/2025. The department reviewed surveillance footage on 10/10/2025, and interviewed a caregiver on 10/15/2025. The investigation revealed that R1 has resided at the facility since March 2004 and Resident #2 (R2) has resided at the facility since October 2024. On 09/24/2025, law enforcement responded to the facility following a report that R2 engaged in inappropriate physical contact with R1 in the dining room. On 10/10/2025, the Department interviewed R1. Due to diminished cognitive capacity associated with dementia, R1 was unable to provide a reliable statement regarding the incident. The Department reviewed surveillance footage, which showed R1 seated in the dining room when R2 approached and made physical contact with R1's chest area over clothing. The footage showed R2 leaving the area immediately after the contact. Staff intervention occurred only after the contact had already taken place, at which time a staff member approached R1, adjusted R1's clothing, and checked on R1's well-being. On 10/15/2025, the Department interviewed a caregiver who witnessed the incident. The caregiver reported observing R2 approach R1 and engage in inappropriate physical contact before leaving the dining room. The caregiver stated that they immediately checked on R1 and reported the incident to the Administrator. During the investigation, the Administrator reported that R2 had a history of inappropriate behaviors and boundary violations involving other residents. The Administrator further reported that approximately one month prior to the incident, R2 was observed entering R1's room without authorization. Although that incident could not be conclusively substantiated due to insufficient evidence, it raised concerns regarding R2's interactions with other residents. The Department's review also identified repeated incidents and concerns involving inappropriate behavior by R2 toward both residents and staff prior to the 09/24/2025 incident. Continue on LIC 9099C The evidence established that facility administration was aware of R2's pattern of inappropriate and escalating behaviors before the incident involving R1. Despite this knowledge, the supervision and protective measures in place were not sufficient to prevent R2 from accessing and engaging in inappropriate physical contact with another resident. The incident occurred in a common area of the facility and was not prevented despite R2's known behavioral history and prior boundary violations. Based on interviews conducted, records reviewed, surveillance footage reviewed, and information obtained during the investigation, the Department determined that the incident occurred as reported. The preponderance of evidence established that the facility was aware of R2's history of inappropriate conduct and escalating behavioral concerns and failed to provide supervision sufficient to protect residents from a foreseeable risk of harm. As a result, R2 was able to engage in inappropriate physical contact with R1 before staff intervention occurred. Therefore, the allegation that staff did not provide adequate supervision resulting in a resident sexually touching another resident is Substantiated. Deficiencies issued and appeal rights explained. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jun 1, 2026 · control 31-AS-20250930090108

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1-3) · Plan of correction due date: Jun 2, 2026

Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the … (1) To be accorded ... (2) To be accorded safe, ... (3) To be free from punishment, humiliation, intimidation, abuse…This requirement is not met as evidenced by: Based on surveillance footage reviewed by the Department and interviews conducted, Resident #2 (R2) approached Resident #1 (R1) in the dining room and made inappropriate physical contact with R1.the state’s words, verbatim · CDSS document, Jun 1, 2026

Plan of correction: The Administrator agreed to provide a training to all staff regarding this section. Administrator will submit the training sheets to LPA by the POC due date. Information obtained during the investigation revealed that the licensee was aware of R2's prior inappropriate behaviors and boundary violations but failed to provide supervision sufficient to prevent the incident. This poses an immediate health, safety, and personal rights risk to residents in care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jun 1, 2026

Personnel Requirements-(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents needs...This requirement was not met as evidenced by: Based on interviews, records, and surveillance footage reviewed, the Department determined that R2 engaged in inappropriate physical contact with R1 before staff intervened.the state’s words, verbatim · CDSS document, Jun 1, 2026

Plan of correction: Administrator shall submit a written plan describing how the facility will ensure adequate supervision of residents with known behavioral concerns. Administrator shall provide training to all staff on resident supervision and abuse prevention & submit the training proof to LPA by POC date. Although the facility was aware of R2's history of inappropriate behaviors and boundary violations, adequate supervision was not provided to prevent the incident, resulting in a foreseeable risk of harm to residents. This poses an immediate health, safety, and personal

Allegation investigated: Staff did not safeguard resident’s belongings.

Licensing Program Analyst, Abeye Duguma (LPA) conducted a subsequent complaint visit to investigate the above allegations. LPA met with Executive Director Susan Park and explained the reason for the visit. --- Staff did not safeguard resident’s belongings. It was alleged that Resident #1’s (R1) camera was taken out of room without R1’s knowledge. To investigate the allegation, on March 25, 2026, LPA requested documents at around 10:00a.m. and interviewed four (04) staff from around 10:30a.m. to 12:00p.m. At approximately 12:30p.m., LPA conducted a physical plant tour and interviewed Resident #1. At the time of R1’s file review, the Safeguards for Personals/Valuables form was not completed and it was annotated, “resident refused”. During interviews with staff, all staff stated they did not take R1’s camera out of their room. (CONT. on LIC9099-C) Unsubstantiated Staff #1 (S1) added they were instructed to take them down and store for safe keeping in their rooms while facility’s Plan of Operation is being revised. During the physical plant tour, LPA observed Staff #2 (S2) take camera out of R1’s private bathroom drawer. During interviews with R1, they stated while in the hospital, R1’s Responsible Party entered their room and noticed the missing camera. R1 stated when their Responsible Party spoke with staff, they informed them there’s a new policy and all cameras were removed. They have not given me my camera back or this new policy they are referring to. After the physical plant tour, R1 added they were not told camera was in the bathroom drawer. Based on interviews, observations and record reviews 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, Mar 25, 2026 · control 31-AS-20260320141457

Allegation investigated: Facility staff are insufficient to meet resident needs. Licensee does not ensure that staff are adequately trained. Licensee does not ensure that the facility has sufficient hygiene supplies.

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced subsequent complaint visit to investigate the above allegations. LPA met with the Administrator Susan Park and explained the reason for the visit. Initial complaint investigation was conducted by LPA Shahbazian on 10/28/2025. LPA obtained copies of pertinent information, such as LIC 500, Resident Roster, care staff job descriptions. From 1:10pm to 2:00pm LPA interviewed residents. Today's visit concentrated maily on interviewing residents. Facility staff are insufficient to meet resident needs. It was alleged that the caregivers are being assigned to care for up to 25 residents per shift. To investigate the allegation, LPA Shahbazian interviewed nine (9) residents in random. Interviews with all nine (9) residents revealed that all residents were happy with the services and staff. Two (2) residents stated that staff assist them with Activities of Daily Living (ADL)s, assist with showering two times weekly and to assist with using the restroom. All nine (9) residents stated that staff check of them on regular basis, sometimes every 2-3 hours and that caregivers assist them in Continued on 9099-C Unsubstantiated their rooms and in the dining room; in addition Med Techs provide medications timely. During interviews with residents, six (06) out of nine (09) residents stated they have not called for assistance but three (3) residents stated that when pulling the cord, staff respond with five (05) to ten (10) minutes or sooner. LPA Shahbazian pulled the cord for the signal system in two rooms and one bathroom and in each incident, caregivers attended to residents within 2 minutes. LPA Shahbazian interviewed nine (9) care staff members, working in various shifts. All care staff members stated that they are assigned to assist 16-20 residents during their daily shift but approximately 5-8 residents needs total care and others require assistance every 2-3 hours. Care staff stated they shower residents two times or more weekly, assist with ADLs, cleaning the rooms, taking out the trash and assisting residents in the dining room. All staff interviewed stated they feel they are short staffed, they all help each other to ensure residents are care for. Several staff members informed LPA that due to shortness of staff, facility is using caregivers from agencies, also Med Techs and LVN do assist caregiver when needed. Interview with Executive Director revealed that usually there are five (5) caregivers in the morning shift, four (4) assigned to pm shift and three (3) to graveyard shift and each caregiver is assigned to approximately sixteen (16) residents daily. Executive Director stated that currently one (1) caregiver is out on medical leave and residents for the caregiver are divided amongst the other caregivers, but there is enough coverage per shift. In addition Executive Director mentioned that caregivers, housekeepers and med techs all assist each other and communicate with each, to ensure residents are assisted as soon as possible or within seven (7) minutes. Executive Director stated that facility uses services from two (2) separate staffing agencies to complete any caregiver staff shortages. Records obtained by LPA from September 2025 through current, revealed that facility has been using caregivers from the staffing agencies, on regular basis, to cover staff during various shifts. During the initial complaint visit on 10/28/2025 LPA had observed a banner hanging outside regarding hiring but during today's visit LPA did not see the banner. Executive Director stated that they have hired a Human Resources Manager at the facility, in order to concentrate on interviewing and hiring staff, including caregivers and housekeepers. Facility has hired five (5) caregivers and one (1) housekeeper in January 2026 and are still recruiting for more caregivers. During facility visits, residents were observed to be appropriately supervised, and staff were present and engaged in resident care activities. Based on staff interviews and records review, if was reveled that facility is using staffing agencies and has hired multiple caregivers to address staff shortages. Therefore, the allegation is UNSUBSTANTIATED at this time. Licensee does not ensure that staff are adequately trained. It was alleged that the caregivers do not have proper training to provide care to residents. To investigate the allegation, LPA Shahbazian interviewed nine (9) caregivers. All caregivers stated that they feel the training was sufficient in the beginning and there is always trainings and meetings to cover various topics. Caregivers stated that initial training is learning facility policies and online training specific for their duties. In addition, they stated for 2-3 weeks caregivers shadow other senior caregivers and med techs to learn their tasks. Based on interviews with staff, it was revealed that staff are satisfied with their training and facility provides continued training to all staff. Therefore, the allegation is UNSUBSTANTIATED at this time. Licensee does not ensure that the facility has sufficient hygiene supplies. It was alleged that facility does not have enough gloves or hygiene supplies such as shampoo or personal care items. To investigate the allegation, LPA Shahbazian interviewed staff who revealed that there is no shortage of personal or hygiene supplies. Staff informed LPA that they are always provided a supply of masks, gloves and any required items at the front desk but several caregivers stated the quality of the gloves are not good. Interview with Office Manager revealed that it is their responsibility to purchase supplies, including office and personal care items. Supplies are ordered every 2 weeks and there is available funds for any immediate purchases. LPA toured the facility with Office Manager and observed three storage areas filled with boxes of masks, alcohol pads, shampoos, gloves, incontinence supplies, office supplies and medical supplies. LPA also observed supplies in med room and front reception area. Based on interviews and observations, the allegation is UNSUBSTANTIATED at this time. Exit interview conducted and copy of the report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Feb 9, 2026 · control 31-AS-20251021115416

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an annual required inspection. LPA was greeted by the front receptionist, who was informed the reason of the visit. Administrator Susan Park was contacted and arrived shortly after, she was explained the purpose of today's visit. Today's census was (89. Facility is licensed to care for (120) non ambulatory elderly residents with a hospice waiver for ten (10). A complete physical plant inspection of the inside and outside was conducted with Administrator. The following areas were observed during the visit. Physical Plant: The facility is a single story building, which consist of 98 rooms; rooms are either private or shared. The front lobby, is a common area for residents to lounge. The main entrance/lobby area is used as the central entry point for everyone. A check-in station is set up at the front desk with a receptionist. There are empty rooms used for storage, and there are administration offices. There is one (1) large activity room/living room, across the activity room is a separate area for library, bingo activity area, pool table, computer room and a room designated for arts and crafts. It has a large dining room, laundry room, nurse's station, medication room and a basement parking. The interior and exterior physical plant was inspected. Exit doors have delayed egress alarms. Smoke and carbon monoxide detectors are operational and located in resident's room. There are fully charged fire extinguishers throughout the hallways,current inspection dates. The facility has a fire suppression system. Cleaning supplies and toxic substances are inaccessible to residents. Hot water temperature were measured from various resident's rooms, and were in within the required Licensing requirements. There is sufficient space to accommodate both indoor and outdoor activities........Continue on 809-C An activity calendar was observed posted in the hallway. 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. Personnel Records-Training: Staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and First Aid/CPR training. They have the required training. Resident Records: Resident files were reviewed containing admission agreements, Physician's Report, Appraisal, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights. Medication: Medication is stored in the medication room which is locked and is inaccessible to residents in care. No health and safety issues noted at the time of this visit, exit interview conducted and copy of report provided to Administrator.the state’s words, verbatim · CDSS document, Sep 9, 2025

Allegation investigated: Staff did not ensure resident had access to medication in a timely manner.

Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the faciity to investigate the above allegation. LPA met with assistant administrator Jessica Favela, and advised her of the complaint. It's being reported that Resident 1's (R1) medication for colitis, was delivered on or around 07/17/25, but R1 was not notified. When R1 called the pharmacy for a refill, the pharmacy advised R1 that the medication was delivered already, and another refill would not be available. Today's investigation consisted of a interviews with staff and residents. LPA also conducted a physical plant inspection and record review. Interviews with the assistant administrator and three (3) out of three staff deny the allegation. Staff acknowledged that R1's medication was delivered to the facility on 07/17/25. Medication was given to the med techs for central storage, as R1 was hospitalized from 07/11/25 to 07/19/25. S1 stated R1 never missed a dose of this medication. When R1 returned from the hospital on or around 07/19/25, staff notified R1 that the medication is held in the med room and ready for R1 to keep. Medication was then given to R1, Unsubstantiated as R1 is able to manage, store, and administer their own medication. Interviews made with ten (10) of ten residents reveal no concern or complaints of residents not having access to their medications in a timely manner. Review of R1's records reveal that R1 is able to manage and administer own medication. LPA reviewed random resident medications and Medication Administrator Records (MAR) and did not observe any discrepancy in medication records. Based on the information obtained, there wasn't enough evidence to corroborate with the allegation of Staff not ensuring resident had access to their medication in a timely manner, Therefore the allegation is deemed Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 31-AS-20250819150511

Allegation investigated: Staff did not ensure the Wi- Fi internet was fixed in a timely manner.

On 08/26/2025 at 10:00 am Licensing Program Analyst (LPA), Lorena Casillas conducted an unannounced complaint visit to investigate the above stated allegation. Staff greeted and allowed LPA entry. Assistant Administrator Jessica Favela met with LPA. LPA explained the reason for the visit and an entrance interview was conducted. At 10:35 PM LPA Casillas conducted a physical plant tour with the Administrator Assistant. During the investigation, interviews and record reviews were conducted. LPA requested resident roster, LIC 500, and Liability Insurance. LPA requested copies of pertinent information relevant to the investigation including, but not limited to, facility records, repair receipts and any other information related to the allegation. Record review was conducted from approximately 11:30am to 12:30pm, and LPA received copies of requested documents. Staff, third-party vendor and resident interviews were done from 12:30 pm to 1:30pm. Continued on LIC9099-C Unsubstantiated Allegation: Staff did not ensure the Wi-Fi internet was fixed in a timely manner. Regarding this allegation it is reported that staff did not ensure that Wi-Fi internet was fixed in a timely manner. Interview with the Assistant Administrator (AA) revealed that the Wi-Fi has been intermittently working in some areas of the facility for approximately two (2) weeks. The AA stated that Spectrum, the internet provider, has been contacted twice, on 8/11/25 and 8/22/25 to resolve the matter, however the internet is still intermittent. Facility has hired a third-party vendor to resolve the concern and interview with this vendor indicates that internet will be at full capacity within the next 72 hours. The facility currently has six (6) access points and will be upgraded to ten (10) access points to provide better coverage for residents and staff. LPA inquired if an alternative was offered and AA stated that residents are free to use the areas of the facility such as the activities room for their internet needs since these areas seem to have Wi-Fi access. Furthermore, the AA made arrangements for staff to help residents make appointments and calls to providers when needed, as well as the use of their hot spots for Wi-Fi access. AA stated that ethernet or hard wire internet is functioning and only Wi-Fi is down, further providing internet to residents in the administration area. Interview with office staff confirmed that the Wi-Fi has been intermittently down, but that staff has been assisting residents with making appointments and any needs that require internet use. Interview with ten (10) out of ten (10) residents revealed that although the Wi-Fi is down, they have no concerns since if/when they ask for assistance to make appointments or need to access the internet, it is always granted. Therefore, based on interviews, observations and record reviews this allegation is deemed unsubstantiated. No citation issued. Exit interview conducted. A copy of the report provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 31-AS-20250820144001

Allegation investigated: Staff inappropriately isolated resident. Staff did not ensure resident was provided with a comfortable environment. Staff did not ensure resident was provided with activities. Staff restricted resident’s access to their personal belongings. Staff spoke to resident in an inappropriate manner.

On 7/21/2025 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 staff and stated the reason for their visit was to deliver the findings of the complaint. The Administrator Susan Park arrived shortly after to assist with today's visit. To investigate the allegation(s), on 7/02/2025 at approximately 10:00 AM, LPA conducted a physical plant tour. By 11:00 AM, LPA requested relevant documentation. From 11:30 AM to 2:30 PM, LPA conducted record review and interviewed four (4) residents (R1-R4) and attempted interviews with six (6) staff members (S1-S6). (continue to LIC 9099-C) Unsubstantiated Regarding the allegation: Staff inappropriately isolated resident. It was alleged that R1 was placed in isolation after being discharged from the hospital, although they were not deemed contagious. To investigate the allegation, LPA interviewed one (1) staff member and one (1) resident. Interview with S1 revealed that when R1 was discharged from the hospital, they were given instructions to place R1 in isolation until their symptoms had subsided. Interview with R1 revealed that they were made aware of their diagnosis while hospitalized and when they returned to the facility, they “…understood and did not object to being isolated…”. LPA’s record review confirmed the instructions given by R1’s Physician stated R1 needed to be placed in, “Isolation”. Further record review of the facility’s Infectious Control Plan (2022) showcased the facility’s policy outlining their procedures to help minimize and/or eliminate exposures related to airborne communicable diseases. Such procedures include precautionary steps involving the avoidance of small, enclosed areas where continual contact with others can or may occur. During LPA’s physical plant tour, LPA observed R1’s bedroom to be a shared room with another resident. LPA observed the temporary room R1 was placed in to be a single room separate from other residents. Based on interviews, record review and observations, the facility followed R1’s physicians order including their Infectious Control Plan regarding R1’s isolation, therefore the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff did not ensure resident was provided with a comfortable environment. It was alleged that R1 was placed in a temporary room where they could hear staff giggling, talking and the radio playing. LPA’s record review of R1’s Admission Agreement revealed that they are to be provided with such amenities as: a comfortable and suitable bed and bedroom furniture. During LPA’s physical plant tour, LPA observed the bedroom R1 was temporarily placed in. LPA observed the room to be neat, clean and organized. LPA observed the bedroom to be equipped with the following: a bed, a closet, a drawer, a chair, a small refrigerator and a bathroom. Additionally, LPA observed the immediate surroundings outside of the bedroom. LPA observed there to be a workstation assigned to the Medication Technicians (Med-Techs). However, LPA observed the station to be empty and observed the Med-techs conducting their rounds throughout the facility. LPA did not observe any radio or music being played. LPA did not observe there to be any staff near the bedroom conversating loudly. Based on record review and observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. (Continue to LIC 9099-C) Regarding the allegation: Staff did not ensure resident was provided with activities. It was alleged that R1 was not provided with a television and/or any activities for them to do. To investigate the allegation, LPA interviewed four (4) staff members and one (1) resident. Interview with all four (4) staff members confirmed that R1 was provided with their laptop and cell phone. LPA’s interview with R1 confirmed that staff did provide them with their electronic equipment, however they were not provided with a television. LPA’s interview with S1 stated that a television was not included in their services but instead considered a resident’s own personal inventory. S1 stated that they offered to bring R1’s television from their room but R1 declined. Interview with R1 confirmed that they, “…didn’t want them touching my TV because I didn’t want them breaking anything”. Further interview with S1 revealed that S5 attempted to call R1 multiple times to inquire if they needed any other activities. LPA’s interview with R1 confirmed that S5 did attempt to call them but they refused to answer. R1 did state that if they would have spoken to S5, they could have asked for anything and S5, “…would have helped me”. LPA attempted to interview S5 but they were not present during LPA’s visit nor could be reached. LPA’s record review of R1’s Personal Property Inventory confirmed a television was listed. Additionally, LPA’s record review of R1’s Admission Agreement under the Facility’s Basic Services plan confirmed that such equipment is not provided. During LPA’s physical plant tour, LPA observed R1’s television mounted onto the wall of their bedroom. Based on interviews, record review and observation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. Regarding the allegation: Staff restricted resident’s access to their personal belongings. It was alleged that R1 was not given access to their personal belongings. To investigate the allegation, LPA interviewed four (4) staff members and one (1) resident. All four (4) staff members confirmed that R1 was given access to their personal belongings such as clothing and electronic equipment. Interview with S2 stated that when R1 would ask for, “…clothes…I would take them…”. Interview with R1 confirmed they were provided with their clothing and electronic equipment. Based on interview with R1 that staff did allow them access to their personal belongings, the allegation is UNSUBSTANTIATED at this time. (Continue to LIC 9099-C) Regarding the allegation: Staff spoke to resident in an inappropriate manner. It was alleged that R1 was yelled at by a staff member. To investigate the allegation, LPA interviewed four (4) staff members and four (4) residents. Interview with R1 revealed that S1 had yelled at them during a phone conversation. Interview with S1 revealed that when they spoke with R1, R1 was upset and raised their voice. S1 stated they told R1, “…my pitch is a little high because I am trying to explain to you, but I am not yelling at you”. Additional interviews with three (3) staff members stated that they have never yelled or witnessed a staff member yell at a resident. LPA’s interview with two (2) out of the four (4) residents stated that they have never witnessed staff yell at any residents nor have they been yelled at. Based on interviews, 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 conducted and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jul 21, 2025 · control 31-AS-20250625091857

Allegation investigated: Staff do not provide adequate supervision to residents.

On 05/13/2025 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation. LPA met with Executive Director (ED), Susan Park. LPA explained the reason for the visit. An entrance interview was conducted. LPA requested copies of the resident roster and personnel report. At 12:03 p.m., LPA Rios conducted a physical plant tour of the facility with the ED. From approximately 12:13 p.m., to 1:50 p.m., LPA Rios interviewed ten (10) residents or 10% of the facility’s census. Allegation: Staff do not provide adequate supervision to residents. Regarding the allegation it was reported that staff did not realize a resident that required supervision exited the facility unattended and was returned to the facility by the local police department. To investigate the allegation LPA Rios conducted an initial complaint visit on 02/14/2025. During the initial visit LPA conducted a physical plant tour. (Continue to LIC9099-C) Unsubstantiated (Continued from LIC9099) Delayed egress exit doors were inspected by LPA Rios. LPA observed, each door required several seconds of pressing before they opened, and the alarm sounded on all attempts. Subsequently, the ED and LPA proceeded to the reception area to observe the camera video stream. The ED explained that when the door is activated, the camera feed switches to focus solely on that door. LPA did not observe any operational concerns with the doors. LPA attempted to review video footage from the day in question. Footage was not saved. LPA's review of fire clearance confirmed, the facility is approved for a secured perimeter. On 02/14/2025 LPA Rios did the following: From 11:18 a.m. to 11:50 a.m., LPA interviewed three (03) staff that were present during the afternoon shift on 02/04/25. LPA also interviewed the ED who was not present when the incident took place. At 11:51 a.m., LPA interviewed resident #1's (R1's) Responsible Party via telephone and at 12:22 p.m., LPA interviewed, staff #1 (S1) via telephone. At 12:45 p.m. LPA reviewed and obtained copies of R1's file, such as their Physician’s Report, Functional Capabilities Resident Appraisal, Preplacement Appraisal and medication list. From 1:29 p.m. to 2:02 p.m., LPA interviewed, R1 and two (02) more staff. LPA’s review of R1’s record corroborates R1 is unable to leave the facility unassisted due to R1’s diagnosis which may cause R1 to become confused and disoriented. LPA’s interview with four (04) staff present on the day in question corroborate R1 did exit the facility but deny that R1 was unsupervised. LPA's interview with S1 revealed they rushed to R1 outside and followed R1 trying to redirect them to return to the facility, then a bystander contacted 911 for assistance. According to S1, police retuned the resident to the facility. R1's, responsible party confirmed staff contacted them when the incident occurred. Resident interviews corroborate they are supervised and those that may leave the building may sign out at reception and those that need assistance go out as groups. Three (03) out of the ten (10) residents reported they had witnessed different residents attempt to leave the building or making it out of the building but according to them staff always responded and assisted the residents back into the facility. LPA Rios submitted a call of service request to the local police department but has not received a response. R1 did not recall the events that took place on 02/04/2025. Based on interviews and observations this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, May 13, 2025 · control 31-AS-20250207131924

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Leslie Ngo-Castaneda delivered, in person, an amended LIC 9099 and LIC 9099-C complaint investigation report in association with complaint report# 31-AS-20250218151741, and the initial complaint investigation visit conducted on 2.25.2025 The Amended LIC-9099 and LIC 9099-C Complaint Investigation Report was hand delivered to executive director, Susan Park.the state’s words, verbatim · CDSS document, May 7, 2025

Allegation investigated: The Administrator became resident's payee for SSI payments. Licensee did not ensure to return resident's SSI checks upon relocation

At approximately 11:30 a.m. on 04/16/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA Valenzuela conducted an initial visit on 09/26/24 and interviewed staff between 12:00pm and 12:45pm. Today, LPA Reed conducted a record review of pertinent records, including but not limited to a care plan, cash ledgers, a face sheet, and staff and client rosters at 12:00 p.m., toured the facility inside and out at 12:10 p.m., and interviewed staff and residents between 12:15 p.m. and 2:00 p.m. Regarding the allegation “The Administrator became resident's payee for SSI payments” it was alleged the administrator directly received and handled the monthly Social Security Income (SSI) of Resident #1 (R1). LPA Valenzuela’s interview with the administrator at approximately 12:10 p.m. on 09/26/24 revealed the administrator was never personally R1’s payee for SSI payments or anything other payments. Unsubstantiated The money went directly to the facility where the only the Business Office Manager and the administrator handled the funds. Interviews with three (03) staff today revealed the administrator was not a payee for residents, and only the administrator and Business Office Manager handle resident funds. Interviews with eight (08) out of 88 residents who allow the facility to handle their money revealed they have had no issues with the facility handling their money. Interview with Resident #2 (R2) at 1:30 p.m. today revealed they have to wait a few days to receive their money, but they always receive the full amount owed. All nine (09) residents stated the facility is the payee of their SSI and not the administrator. Record Review of R1’s face sheet revealed the administrator was not the payee for R1. Based on record review and interviews, the administrator was not R1’s payee. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation “Licensee did not ensure to return resident's SSI checks upon relocation” it was alleged that from December 2023 to April 2024, the licensee received R1’s SSI payments without returning them. Interview with the administrator at 12:15 p.m. today revealed all of R1’s SSI funds were properly returned to the Social Security Administration. Record review of banking and SSI documents revealed the facility returned all SSI funds belonging to R1 from December 2023 to April 2024 on 04/19/24. Review of check photocopies at 1:45 p.m. today confirmed a check was issued from the facility to the Social Security Administration in the full amount owed on 04/19/24. Based on record review and interviews, the licensee ensured R1’s SSI checks were returned. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. During today’s inspection, no immediate health or safety concerns were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 16, 2025 · control 31-AS-20240917152632

Allegation investigated: Staff is selling drugs Staff is abusing the residents

At approximately 11:30 a.m. on 04/16/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with the administrator and disclosed the reason for the visit. To investigate the allegations above, LPA Valenzuela conducted an initial visit on 07/22/24 and interviewed staff between 1:00 p.m. and 2:00 p.m. and conducted a record review of the personnel report at 2:00 p.m. Today, LPA Reed conducted a record review of pertinent records, including but not limited to a care plan, cash ledgers, a face sheet, and staff and client rosters at 12:00 p.m., toured the facility inside and out at 12:10 p.m., and interviewed staff and residents between 12:15 p.m. and 2:00 p.m. Regarding the allegation "Staff is selling drugs" it was alleged that the licensee is selling drugs. LPA Valenzuela’s interview with the administrator at approximately 1:10 p.m. on 07/22/24 revealed the licensee is rarely at the facility and does not sell drugs. Interviews with three (03) staff today revealed they have not witnessed or heard about the licensee or anyone selling drugs. Unsubstantiated Interviews with nine (09) out of 88 residents, which was at least 10% of the current census, revealed they had no knowledge of the licensee, other staff, or anyone else selling drugs in the facility. Residents interviewed had not seen the licensee in the facility. LPA observed no indications of drug sales in the facility during the physical plant tour today. Based on observations and interviews, the licensee is not selling drugs. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff is abusing the residents" it was alleged that the licensee is abusing residents. LPA Valenzuela’s interview with the administrator at approximately 1:10 p.m. on 07/22/24 revealed the licensee is rarely at the facility and does not abuse residents. Interviews with three (03) staff today revealed they have not witnessed or heard any reports of the licensee or any staff abusing residents. Interview with Staff #1 (S1) at 12:20 p.m. today who was watching the camera footage in common areas confirmed they had not observed any abuse on surveillance footage. Interviews with nine (09) out of 88 residents, which was at least 10% of the current census, revealed they had never been abused by the licensee or any staff. LPA observed no indications of abuse in the facility during the physical plant tour today. Based on observations and interviews, the licensee is not abusing residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. During today’s inspection, no immediate health or safety concerns were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Apr 16, 2025 · control 31-AS-20240717160937

Allegation investigated: Staff are not preventing resident from engaging in inappropriate behavior(s) in the presence of other residents in care. Staff are not preventing resident from harassing other residents in care.

Licensing Program Analysts (LPA) Abeye Duguma conducted a subsequent complaint visit to the facility to further investigate the above allegations. LPA met with Executive Director, Susan Park, and explained the reason for the visit. ---Staff are not preventing resident from engaging in inappropriate behavior(s) in the presence of other residents in care. It was alleged that Resident #2 (R2) exposes themselves by not wearing clothes from the waist down. To investigate the allegations, on 10/17/2024, LPA interviewed four (04) staff and nine (09) residents from around 11:00a.m. to 1:30p.m. On 03/22/2025, LPA reviewed the Department’s records. During interviews with staff, Staff #4 (S4) stated they witnessed R2 exposed in the hallway after exiting the communal shower. (CONT. LIC9099-C) Substantiated All other staff stated that R2 does not exposes themselves from the waist down to other residents. During interviews with residents, Resident #1 (R1) stated that R2 inappropriately exposes themselves. All other residents stated that they have never witnessed R2 exposing themselves from the waist down. A review of the Department’s Incident Report logs revealed that R2 has multiple reported incidents of exposing themselves. Based on interviews and record review, 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): --- Staff are not preventing resident from harassing other residents in care. It was alleged that R2 calls people socialist, Marxist, communist and makes trouble for everyone. To investigate the allegations, LPAs interviewed four (04) staff and nine (09) residents from around 11:00a.m. to 1:30p.m. On 03/22/2025, LPA reviewed the Department’s records. During interviews with staff, all staff stated that R2 calls staff socialist and Marxist but does not make trouble for resident. During interviews with residents, R1 stated that R2 calls them socialist and Marxist and makes trouble. All other residents stated residents do not make trouble or call them socialist and Marxist. A review of the Department’s Incident Report logs revealed that R2 has multiple reported incidents of aggressive behavior towards residents and staff. Based on the interviews and record review, 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. Executive Director, Susan Park, does not agree with the finding and declined to sign the report. A copy of the report and Appeal Rights were printed and issued.the state’s words, verbatim · CDSS document, Mar 22, 2025 · control 31-AS-20241015110335

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1)(2)(3) · Plan of correction due date: Mar 24, 2025

87468.1 Personal Rights of Residents in All Facilities(a)Residents...shall have all of the following personal rights:(1)To be accorded dignity in their personal relationships with staff, residents, and other persons.(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. (3) To be free from punishment, humiliation, intimidation, abuse, or other actions….This requirement is not met as evidenced by; Based on record review and interviews, R2 exposed themselves and intimidated residents with acts of aggression on multiple occasions.the state’s words, verbatim · CDSS document, Mar 22, 2025

Plan of correction: The Licensee/Administrator will review Title 22, Division 6 Chapter 8 Article 08 87468.1 Personal Rights of Residents in All Facilities and submit a written letter stating they have reveiwed and will adhere to the regulation by the POC due date

Allegation investigated: Staff are not ensuring oxygen machine works properly. Due to lack of supervision, resident was left on floor for an extended period of time.

Licensing Program Analyst (LPA) Abeye Duguma conducted a subsequentl complaint visit to the facility to investigate the above allegations. LPA met with Executive Director, Susan Park, and explained the reason for the visit. ---Staff are not ensuring oxygen machine works properly. It was alleged that staff are not cleaning oxygen filter regularly. To investigate the allegation, on 12/18/2024, LPA interviewed four staff from 10:30a.m. to 11:30a.m. and nine (09) residents from around 11:30a.m. – 1:00p.m. During interviews with staff, all staff stated they are not skilled medical professionals, they call a third-party company deals with the oxygen tanks. Staff added they only change the nasal device once every 30 days and assist with tubes if they are tangled, if there are any kinks and other simple and non-technical assistance. (CONT. on LIC9099-C) Unsubstantiated During interviews with residents, one (01) out of nine (09) residents stated staff are not cleaning filter regularly. All other interviewed residents stated they do not have issue with their oxygen filters. Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Due to lack of supervision, resident was left on floor for an extended period of time. It was alleged that the resident fell and was found on the floor for unknown duration of time before staff found the resident. To investigate the allegation, LPA interviewed four staff from 10:30a.m. to 11:30a.m. and nine (09) residents from around 11:30a.m. – 1:00p.m. On 03/22/2025, LPA reviewed the Department’s records which shows resident had a fall on 10/25/2024 and 11/15/2024, however, there was nothing that indicate resident was left for an extended time. During interviews with staff, all staff stated they check on residents every two (02) hours, respond to the call button within five (05) to ten (10) minutes and do not leave residents on the floor for an extended time. During interviews with residents, one (01) out of nine (09) residents stated staff doesn’t check on them frequently and left them on the floor for an extended time. Resident was unable to provide dates or identify alleged negligent staff. All other interviewed residents stated staff check on them about every two (02) hours and have not experienced being left on the floor for an extended time. 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 were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Mar 22, 2025 · control 31-AS-20241210123911

Allegation investigated: Staff did not safeguard resident's personal items. Staff are retaliating against resident for making a report against the facility.

This is an amendment of the original report issued 02-25-2025. The report is being amended to clarify the details of the findings. Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced initial complaint visit to the facility and met with the Administrator (Susan Park- S1). Entrance interview conducted. Allegation#1: Staff removed resident’s personal items. It was alleged that Resident #1 (R1)'s belongings for their supplements and vitamins were taken by the facility staff. To investigate the allegation, at 9:38 AM, LPA conducted physical plant tour at (time). At (time) LPA requested copies of facility documents relevant to the investigation, including R1’s physician report, need and service plan and inventory logs for personal belongings. LPA interviewed residents and staff between 10 AM to 12 PM. Inspection of R1’s room revealed that R1 is keeping their vitamins and supplement on nightstand in between their bed and door. Continue to LIC 9099-C Unsubstantiated Staff interviews revealed that R1 was admitted at this facility on 8.31.2020. R1 purchases vitamins and supplements through Amazon without a prescription/ approval from Primary Care Physician (PCP)/ specialists. Packages delivered to the facility would be opened by R1 in-front of staff. In order to protect R1, facility takes away R1 belongings (vitamins and supplements) until obtaining a prescription/ approval from PCP/ specialists. LPA interviewed R1 at 10:28AM and they verified the information provided by staff. LPA interviewed eight (8) out of eighty-eight (88) residents who are at the facility, and it was revealed unanimously that residents have all their belongings with them and that they are happy and safe living at the facility. A review of R1’s records records between 12 PM to 1:30 PM, revealed that R1 required staff assistance to manage their medication. Based on inspection, observation, interviews and record reviews, it was concluded that there is no sufficient information to determine validity of the complaint. Therefore, the allegation is UNSUBSTANTIATED at this time. Allegation #2: Staff are retaliating against resident for making a report against the facility. It was alleged that resident #1 (R1) fears that facility staff is retaliating against them for filing reports. To investigate this allegation, LPA spoke with the administrator and interviewed five (5) staff and they denied retaliating against residents for any reason. They treat all their residents with respect and dignity. LPA interviewed eight (8) out of eighty-eight (88) residents and they revealed unanimously that they were never were retaliated by staff and all of them are treated well. They are happy and have no concerns about staff. Based on overall information obtained during investigation, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted, no citations were issued for the above allegation(s), and a copy of this report was given to the executive director.the state’s words, verbatim · CDSS document, Feb 25, 2025 · control 31-AS-20250218151741

Type of visit: Case Management - Deficiencies

In conjunction with control number 31-AS-20250207131924 complaint visit, Licensing Program Analyst (LPA) Evelin Rios did an unannounced CASE MANAGEMENT - Deficiencies visit. A case management report is being issued today in conjunction to the complaint visit report for observed deficiencies not related to complaint. LPA met with Susan Park the Executive Director. During the course of complaint investigation, interview with Executive Director and review of Personnel Report (LIC500) revealed staff #1 (S1) is not on the report. According to ED, S1 was hired as a caregiver from a temporary agency. According to interviews S1 has worked for the facility for over a year in the capacity as receptionist and caregiver. Based on staff interviews, at least on one occasion S1 has been alone to provide care and supervision to one (1) resident. Review of Guardian Background Check System and Licensing information System (LIS) S1 is background cleared but not associated to the facility. Per the California Code of Regulations (CCR), the following deficiencies were observed and cited (refer to LIC 809-D) and a Civil Penalty assessed (refer to . Exit Interview Conducted / Appeal Rights Discussed / A Copy of Report Issued.the state’s words, verbatim · CDSS document, Feb 14, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Feb 15, 2025

87355(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Based on record review and interviews, licensee failed to have staff #1 (S1) associated to the facility or transfer of a criminal record clearance which is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 14, 2025

Plan of correction: Administrator will not allow staff to work at the facility unless proper transfer clearance is submitted to CCLD.

Allegation investigated: . Staff are not providing adeuqate food service to resident 2. Unqualified staff handling food

Licensing Program Analyst (LPA) Tuesday Cabiness conducted a complaint visit to discuss the allegations mentioned above. LPA met with administrator assistant Bryanna Luke, who was informed the reason of the visit, who had to leave and requested Crystal Lopez, Office Manager to conclude the visit. The following information was obtained during the investigation: Allegation #1: Staff are not providing adequate food service to residents. During the visit, from 10am to 230pm, LPA conducted a physical plant inspection and interviewed staff and residents. From interviews and documentation obtained during the visit, it was reported to LPA, that hair was found in a meal that was served to a resident. Staff confirmed the incident, and an in-service training was immediately conducted. This is a health and safety risk to residents in care. Therefore, based on interviews and documentation, the allegation is Substantiated, and the plan of correction (POC) will be cleared during the visit. (CONT. on LIC9099-C) Substantiated Allegation #2: Unqualified staff handling food. During the visit, from 10am to 230pm, LPA conducted a physical plant inspection and interviewed staff and residents. From interviews conducted, it was reported to LPA, that several staff who perform caregiver and housekeeping duties assist in the kitchen, serving or preparing food to residents. Although their job description requires them to assist in the kitchen, it was reported to LPA, those staff were not properly trained in handling or preparing food. This poses a potential health and safety risk to residents in care. Therefore, the allegation is Substantiated at this time. Plan of correction (POC) will be cleared during the visit. Citations issued, appeal rights, exit interview, and copy of report provided. (SEE LIC9099D - citations)the state’s words, verbatim · CDSS document, Jan 28, 2025 · control 31-AS-20250121152426

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(15) · Plan of correction due date: Jan 28, 2025

General Food Service Requirements. (15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination.the state’s words, verbatim · CDSS document, Jan 28, 2025

Plan of correction: Assistant Administrator Bryanna Luke provided food hygiene in-service training record to LPA. POC is cleared during the visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(1) · Plan of correction due date: Feb 4, 2025

Personnel Requirements - General (d)All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned...(1) Principles of good nutrition good food preparation and storage, and menu planning. This requirement was not met, evidenced by: based on interviews, staff who are assigned to work in the kitchen, never received proper training when preparing food to residents. This is a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 28, 2025

Plan of correction: Assistant Administrator Bryanna Luke provided food hygiene in-service training record to LPA. POC is cleared during the visit.

Allegation investigated: Staff served expired food to a resident in care. Staff did not administer medications as prescribed.

Licensing Program Analyst (LPA) Abeye Duguma conducted an initial complaint visit to the facility to investigate the above allegations. LPAs met with Executive Director, Susan Park, and explained the reason for the visit. --- Staff served expired food to a resident in care. It was alleged that facility served moldy bread. To investigate the allegation, LPA conducted a physical plant tour at around 9:30a.m., interviewed four staff from 10:30a.m. to 11:30a.m. and nine (09) residents from around 11:30a.m. to 1:00p.m. During the physical plant tour, LPA did not observe any expired foods or moldy breads. During interviews with residents, Resident #1 (R1) stated they asked for bread the other day and was served moldy bread. (CONT. on LIC9099-C) Unsubstantiated R1 added when they asked why, staff replied it is because they asked specifically for sourdough and they only had a few slices. All other residents stated they are not served expired foods or moldy bread. During interviews with staff, all staff stated they do not recall the incident and do not serve expired foods or moldy breads to residents. 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 administer medications as prescribed. It was alleged that staff do not administer medications on time. To investigate the allegation, LPA requested documents at around 9:30a.m., interviewed four staff from 10:30a.m. to 11:30a.m. and nine (09) residents from around 11:30a.m. to 1:00p.m. A review of Resident #2’s (R2) Medication Administration Records lists all medications, however, there are many empty spaces. When staff were questioned about the blank spaces, they stated it is a system error they have not been able to fix it, and the meds were given on those dates. The records also have several “refused” and “away” indications for medications. During interviews with residents, R1 and R2 stated facility does not give two (02) of the medications to R2 during food as prescribed. R1 and R2 added that one (01) of the MedTechs refused to give R2 medications while they were in R1’s room. During interviews with staff, Staff #2 (S2) stated they give R2 their medications as prescribed but at times R2 either does not wait for the medications to be given or refuses medications entirely. S2 added, R2 is sometimes away without prior notice. All other staff stated, to their knowledge, residents are being 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. No health and safety hazards were noted during the visit. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 31-AS-20250107111055

Type of visit: Case Management - Other

At approximately 10:30 a.m. on 01/14/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and later the assistant 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 toured the facility at 10:45 a.m. and interviewed the assistant administrator at 11:00 a.m. Interview with the assistant administrator revealed the facility admitted twenty-two (22) residents on 01/08/25, and all residents left as of 01/12/25. As of today, no residents from other facilities still reside at this facility. 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: Residents room smells malodorous. Staff do not answer residents calls for assistance timely. Staff are not ensuring resident's room is cleaned properly.

Licensing Program Analyst (LPA) Abeye Duguma conducted an initial complaint visit to the facility to investigate the above allegations. LPAs met with Executive Director, Susan Park, and explained the reason for the visit. ---Residents room smells malodorous. It was alleged that residents’ rooms smell bad and smells like roach spray. To investigate the allegation, LPA conducted a physical plant tour at around 9:30a.m., interviewed four staff from 10:30a.m. to 11:30a.m. and nine (09) residents from around 11:30a.m. – 1:00p.m. During the physical plant tour, LPA did not experience any malodor or roach spray odor. During interviews with staff, all staff stated residents’ rooms do not consistently have malodor or smell of roach spray. (CONT on LIC9099-C) Unsubstantiated During interviews with residents, one (01) out of nine (09) residents stated room had a bad smell and smelled of insect spray but that now everything is okay as they move to another room. All other residents stated they do not experience malodor in the facility. 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 answer residents calls for assistance timely. It was alleged that staff does not answer the call for the resident’s pull cord. To investigate the allegation, LPA conducted a physical plant tour at around 9:30a.m., interviewed four staff from 10:30a.m. to 11:30a.m. and nine (09) residents from around 11:30a.m. – 1:00p.m. During the physical plant tour, LPA selected five (05) rooms at random and observed an average response time of six (06) minutes. During interviews with staff, all staff stated they respond to the call button within five (05) to ten (10) minutes. During interviews with residents, three (03) out of nine (09) residents stated staff respond within ten (10) to fifteen (15) minutes. All other residents stated staff respond with five (05) to ten (10). Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff are not ensuring resident's room is cleaned properly. It was alleged that resident had an accident on the floor and the staff did not ensure that they cleaned it up properly. To investigate the allegation, LPA conducted a physical plant tour at around 9:30a.m., interviewed four staff from 10:30a.m. to 11:30a.m. and nine (09) residents from around 11:30a.m. – 1:00p.m. During the physical plant tour, LPA did not observe any stains on the carpet of Resident #1’s (R1) old room or any other room. During interviews with staff, all staff stated R1’s carpet was shampooed and vacuumed and that it was cleaned right away. Staff #1 (S1) added that they tried removing the carpet to install vinyl but that the store was out of stock. S1 also stated R1 was moved to a room without carpeting as soon as one became available. (CONT. on LIC9099-C) During interviews with residents, one (01) out of nine (09) residents stated staff does not clean the room properly. All other residents stated they feel staff does a good job of keeping their rooms clean. 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 was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 18, 2024 · control 31-AS-20241210123911

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 did not provide adequate food service to residents in care. Staff do not treat resident(s) with dignity and respect.

Licensing Program Analysts (LPA) Abeye Duguma and Angelica Segovia conducted a subsequent complaint visit to the facility to investigate the above allegations. LPAs met with Executive Director, Susan Park, and explained the reason for the visit. ---Staff did not provide adequate food service to residents in care. It was alleged that the facility fails to consider the diverse cultural backgrounds of its residents in meal preparation. To investigate the allegation, LPAs requested documents at around 11:00a.m., interviewed three (03) staff and nine (09) residents from around 11:00a.m. to 1:15p.m. A review of the facility’s weekly menus revealed that a variety of well-balanced, diverse and nutritious foods are served. During interviews with staff, all staff stated they provide a variety of well-balanced meals. (CONT. on LIC9099-C) Unsubstantiated During interviews with residents two (02) out of nine (09) residents stated they feel facility does not provide a variety of diverse foods, all remaining residents stated meals are diverse and well-balanced. Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. ---Staff do not treat resident(s) with dignity and respect. It was alleged that staff lack proper "bedside manners" and yell at other residents. To investigate the allegation, LPAs interviewed three (03) staff and nine (09) residents from around 11:00a.m. to 1:15p.m. During interviews with staff, all staff stated they treat residents with dignity and respect. During interviews with residents one (01) out of nine (09) residents stated they feel staff do not treat them with dignity and respect. All other residents stated they feel staff treat them with respect and dignity. 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 was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 31-AS-20241016090824

Allegation investigated: Facility staff are not allowing residents to leave the building. Facility staff are tying the doors at night trapping residents in the facility. Facility staff steal residents' money and belongings. Facility staff allow residents with prohibited health conditions. Facility staff deny residents food. Facility staff are emotionally abusing residents. Facility staff threaten residents.

On 11/13/24 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent visit to continue the investigation on the above allegations and deliver determinations. LPA was greeted by the Executive Director (ED), Susan Park. LPA explained the reason for the visit. Entrance interview conducted. To investigate the allegations, an initial visit was conducted on 05/30/23, by LPAs Michael Cava and Mariana Agban. During the initial visit LPAs interviewed the ED, Susan Park and conducted a record review. On 10/10/24 LPA Rios interviewed ten (10) randomly selected residents, the ED and one (1) staff. Residents interviewed were living in the facility during the initial visit on 05/30/23. LPA reviewed five (5) resident records and obtained copies of pertinent documents. On 11/12/24, LPA Rios conducted four (4) staff interviews. LPA also reviewed three (3) resident records. LPA reviewed 9 residents' medication and medication records for correctness. To assist with the investigation LPA Rios referenced the investigation conducted by LPAs Esther Cortez, Ashley Smith, and Kelly Dulek at Glen Park at Ojai, Complaint Control 29-AS-20230406155619. (Cont. to LIC9099-C) Unsubstantiated Allegation: Facility staff are not allowing residents to leave the building. Allegation: Facility staff are tying the doors at night trapping residents in the facility. Based on the information gathered, LPA addressed the above allegations collectively, which claim that residents are prevented from leaving the building by staff obstructing the facility doors. Interviews conducted by LPA Rios on 10/15/24 and 11/12/24 revealed that eight (8) residents and five (5) staff members who were present during the initial visit denied witnessing any instances of the doors being tied up or obstructed by furniture or other means, day or night. According to resident interviews, those who do not require assistance when leaving the facility can do so by signing out. According to residents that are not able to leave the facility unassisted based on their Physician’s Report (LIC602), theydid not express concerns about being able to leave the facility. Staff interviews indicated that residents who need assistance, as per their LIC602, typically leave with the Activities Coordinator for planned outings, with family members, or are redirected to stay while waiting for a planned outing. The Executive Director denies that residents are trapped in the building. Furthermore, according to the ED cameras placed in common areas that have been reviewed have not alerted to such instances. LPAs' tours of the facility on 05/30/23, 10/15/24, and 11/12/24 did not observe any health or safety concerns. Based on interviews, record reviews, and observations, the allegation is deemed Unsubstantiated at this time. Allegation: Facility staff steal residents' money and belongings. In regards to the allegation, it was alleged resident’s money, medication, and belongings are being stolen. On 10/15/24, LPA's interview with six (6) out of eight (8) residents that were interviewed denied having money or items stolen or witnessing staff stealing from residents. Two (2) out of eight (8) residents interviewed reported items being stolen or going missing, eight (8) to thirteen (13) years ago. Both stated that the issue was addressed and has not reoccurred. LPA's interviews with five (5) staff and the ED between 10/15/24 and 11/12/24, deny the allegation. On 10/15/24 the ED informed LPA, residents that receive P&I sign a log when a check is provided to them and the facility keeps petty cash and receipts when purchases are made. ED also informed LPA residents' personal belongings are recorded and updated annually on a Personal Property Inventory form by residents and family members. Staff and the ED noted, resident diagnosed with Dementia occasionally claim money or items are missing, but these are typically found to be misplaced or already spent by the resident. On 11/12/24, LPA with the assistance of the LVN conducted a medication and medication record review for nine (9) residents of which four (4) are taking a PRN narcotic medication. (Continue to LIC9099-C) Page 2 of 4 Centrally Stored Medication and Destruction records matched medication in locked cart. LPA observed narcotic pills popped out of bubble wrap packs were documented on the electronic medication administration record (MAR). LPA observed narcotic PRN medication from 2023 that had not yet expired, was still intact in bubble wrap. Based on interviews, observation and record review the allegation is deemed Unsubstantiated at this time. Allegation: Facility staff allow residents with prohibited health conditions. Regarding the allegation, it was alleged the facility retains residents with prohibited health condition such as severe pressure injuries. Interview with the ED on 10/15/24 and 11/12/24 revealed residents who have prohibited health conditions are receiving Hospice services for such conditions and have care plans on file. ED also noted training is conducted by a certified professional and the facility documents such training when they are done for residents with prohibited and restricted health conditions. There is currently one (1) resident, Resident #1 (R1) with a pressure injury. LPA's review of R1's file on 10/15/24, revealed R1 is receiving Hospice services and wound care by Hospice for a stage 3 pressure wound. The prohibited health condition is allowable as R1 has been diagnosed as terminally ill and is currently receiving hospice care. Record review confirmed a wound care specialist is seeing R1 and providing proper and adequate care for the wound. Review of eight (8) other resident records revealed resident #2 (R2) has a restricted but allowable health condition and is also receiving services from a Hospice agency. Interviews with eight (8) residents revealed no issues with pressure injuries. Based on record review and interviews, the allegation is deemed Unsubstantiated at this time. Allegation: Facility staff deny residents food. Regarding the allegation, it was alleged residents are being denied food. Interviews conducted on 10/15/24 with eight (8) residents revealed that the facility provides meals and snacks regularly, and none of the residents reported being denied food by the staff. One of the eight residents mentioned that the facility had stopped serving oranges and apples, but LPA and resident noted that other fruit options were available. Resident interviews also indicated that they had not observed any staff members denying food to other residents. Additional interviews with five (5) staff members and the Executive Director (ED) on 10/15/24 and 11/12/24 further confirmed that staff have never denied food to the residents. According to two staff members, residents who refuse a meal are offered a substitute. One staff member mentioned that the facility provides special meal and snack requests made by residents. Based on interviews, there is insufficient evidence to support the claim, facility staff deny residents food. Therefore, this allegation is deemed Unsubstantiated at this time. (Continue to LIC9099-C) Page 3 of 4 Allegation: Facility staff are emotionally abusing residents. Allegation: Facility staff threaten residents. Based on the information gathered, LPA addressed the above allegations collectively, which claimed that residents are being bullied and threatened, causing emotional damage. LPA Rios interviewed eight (8) residents living in the facility during the initial visit. They revealed having no knowledge of bullying or emotional damage caused by staff. One of the eight residents stated they had observed preferential treatment given to certain residents during lunch and expressed that Staff #3 (S3) lacked professionalism. Resident interviews also revealed that there are staff members whom residents are very happy with and that they are satisfied with the assistance provided. Interviews with five staff members on 10/15/24 and 11/12/24 denied the allegations. Two staff members stated they had witnessed residents being confrontational with other residents but never witnessed staff being confrontational with residents. LPAs' tours of the facility on 05/30/23, 10/15/24, and 11/12/24 did not reveal any health or safety concerns. Based on interviews and observations, there is insufficient evidence to support the claims that facility staff are emotionally abusing or threatening residents. Therefore, these allegations are deemed Unsubstantiated at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued. Page 4 of 4the state’s words, verbatim · CDSS document, Nov 13, 2024 · control 31-AS-20230523084151

Allegation investigated: Staff are sexually abusing residents and staff. Facility staff are not qualified.

On 11/12/24 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent visit to continue the investigation and provide determinations on the above allegations. LPA was greeted by the Executive Director (ED), Susan Park. LPA explained the reason for the visit. To investigate the allegations, an initial visit was conducted on 05/30/23, by LPAs Michael Cava and Mariana Agban. During the initial visit LPAs interviewed the ED, Susan Park and conducted a record review. On 10/10/24 LPA Rios interviewed ten (10) randomly selected residents, the ED and one (1) staff. LPA reviewed five (5) resident records and obtained copies of pertinent documents. On todays visit 11/12/24, at approximately 10:10 a.m. LPA Rios conducted four (4) staff interviews. Residents interviewed were living in the facility during the initial visit on 05/30/23. At 12:00 p.m. LPA reviewed three (3) resident records. LPA reviewed 9 residents' medication and medication records for correctness. To assist with the investigation LPA Rios referenced the investigation conducted by LPAs Esther Cortez, Ashley Smith, and Kelly Dulek at Glen Park at Ojai, Complaint Control 29-AS-20230406155619. (Cont. to LIC9099-C) Unsubstantiated (Continued from LIC9099) Allegation #1: Staff are sexually abusing residents and staff. Regarding the allegation, it was reported that Staff#1 (S1) has been sexually abusing residents. Interviews conducted by LPA Rios on 10/15/24, and 11/12/24 revealed eight (8) residents and five (5) staff that lived and worked in the facility since the initial visit all denied either being sexually abused or witnessing any staff sexually abuse residents. Interview obtained from Complaint Control 29-AS-20230406155619 with S1 revealed they deny ever abusing any residents in any form. Staff interviews revealed S1 has minimal to no contact with residents at this facility and they have never witnessed S1 alone with a resident. Furthermore seven (7) out of the ten (10) residents interviewed revealed all staff in general treat residents well, and residents did not voice any concerns of sexual abuse. Interview with one (1) resident had concerns regarding staff, but it did not involve sexual abuse and two (2) residents were asleep during visit. LPAs tours of the facility on 05/30/23, 10/15/24 and 11/12/24 did not observe and health or safety concerns or issues. Based on interviews, there is insufficient evidence to support the claim that, staff are sexually abusing residents and staff, therefore the allegation is deemed Unsubstantiated at this time. Allegation #2: Facility staff are not qualified. Regarding the allegation, it was reported that Staff#1 (S1) is not qualified to run and manage the facility. To investigate the allegation LPA conducted interviews with the ED and staff. According to the ED, S1 is part of the cooperation and has no contact with residents directly. When S1 visits the facility they meet with the administration to discuss and conduct building safety checks. S1 reports any concerns to the Administrator. According to the ED, S1 does not work in the capacity to "run and manage" the facility. The ED is responsible for the day to day operations of the facility. Furthermore, the there is also an administrator assistant at this facility. Review of the Administrator Certification for Susan Park is active and she has been the administrator since the initial visit. According to staff, S1 conducts quality assurance visits, for example issues with the physical building in regards to issues like workers compensation. Based on interviews and record review the allegation is deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was issued to Assistant Administrator, Bryanna Luke.the state’s words, verbatim · CDSS document, Nov 12, 2024 · control 31-AS-20230523084151

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 do not treat residents with dignity Staff steals residents P&I monies Staff are using illegal substance during working hours Staff steal residents medications

At 1:45 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 10/22/24 and toured the facility at 10:15 a.m., interviewed residents and staff between 10:25 a.m. and 11:45 a.m., conducted a medication review at 11:45 a.m. and a record review of records pertinent to the investigation, including but not limited to staff and client rosters at 12:00 p.m. LPA conducted a subsequent visit on 10/29/24 and interviewed two (02) additional residents at 10:00 a.m. and 10:15 a.m. and toured the facility inside and out at 10:30 a.m. Today, LPA toured the facility at 1:45 p.m. and reviewed a Personal and Incidental funds (P&I) ledger at 2:00 p.m. Regarding the allegation "Staff do not treat residents with dignity" it was alleged staff treat residents poorly. Unsubstantiated Interviews with ten (10) out of ten (10) residents revealed no staff abuse or treat them or other residents poorly. Interviews with staff revealed they and residents have good relationships. No staff revealed information regarding mistreatment of residents. The administrator stated that all staff and owners treat residents with dignity and respect. During facility tours on 10/22/24 and today, LPA observed staff addressing residents’ needs and providing activities. Based on observations and interviews, staff treat residents with dignity. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. Regarding the allegation "Staff steals residents P&I monies" it was alleged staff members steal residents’ monthly income. Interviews with ten (10) out of ten (10) residents revealed no occurrences of stolen or missing money. Residents interviewed who receive P&I money had no problems with accessing all 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 all 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 are using illegal substance during working hours" it was alleged staff use and sell drugs at the facility. Interviews with ten (10) out of ten (10) residents revealed no occurrences of drug use or sales in the facility. Interviews with staff revealed no reports of staff using or selling drugs. The administrator also confirmed no staff use or sell drugs in the facility. During facility tours on 10/22/24 and today, LPA did not observe any indications of drug use or transactions. Based on observations and interviews, staff do not steal residents’ money. 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 ten (10) out of ten (10) 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 on 10/22/24 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. 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-20241018124023

Allegation investigated: Staff are not preventing resident from engaging in inappropriate behavior(s) in the presence of other residents in care. Staff are not preventing resident from harassing other residents in care.

Licensing Program Analysts (LPA) Abeye Duguma and Angelica Segovia conducted an initial complaint visit to the facility to investigate the above allegations. LPAs met with Executive Director, Susan Park, and explained the reason for the visit. --- Staff are not preventing resident from engaging in inappropriate behavior(s) in the presence of other residents in care. It was alleged that Resident #2 (R2) exposes themselves by not wearing clothes from the waist down. To investigate the allegations, LPAs conducted a physical plant tour at around 10:00a.m. and interviewed four (04) staff and nine (09) residents from around 11:00a.m. to 1:30p.m. During interviews with staff, Staff #4 (S4) stated they witnessed R2 exposed in the hallway after exiting the communal shower. All other staff stated that R2 does not exposes themselves from the waist down to other residents. (CONT. LIC9099-C) Unsubstantiated During interviews with residents, Resident #1 (R1) stated that R2 inappropriately exposes themselves. All other residents stated that they have never witnessed R2 exposing themselves from the waist down. Based on observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff are not preventing resident from harassing other residents in care. It was alleged that R2 calls people socialist, Marxist, communist and makes trouble for everyone. To investigate the allegations, LPAs interviewed four (04) staff and nine (09) residents from around 11:00a.m. to 1:30p.m. During interviews with staff, all staff stated that R2 calls staff socialist and Marxist but does not make trouble for resident. During interviews with residents, R1 stated that R2 calls them socialist and Marxist and makes trouble. All other residents stated residents do not make trouble or call them socialist and Marxist. Based on the 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 was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 17, 2024 · control 31-AS-20241015110335

Allegation investigated: The Administrator became resident's payee for SSI payments. Licensee did not ensure to return resident's SSI checks upon relocation

LIcensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegations. LPA met with Executive Director (E.D.) Susan Park and explained the reason for the visit. It was reported that the Administrator became resident's payee for SSI payments. To investigate this allegation on on 09/26/2024, between 12:00pm and 12:45pm, staff interviews were initiated. Interviews revealed that Administrator was never Resident #1 (R1)'s payee for SSI payments or anything other payments. SSI sent the money directly to the facility. Between 1:00pm and 1:30pm, LPA reviewed facility records. Records confirmed what staff had 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. Continue on 9099-C Unsubstantiated It was alleged that Licensee did not ensure to return resident's SSI checks upon relocation. To investigate this allegation on 07/22/2024, between 1:00pm and 2:00pm, staff interviews were initiated. Interviews revealed that the facility did contact Social Security and had notified them that R1 had moved out of the community and that their money needed to be paid to the other facility. Between 1:00pm and 1:30pm, LPA reviewed facility records. Records revealed that facility returned $7,171,.79 back to Social Security. Based on interviews and records review, there is not sufficient information to support this 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, Sep 26, 2024 · control 31-AS-20240917152632

Allegation investigated: Staff is selling drugs Staff is abusing the residents

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegations. LPA met with Executive Director (ED) Susan Park and explained the reason for the visit. It was reported that staff is selling drugs. To investigate this allegation on 07/22/2024, between 1:00pm and 2:00pm, staff interviews were initiated. Interviews revealed that Staff #1 (S1) is not a staff memeber at the facility, but rather is the Licensee. The Licensee rarely if ever goes to the facility. The Licensee does not sell drugs. Between 2:00pm and 2:30pm, LPA reviewed the Personnel Report and confirmed what staff had told LPA. Based on interviews and records review, there is not sufficient information to support this allegation. Therefore, the allegation will be UNSUBSTANTIATED at this time. Continue on 9099-C Unsubstantiated It was alleged that Staff is abusing the residents. To investigate the allegation, between 1:00pm and 2:00pm, staff interviews were initiated. Interviews revealed that Staff #1 (S1) is not a staff member at the facility, but rather is the Licensee. The Licensee is not present at the facility and does not abuse residents since they do not interact, have contact with, or see any residents. Between 2:00pm and 2:30pm, LPA reviewed the Personnel Report and confirmed what staff had told LPA. Based on interviews and records review, there is not sufficient information to support this allegation. Hence, the allegation will be UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Jul 22, 2024 · control 31-AS-20240717160937

Allegation investigated: Staff do not provide adequate food service Staff do not ensure the residents have hygiene products while in care

On 7.10.2024 Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at the facility to conduct an unannounced subsequent visit to deliver the determination on the above allegations. LPA was greeted by Susan Park who is the Executive Director (ED) of the facility. An entrance interview was conducted. At 10:00 AM LPA conducted a physical plant tour to ensure the health and safety of the residents in care. To investigate the allegations above, LPA conducted an initial visit on 6.03.2024. LPA toured the facility and requested and reviewed the staff roster, resident roster, admissions agreement, appraisals, and incident reports. LPA interviewed staff and residents. LPA reviewed records on 6.07.2024. Continue to LIC 9099-C Unsubstantiated Interviews with (10) residents out of eighty-nine (89) residents and five (5) out of forty-five (45) staff that the above statement is untrue, and all residents expressed no concern regarding this allegation. Allegation: Staff do not provide adequate food service. More specifically the complainants concern was that the facility does not provide adequate food service, which result in an illness of a resident in care. On May 27, 2024, one resident in care suffered an upset stomach after having breakfast and believes it came from old, spoiled food. On June 3, 2024, LPA Ngo-Casteneda conducted a facility tour which included a food service tour and inspection. LPA observed sufficient supply of 2-day perishable foods and one week of non-perishable foods. LPA inspected food service area which include food storage and prep areas, refrigerator, and freezer. LPA observed areas to be clean. Foods were observed to be properly stored at temperatures within regulations. Foods were observed to be property wrapped and stored to protect foods from spoilage and cross-contamination. Interviews with facility staff revealed that when food supplies arrived from Sysco food is immediately stored in the freezer and walk-in refrigerator. Based on the information received this allegation is Unsubstantiated at this time. LPA could not determine that the resident in care became ill from the food. Proper food handling appears to be followed. No other residents reported illness related to food on or about June 3, 2024. Allegation: Staff do not ensure the residents have hygiene products while in care. It was alleged that R1 was not supplied enough hygiene products from the facility. During the interview, it was revealed that R1 would not ask staff for more supplies when they run out of products. R1 is expecting to be given and handed the number of supplies as requested without using the supplies they have first. ED advised LPA that the following number of products are given to residences: two (2) daily towels, toilet paper one (1) per week, One (1) paper towel monthly, one (1) shampoo per month, one (1) bodywash (or soap) per month, and one (1) toothpaste per month. Interview with residents six (6) residents out of ten (10) revealed that there is no issues with receiving extra supplies when asked. If the facility runs out of supplies, the facility has a driver who can run errands for them to purchase and supply the residents with what the facility needs. During the facility tour, LPA also observed a supply of hygiene products. Based on the information received this allegation is Unsubstantiated at this time.the state’s words, verbatim · CDSS document, Jul 10, 2024 · control 31-AS-20240529144810

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an annual required inspection. LPA met with Susan Park Administrator and explained the purpose of today's visit. There are currently 89 residents at the facility. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant/Environment Safety: The facility is a single story building located in a residential neighborhood consisting of 98 rooms, some of which are being used as model rooms, administration offices and storage rooms. There is one (1) large activity room/living room, across the activity room is a separate area for library, bingo activity area, pool table, computer room and a room designated for arts and crafts. It has a large dining room, laundry room, nurse's station, medication room and a basement parking. It is licensed to care for 120 non ambulatory elderly residents with a hospice waiver for ten (10). Current census is (89) elderly residents. The facility has some Dementia residents. The main entrance/lobby area is used as the central entry point for everyone. A check-in station is set up at the front desk. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has twenty six (26) fully charged fire extinguishers which were last inspected on Jan of 2024. Administrator stated that the local fire department conducted an annual inspection of the facility in January 2024. The facility has a fire suppression system. Cleaning supplies and toxic substances are inaccessible to residents. Hot water temperature readings measured within the required 105-120 degrees Fahrenheit. The hot water temperature measured at 114 degrees F. Continue on 809-C Personnel Records-Training: Five (5) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings and First Aid/CPR training. Staff employed are over the age 18 and are fingerprint cleared. They have the required training. Resident Records-Incident Reports: Five (5) resident files were reviewed containing admission agreements, Physician's Report, Appraisal, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Notes/Records were reviewed. Resident Rights-Information: Resident personal rights were posted near the lobby area. The Incident report binder was also reviewed. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. Information regarding Dementia is part of the training for direct care staff and is included in the Plan of Operation. An activity calendar was observed posted in the hallway. The facility has a Resident Council. 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. Medication: Medication is stored in the medication room which is locked and is inaccessible to residents in care. 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 22, 2024

Allegation investigated: Staff not providing adequate supervision to resident in care.

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced subseqent visit for the above noted allegation. LPA met with Administrator Susan Park and explained the reason for the visit. It was reported that staff did not provide adequate supervision to a resident in care and as a result Resident #1 (R1) walked out of the facility undetected. This complaint was previously investigated by LPA Michael Cava on 1/26/2023, under control # 28-AS-20230117101259. To investigate the allegation on 01/26/2023, LPA Cava interviewed staff, conducted record review, and a physical plant tour. Staff interviews confirmed that R1 had wandered out of the facility unsupervised on 1/14/2023. According to staff, on 1/14/2023, the facility had received some deliveries and the boxes that were left caused a blind spot. R1 excited the facility withthe delivery person, and no one noticed. About an hour later, staff realized R1 was missing. As staff was getting ready to file a missing person report to the police, R1 was brought back by Law Enforcemtent to the facility. R1 was assessed and no noted injuries were Substantiated observed. On this visit, the allegation that staff are not providing adequate supervision to resident in care has been verified. The allegation has been SUBSTANTIATED. No citations will be issued today since the facility was already cited for this same allegation on 1/26/23. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 29, 2024 · control 28-AS-20230216171103