Glen Park at Long Beach

Type of visit: Case Management - Annual Continuation

On September 3, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent 1 Year Required visit. LPA met with Executive Director Ace Huynh. LPA explained the purpose of today’s visit. The facility is licensed to serve four (4) ambulatory, 174 non-ambulatory, and 30 bedridden resident age 60 and above. The facility is approved (30) residents on hospice. Currently, the facility has 106 residents with no hospice residents. LPA toured the physical plant. There were no bodies of water or obstructions on the premises. Rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #101: #114; #122; #124; #130; #136; #137; #211; #216 #227; #255; #262 in assisted living and #233 #238; #243 and #247 in memory care. The water temperature ranges from 106.9- 115.9 degrees F.; room temperature ranges from 70- 76 degrees F.; call buttons and smoke and carbon monoxide detectors are all in operating condition. LPA observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, as well as sanitizing stations in common areas and restrooms. All mandated inspection control posters, including the Activities Calendar and Food Menu, were posted. (Evaluation Report continues LIC 809-C) DEFICIENCIES: Rooms with no sliding door screens #101; #102; #122; #130; #137. Room #255 wash basin cabinet missing doors. Room #243 toilet not flushing properly Room #206 had medication of Fluticasone and Mupirocin ointment inside the room. Room #122 and #262 had toxic chemical cleaners in their rooms. Deficiencies were cited during this inspection visit. Due to time constraints, LPA was unable to complete the visit and will return at another unannounced time. An exit interview was conducted and a copy of this report was provided to ACE HUYNH. Note: Due to technical difficulties, LPA was unable to generate an electronic inspection tool and instead used a printable/PDF version.the state’s words, verbatim · CDSS document, Sep 3, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a)(b) · Plan of correction due date: Sep 4, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances... items which could pose a danger to residents are in locked storage and are not left unattended... This requirement is not met as evidence by: Based on observation, Licensee failed to adhere to ensure toxic poisonous chemicals in room #122 & #262 substances were not locked in storage and left unattended. This violation possesses an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Licensee must comply with Title 22 Section 87309 and provide a plan on how to ensure toxic chemical substances are kept out of reach of residents in care. Proof of correction, must be submitted by the due date of 10/04/26 to 424-544-1016. Licensee must comply with Title 22 Section 87465 and provide a plan for how to ensure medications are kept out of reach of residents in care. Proof of correction, must be submitted by the due date of 10/04/26 to 424-544-1016.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Sep 4, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications...(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement is not met as evidence by: Based on observation, Licensee failed to adhere to ensure medications are kept out of the hands of residents in room #206 and not left unattended. This violation possesses an immediate Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

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

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by Based on observation, the Licensee failed to ensure the facility is in good repair. The room is missing screen doors and cabinet doors. A toilet is not in working condition. This violation poses a potential Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Licensee must comply with Title 22 Section 87303 and repair missing screen doors, cabinet doors, and the toilet that is not flushing properly. Proof of correction, including photos of the repairs, must be submitted by the due date of 10/03/26 to 424-544-1016.

Type of visit: Required - 1 Year

On August 26,2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Executive Director Ace Huynh. LPA explained the purpose of today’s visit. The facility is licensed to serve four (4) ambulatory, 174 non-ambulatory, and 30 bedridden resident age 60 and above. The facility is approved (30) residents on hospice. Currently, the facility has 105 residents with no hospice residents. The two-story commercial building consists of one hundred (100) resident bedrooms, multiple resident bathrooms,(3) common bathrooms, (4) shaded patios, (1) smoking area, dining room, commercial kitchen, staff room, office area, media room, garden area, a laundry, and multiple storage rooms. The facility has a memory care unit with delay egress doors. During the visit LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters, including the Activities Calendar and Food Menu, were posted. An audit of resident's service records for resident #1-#5 (R1-R5) and staff personnel records for staff #1-#5 (S1-S5) were accurate and complete. The facility is current on Community Care Licensing annual fees. Due to time constraints, LPA was unable to complete the visit and will return at another unannounced time. No citations have been issued during this visit. An exit interview has been conducted and a copy of this report has been provided to Executive Director ACE HUYNH.the state’s words, verbatim · CDSS document, Aug 26, 2026

Allegation investigated: Staff mismanaged resident's medication. Staff handle resident in an inappropriate manner. Staff do not ensure resident is treated with dignity and respect.

On August 24, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted an initial unannounced complaint visit. Ace Huynh, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation, a collection of documents, and a tour of the facility. A review of Personnel Report LIC 500 (dated 08/12/26), Resident Roster (dated 07/30/26), Medication Administration Record (dated 07/01/26 through 08/13/26), Admissions Agreement (dated 09/16/25), ID and Emergency Informaiton LIC 601 (dated 09/23/25), and other pertinent records associated with this complaint. Interviews conducted with Resident #1-10, Staff #1-#6 and Witness #1. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff mismanaged resident’s medications. It is alleged that staff mismanaged Resident #1's (R1’s) medications. Reports indicate that (R1) missed a scheduled dose of medication on one occasion. Additional details regarding the circumstances of this incident were not provided. On August 24, 2026, between 09:45 AM and 3:32 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members could not support this claim. Interviews with staff consistently reported that all medications are administered according to physician orders, logged daily, and stored securely. (S1-S5) confirmed their lack of awareness of any incidents involving missed doses, medication errors, or improper handling of (R1’s) medications. On August 24, 2026, between 10:05 AM and 11:38 AM, the Department interviewed residents identified as Resident #2 through Resident #10. Eight (8) out of nine (9) residents could not corroborate this claim. According to reports from (R2-R9), there have been no incidents related to missed doses, medication errors, or improper medication handling. (R1) was unavailable for an interview because the resident passed away in the hospital on August 20, 2026. On August 14, 2026, between 1:10 PM and 01:22 PM, the Department interviewed a witness member identified as (R1’s) responsible party, as Witness #1 (W1). (W1) reported incidents related to (R1’s) care based solely on (R1’s) account. However, (R1) could not provide any specific dates, times, types of medication, or names of those involved. The Department reviewed (R1’s) Medication Administration Records (MAR) and Centrally Stored Medication records for the period of (07/01/26 through 08/13/26. All records were complete, legible, and showed no evidence of missing doses or incorrect administration. Physician orders on file matched the medications listed on the (MAR). No discrepancies were identified between medication labels, logs, or documentation. During the visit on August 13, 2026, the LPA observed that (R1’s) medications were stored in the locked medication cart/room in a manner consistent with Title 22 requirements. (Evaluation Report continues LIC 9099-C) Labels were intact, medications were not expired, and procedures observed during medication pass aligned with facility policy and regulatory standards. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Allegation: Staff handled resident in an inappropriate manner. It is alleged that staff handled Resident #1 (R1) in an improper manner. Reports indicate (R1) was placed in bed forcefully by staff. No further details regarding the circumstances of this incident were provided. On August 24, 2026, between 09:45 AM and 3:32 PM, the Department interviewed staff members identified as Staff #1 through Staff #4 (S1-S5). Four (4) out of the five (5) staff members could not validate this claim. (S1) stated that there have been no incidents of (R1) being handled inappropriately. (S1-S5) denied handling (R1) in any rough, forceful, or inappropriate way. All staff confirmed they used approved techniques to assist residents with transfers, mobility, and daily activities. On August 24, 2026, between 10:05 AM and 11:38 AM, the Department interviewed residents identified as Resident #2 through Resident #10. Nine (9) out of nine (9) residents could not corroborate this claim. None of the individuals from (R2-R10) reported witnessing any inappropriate physical interactions between staff and residents. (R1) was unavailable for an interview because the resident passed away in the hospital on August 20, 2026. On August 14, 2026, from 1:10 PM to 1:22 PM, the Department conducted an interview with a witness identified as the responsible party for (R1), as Witness #1 (W1). (W1) detailed incidents concerning (R1’s) care based solely on (R1’s) description. (W1) could not remember specific dates, times, or names of individuals involved. The Department reviewed personnel files and found current training in Resident Rights, Personal Care, and Safe Transfer Techniques. No incident reports regarding improper physical handling of (R1) were found for the relevant time period. During the visit on August 13, 2026, the LPA observed staff assisting several residents with transfers, ambulation, and routine care. Staff were observed to be gentle, respectful, and consistent with Title 22 regulations and facility policies. No inappropriate handling was observed at any time. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099-C) Allegation: Staff do not ensure resident is treated with dignity and respect. It is alleged that staff failed to ensure that Resident #1 (R1) was treated with dignity and respect. Reports indicate that the resident is not treated with dignity and respect during care. Additional details regarding the circumstances of this incident were not provided. On August 24, 2026, between 09:45 AM and 03:32 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Three (3) out of the five (5) staff members could not support this claim. Interviews with Staff #1 and Staff #4 (S1 and S4) had knowledge of an incident involving (R1) and staff improper behavior as it was reported to them by (R1) and in which (S1) followed up with an internal investigation into the incident. Staff #5 (S5) denied ever speaking rudely to (R1) or ever refusing to provide care services. (S5’s) statements are consistent with statements (S5) had given during the facility's internal investigation. Staff #6 (S6), who had witnessed (S5) speaking offensively to (R1) during an internal investigation, was unavailable for an interview with the Department and did not respond to phone calls. (S1-S5) reported they regularly receive training on resident rights, dignity, privacy, and respectful communication. On August 24, 2026, between 10:05 AM and 11:38 AM, the Department interviewed residents identified as Resident #2 through Resident #10. Nine (9) out of nine (9) residents could not support this claim. All residents interviewed expressed they had not seen any incidents of disrespectful treatment towards themselves or other residents. (R1) was unavailable for an interview because the resident passed away in the hospital on August 20, 2026. On August 14, 2026, from 1:10 PM to 1:22 PM, the Department conducted an interview with a witness identified as the responsible party for (R1), as Witness #1 (W1). (W1) recounted specific events related to (R1’s) care based entirely on (R1’s) account. (W1) was unable to recall particular dates, times, or the names of people involved. The Department reviewed facility training records and confirmed staff had completed current training on resident rights, dignity, and respect. No incident reports or complaints regarding disrespectful treatment of (R1) were found in the facility’s files for the relevant period. (Evaluation Report continues LIC 9099-C) Further review of the facility’s Internal Investigation revealed the facility had responded appropriately. During the visit August 13, 2026, and August 24, 2025, the LPA observed staff engaging with residents during routine care and activities. Staff were observed addressing residents by name, speaking calmly and respectfully, and providing care consistent with regulatory requirements related to dignity, privacy, and personal rights. No interactions were observed that appeared disrespectful or in violation of Title 22 regulations. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. No deficiencies cited. An exit interview was conducted with Catherine Dacara, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Aug 24, 2026 · control 11-AS-20260811160322

Type of visit: Case Management - Deficiencies

On August 13, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit. LPA Dabuet met with Executive Director ACE HUYNH to discuss an incident involving Resident #1 (R1) that occurred on August 7, 2026. The Department received an Unusual Incident Report (LIC 624) on August 7, 2026, regarding an incident that took place at 10:30 AM. It was reported that R1 eloped unsupervised from the community. R1 had been admitted to the community on July 24, 2026, and was diagnosed with a Major Neurocognitive Disorder (NCD). R1 resided on the second floor, which is designated as the "memory care" area. According to Staff #1 (S1) and Staff #2 (S2), while conducting routine checks on residents, they discovered that R1 was not in their room or anywhere on the floor. They immediately contacted the front desk to initiate an elopement alert. Surveillance camera footage confirmed that R1 exited the facility through the front exterior gate without supervision. A door on the second floor, which required a key fob to open, had malfunctioned, allowing R1 to leave the premises via the exterior stairs. R1 was located by law enforcement, who contacted the family, and R1 was returned to the facility on August 8, 2026. Upon return, R1 was reassessed by a Licensed Vocational Nurse (LVN), who found no signs of injury or discomfort. S1 informed the family representative and the physician about the incident. The Department reviewed (R1)'s Medical Assessment LIC 602A (dated 06/16/26) revealed that R1 has a history of "unsafe wandering" and "elopement" which is associated with behaviors in residents diagnosed with (NCD). Further review of camera surveillance footage (dated 08/07/26) verified R1's elopement from the premises. (Evaluation Report continues LIC 809-C) The licensee violates Title 22, Section 87411, Personnel Requirements. California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 809-D). An exit interview was conducted, and a copy of the Evaluation Report and Appeal Rights was provided to Ace ACE HUYNH.the state’s words, verbatim · CDSS document, Aug 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Aug 27, 2026

87411 Personnel Requirements - General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required... This requirement is not met as evidence by: Based on interview, Licensee failed provide necessary supervision services to meet resident needs and eloped from the facility unattended. This violation possesses a potential Health and Safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: The Licensee will adhere to the regulations and ensure review of Title 22, Section 87411. The Licensee will provide care staff training to address (NCD) wandering and elopement behaviors—proof of correction, including a sign sheet, to be sent by fax to the El Segundo Regional office at 424-544-1016 by 08/27/26.

Allegation investigated: Staff did not report an incident as necessary.

On 7/24/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Executive Director, Ace Hunyh and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 7/24/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Identification and Emergency Contacts, Physician’s Report, Unusual Incident Report, Internal Incident Report, Emergency Department Discharge Instructions and Discharge Orders. LPA Felisa Shirley conducted a tour of the facility and viewed facility video footage. LPA Shirley interviewed Staff 1 – Staff 7 (S1 – S7), and Resident 1 – Resident 5 (R1-R5). Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not report an incident as necessary. It is being alleged that R1 was stabbed in the back with a pen by R3 and staff failed to report the incident. On 7/24/26, LPA Felisa Shirley observed an Unusual Incident Report dated 7/24/26 for an incident involving R1 on 7/18/26. LPA Felisa Shirley also observed and reviewed an Internal Resident Incident Report dated 7/18/26. Per Unusual Incident Report, on 7/18/26 the front desk was notified that R1 had a wound on their back which appeared to be a puncture wound. Upon review of the Internal Resident Incident Report, staff observed blood seeping through R1’s shirt and observed a long blood stain across the back of the shirt. On 7/24/26, LPA Shirley reviewed the surveillance video which contained R1 and R3 sitting at the table in the activities room. R1 was sitting drinking iced tea and R3 had an activity book. The surveillance video covered the time period from 5:30 pm through 7:33 pm and there was no indication of an assault or any involvement by another resident. At 7:33pm, the caregivers made contact with the resident and observed blood on R1’s shirt. LPA Shirley toured the facility on 7/24/26 and inspected R1’s room to locate the shirt R1 was wearing on the day of the incident. Upon examination, no holes or tears were observed in the shirt. LPA interviewed staff 1 – staff 7 (S1 – S7). Of those interviewed 4 out of 7 denied the allegation. Three staff did not know if incident was reported. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 0 out of 5 denied the allegation. Four residents didn’t know if incident was reported and 1 resident did not answer. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not report an incident as necessary,” therefore, the allegation is unsubstantiated. No deficiencies were cited for these allegations. An exit interview was conducted and a copy of this report was provided to the Executive Director, Ace Huynh.the state’s words, verbatim · CDSS document, Jul 24, 2026 · control 11-AS-20260720121155

Allegation investigated: Staff do not ensure resident medication records are properly managed

On 07/16/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent Complaint Visit to the facility listed above. LPA met with Ace Huynh, Administrator, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA conducted a medication review for eight (8) residents. During a subsequent visit on 07/15/2026, LPA interviewed Staff S6 and S7 and conducted a medication review for two (2) residents. During the initial visit conducted on 04/30/2026, LPA inspected the facility, interviewed Staff S1, interviewed Resident R1-R12, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician’s Report (dated 08/04/2025), Appraisal/Needs and Service Plan (dated 04/17/2026), Internal Resident Incident Report (various dates), After Visit Summary (dated 11/19/2025 and 07/08/2025), St. Mary Medical Center – Long Beach Discharge Instruction Document (dated 04/17/2026), Medication Administration Records (MAR) (March 2026 and April 2026), and Memory Care Communication Log (04/17/2026 through 04/29/2026). The investigation revealed the following: Substantiated Allegation: Staff do not ensure medication records are properly managed The allegation alleges that there was no incident report for a resident’s medication that was observed on their bed and not taken. During the facility visit, LPA conducted an audit of ten (10) residents Centrally Stored Medications using the electronic Medication Administration Record (eMAR). During the review, LPA observed the following medications not signed off as taken or refused for Resident R1, R13-R21: >Resient R1 -Divalproex Sod ER 500mg > not signed off on MAR 07/03/2026, no comments -Donepezil HCL 5 MG Tables > not signed off on MAR 07/03/2026, no comments -Mirtazapine 15mg > not signed off on MAR 07/03/2026, no comments -Mirtazapine 7.5mg > not signed off on MAR 07/03/2026, no comments -Atrovastain 20mg > not signed off on MAR 07/03/2026, no comments -Busprione HCL 10mg > PM not signed off on MAR 07/02/2026, 07/05/2026, and 07/11/2026, no comments -Quietapine Fumarate 25mg > PM not signed off on MAR on 07/03/2026, no comments. >Resident R13 -Eliquis 5mg > not signed off AM on MAR 07/08/2026 and 07/10/2026, no comments -Escitalopram 5mg > not signed off on MAR 07/08/2026 and 07/10/2026, no comments -Potassium CL ER 20 Meq > not signed off on MAR 07/08/2026 and 07/10/2026, no comments -Folic Acid 1mg> not signed off on MAR 07/08/2026 and 07/10/2026, no comments -Hydralazine 50mg > not signed off on AM MAR 07/08/2026 and 07/10/2026, no comments -Metoprolol Taritrate 25mg> not signed off on AM MAR 07/08/2026 and 07/10/2026, no comments -Vitamin B-1 100mg> not signed off on MAR 07/08/2026 and 07/10/2026, no comments -Vitamin B12 500mcg > not signed off on AM MAR 07/08/2026 and 07/10/2026, no comments >Resident R14 -Asprin EC 81 mg > not signed off on AM MAR 07/08/2026, no comments -Docusate Sodium 100mg > not signed off on AM MAR 07/08/2026, no comments -Fluticasone Prop 50 mcg > not signed off on AM MAR 07/08/2026, no comments. -Lactulose 10 gm/15ml > not signed off on AM MAR 07/08/2026, no comments. -Pantoprazole SOD DR 40mg > not signed off on AM MAR 07/11/2026 and 07/12/2026, no comments. -Potassium CL ER 20 MEQ > not signed off on AM MAR 07/08/2026, no comments. -Quetiapine Fumarate 50mg > not signed off on PM MAR 07/08/2026, no comments. -Refresh Tears 0.5% drops 1 OP > not signed off on AM MAR 07/08/2026, no comments. -Resperidone 0.5 MG > Not signed off on AM MAR 07/08/2026, no comments >Resident R16 -Amlodipine Besylate 5 MG> not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Ammonium Lactate 12% Cream> not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Asprin EC 81 MG > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Clopidogrel 75 MG > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Escitalopram 10 MG > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Famotidine 20 MG > not signed off on AM and PM MAR for 07/07/2026 and not signed off on AM 07/10/2026, no comments. -Geri-Mucil Powder 1 PO > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Glucosamine Daily Complex T 1 PO > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Januvia 100 MG - not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Metformin 500MG > not signed off on AM and PM MAR 07/07/2026 and not signed off on AM 07/10/2026, no comments. -Sitagliptin Phos 100 MG > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. -Tamsulosin 0.4 MG > not signed off on AM MAR 07/07/2026 and 07/10/2026, no comments. >Resident R17 -Aripiprazoles 5 MG > 07/11/2026 pill in packet, not signed on MAR, and no comment. 07/12/2026 pill in packet, not signed on MAR, and no comment. 07/13/2026 removed from packet, not signed off on MAR, and no comment. 07/14/2026 removed from packet, not signed off on MAR, and no comment. -Hydrocodone-Acet 5-325 > Not signed off on eMAR for 07/08/2026 and 07/11/2026 -Lidocaine 4% Patch > Not signed off on MAR for 07/11/2026. No Comment. -Pantoprazole SOD DR 40 MG > Not signed off on 07/11/2026 and 07/12/2026. -Vitamin C 1,000 MG > Not signed off on MAR on 07/11/2026, No comment. -Vitamin D3 50 MG > Not signed off on MAR on 07/11/2026, No comment. > Resident R18 -Oxybutynin 5 MG - Not signed off on 07/11/2026 12pm. No comments. -Pantoprazole SOD DR 40 MG > Not signed off on AM 07/11/2026 and 07/12/2026. No comments. -Vitamin D3 2000 IU 50 MG >Not signed off on AM 07/11/2026. > Resident R19 -Levothyroxine 50 MCG > Not signed off on AM 07/11/2026. No comments. > Resident R20 - Aspirin 81 MG > Not signed off on AM 07/10/2026. No comments. -Clopidogrel 75 MG > Not signed off on AM 07/10/2026. No comments. -Famotidine 20 MG > Not signed off on AM 07/10/2026. No comments. -Metoprolol Tartirate 50 MG > Not signed off on AM 07/10/2026. No comments. - Naltrexone 50 MG > Not signed off on AM 07/11/2026 and 07/12/2026. No comments. -Quetiapine Fumarate 100 MG > Not signed off on AM 07/10/2026. No comments. -Vitamin B-12 1,000 Unit> Not signed off on AM 07/10/2026. No comments. -Vitamin D3 5,000 Unit > Not signed off on AM 07/10/2026. No comments. > Resident R21 -Atorvastatin 40 MG > Not signed off on PM 07/01/2026, 07/02/2026, and 07/03/2026. No comments. -Divalproex SOD DR 125 mg > Not signed off on PM 07/02/2026, 07/05/2026, and 07/11/2026. No comments. -Donepepezil HCL 5 MG > Not signed off on PM 07/3/2026. No comments. -Memantine HCL 5 MG > Not signed off on PM 07/02/2026, 07/05/2026, and 07/11/2026. No comments. -Quetiapine Fumarate 100 MG > Not signed off on PM 07/03/2026. No comments. -Senna 8.6 MG > Not signed off on PM 07/02/2026, 07/05/2026, and 07/11/2026. No comments. During interviews with Staff S1-S7, were asked if staff keep accurate records of residents medications and doses taken, seven (7) out of seven (7) stated yes, staff keep accurate records of residents medications taken. During interview's with Residents R1-R12, were asked if they feel staff properly manage their medication records, twelve (12) out of twelve (12) stated yes, they believe staff properly manage their medication records. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Brenna Randolph, Business Office Manager, and a copy of this report and the Appeals Rights were provided.the state’s words, verbatim · CDSS document, Jul 16, 2026 · control 11-AS-20260421155314

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87505(a) · Plan of correction due date: Jul 30, 2026

87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Based on observations, interviews, and record review Staff failed to ensure medications were documented as administered or refused for R1, R13, R14, R16-R21, This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 16, 2026

Plan of correction: Administrator will develop a plan to ensure that medication administration records are checked frequently to avoid discrepancies. Administrator will submit plan to LPA by POC due date.

Allegation investigated: Staff do not ensure reporting requirements are being followed Staff did not ensure resident was provided medical care

On 07/14/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent Complaint Visit to the facility listed above. LPA met with Ace Huynh, Administrator, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today's visit, LPA interviewed Staff S6 and S7 and conducted a medication review for two (2) residents. During the initial visit conducted on 04/30/2026, LPA inspected the facility, interviewed Staff S1, interviewed Resident R1-R12, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician’s Report (dated 08/04/2025), Appraisal/Needs and Service Plan (dated 04/17/2026), Internal Resident Incident Report (various dates), After Visit Summary (dated 11/19/2025 and 07/08/2025), St. Mary Medical Center – Long Beach Discharge Instruction Document (dated 04/17/2026), Medication Administration Records (MAR) (March 2026 and April 2026), and Memory Care Communication Log (04/17/2026 through 04/29/2026). The investigation revealed the following: Substantiated Allegation: Staff do not ensure reporting requirements are being followed The allegation alleges it was not reported when a resident’s medication was not taken and when a resident was observed with feces in their mouth. During record review, LPA received and reviewed two Internal Resident Incident Reports, one is dated 04/13/2026 at 3:20am that indicates R1 was observed with feces in their mouth. Staff attempted to assist R1 and R1 was combative and went back to sleep. Staff attempted to assist R1 again 10 minutes later and R1 was still combative and went back to sleep. When AM shift arrived, Staff tried to assist with brushing teeth and R1 was combative. LPA observed in the Contact Made section under Physician was indicated “no,” and under the Responsible Party it was not indicated whether they were contacted. The second Internal Resident Incident Report is dated 04/13/2026 at 3:15am, S2 was informed R1 was observed with feces in their mouth and was asked if R1 should be sent out. S2 informed Staff that R1 could be sent out for altered mental status but may be returned right away if R1 has a diagnosis of dementia. Under Action Taken indicates nurse to follow up with Primary Care Physician (PCP) and family. LPA observed in the Contact Made section there was no indication if the Physician or Responsible Party were notified. Staff were unable to provide documentation that the Physician or Responsible Party were notified. Additionally, LPA received and reviewed St. Mary Medical Center – Long Beach Discharge Instruction Document dated 04/17/2026, indicates R1 was examined due to abdominal pain and acute chest pain during respiration. LPA observed on the eMAR that R1 refused medications on 04/02/2026 and 04/13/2026. LPA did not observe any notes or indication that the POA or Physician was notified of the medication refusals. Additionally, during records review and LPA observed the following: R1 has a POA, according to a document titled Power of Attorney for California (dated on 05/11/2024). This POA is also mentioned on the LIC 601 has the person responsible for final affairs, payment for care and legal guardian if any and this is also indicated on LIC 603 that POA is the person who manages R1’s finances. During a file review, LPA reviewed the Unusual Incident/Injury Reports faxed to the department, LPA did not observe any reports regarding R1 having feces in their mouth on 04/13/2026 or regarding being transferred to the Emergency Room on 04/17/2026. During interviews with Staff S1-S7, were asked if staff meet the reporting requirements, informing the residents responsible party, physician, and/or Community Care Licensing (CCL) of unusual incidents and/or injury’s, seven (7) out of seven (7) stated yes incidents are reported to the responsible party or power of attorney, the physician, and CCL. During interviews with Residents R1-R12, were asked if they feel staff meet reporting requirements, informing responsible party or physician, twelve (12) out of twelve (12) stated they feel staff meet reporting requirements. During an interview with a resident’s family member W1, was asked if the facility stated the POA was not made aware of the incident until they visit the facility on 04/15/2026. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. Allegation: Staff do not ensure resident was provided medical care The allegation alleges that a resident was not sent to the hospital to be evaluated after not eating meals and being observed with feces in their mouth. During record review, LPA received and reviewed two Internal Resident Incident Reports, one is dated 04/13/2026 at 3:20am that indicates R1 was observed with feces in their mouth. Staff attempted to assist R1 and R1 was combative and went back to sleep. Staff attempted to assist R1 again 10 minutes later and R1 was still combative and went back to sleep. When AM shift arrived, Staff tried to assist with brushing teeth and R1 was combative. The second Internal Resident Incident Report is dated 04/13/2026 at 3:15am, S2 was informed R1 was observed with feces in their mouth and if R1 should be sent out. S2 informed Staff that R1 could be sent out for altered mental status but may be returned right away if R1 has a diagnosis of dementia. Under Action Taken indicates S2 to follow up with Primary Care Physician (PCP) and family. LPA observed in the Contact Made section there was no indication if the Physician or Responsible Party were notified. Additionally, LPA received and reviewed St. Mary Medical Center – Long Beach Discharge Instruction Document (dated 04/17/2026) that indicates R1 was examined due to abdominal pain and acute chest pain during respiration. During interviews with Staff S1-S7, were asked if residents receive medical care when needed, seven (7) out of seven (7) stated resident receive medical care when needed. During interviews with Residents R1-R12, were asked if staff ensure they receive medical care when needed, twelve (12) out of twelve (12) stated yes they receive medical care when needed. During an interview with a resident’s family member W1, stated the POA was not made aware of the incident until they visited the facility on 04/15/2026 and were told by a nurse they were not going to send R1 out to the hospital due to their given health. R1 was later seen at the hospital on 04/17/2026 for abdominal pain and acute chest pain during respiration. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Ace Huyhn, Executive Director, and a copy of this report and the Appeals Rights were provided.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 11-AS-20260421155314

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jul 29, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met based on record review, interviews, and observations, there was no incident reports submitted to CCL for the incidents of R1 on 4/13/2026 or of R1's Emergency Room visit on 04/17/2026, which poses a heath and safety risk.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Staff retraining regrading reporting incidents to CCL and Responsible party was conducted in June 2026. The Administrator will email the staff training log to LPA at Wendy.Gibbs@dss.ca.gov by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(5) · Plan of correction due date: Jul 29, 2026

87411 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 and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement was not met based on an incident of R1 who was observed with feces in their mouth on 04/13/2026 and was not evaluated by a medical professional on 04/17/2026 due to abdominal pain.the state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: Administrator will retrain staff on documenting communication with the Primary Care Physician and Responsible Party of resdients regarding incident that occur. Administrator will email the staff training log to LPA at Wendy.Gibbs@dss.ca.gov by POC due date.

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

Allegation investigated: Facility is in disrepair

On 07/14/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent Complaint Visit to the facility listed above. LPA met with Ace Huynh, Administrator, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today's visit, LPA interviewed Staff S6 and S7. During the initial visit conducted on 04/30/2026, LPA inspected the facility, interviewed Staff S1, interviewed Resident R1-R12, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician’s Report (dated 08/04/2025), Appraisal/Needs and Service Plan (dated 04/17/2026), Internal Resident Incident Report (various dates), After Visit Summary (dated 11/19/2025 and 07/08/2025), Medication Administration Records (March 2026 and April 2026), Memory Care Communication Log (04/17/2026 through 04/29/2026), Maintenance Request (01/28/2025 through 04/30/2026), and Maintenance & Equipment Request Form (various dates). The investigation revealed the following: Substantiated Allegation: Facility is in disrepair. The allegation alleges that in a resident’s room the shower head is not in working condition and spays outside of the shower getting the floor wet and the handle on the closet in the room is broken. During the facility inspection LPA observed the handle on the closet door in room 245 was broken with the broken piece lying on the window ledge next to the closet. Additionally, LPA and Staff turned on the shower in room 245 and it sprayed outside of the shower. During record review, LPA received and reviewed the Maintenance and Equipment Request Forms for repairs dated 04/19/2026 for room 101, 02/26/2026 for room 104, 02/23/2026 for room 118, 02/02/2026 for room 227, and 01/24/2026 room 101. Additionally, LPA received and reviewed Maintenance Request that lists the following repair description and repairs dated 01/03/2026 for window screens in the memory care, 01/23/2026 for the AC in memory care, 04/28/2026 for new blinds in room 120, and 04/30/2026 new room key for new resident move in. During interviews with Staff S1-S7, were asked if any part of the facility is in disrepair, five (5) out of seven (7) stated no, the facility is not in disrepair. Two (2) out of seven (7) stated there are items that need repaired including the closet handle and shower in room 245 and a ceiling tile that came down in the activity room. During interviews with Residents R1-R12, were asked if they felt the facility is in disrepair, twelve (12) out of twelve (12) stated no, the facility is not in disrepair During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Ace Huyhn, Executive Director, and a copy of this report and the Appeals Rights were provided. Allegation: Staff are falsifying resident records The allegation alleges that a resident’s family was given an incident report indicating staff observed a resident eating feces and when speaking to the Primary Care Physician they were notified it was reported that it was observed in the resident’s teeth during oral care. During record review, LPA received and reviewed two Internal Resident Incident Reports, one is dated 04/13/2026 at 3:20am that indicates R1 was observed with feces in their mouth. Staff attempted to assist R1 and R1 was combative and went back to sleep. Staff attempted to assist R1 again 10 minutes later and R1 was still combative and went back to sleep. When AM shift arrived, Staff tried to assist with brushing teeth and R1 was combative. There was no indication on the report if the residents Physician or Responsible Party were notified. The second Internal Resident Incident Report is dated 04/13/2026 at 3:15am, S2 was informed R1 was observed with feces in their mouth and if R1 should be sent out. S2 informed Staff that R1 could be sent out for altered mental status but may be returned right away if R1 has a diagnosis of dementia. Under Action Taken indicates S2 to follow up with Primary Care Physician (PCP) and family. LPA observed in the Contact Made section there was no indication if the Physician or Responsible Party were notified. During interviews with Staff S1-S7, were asked if they have observed staff falsify resident’s records, seven (7) out of seven (7) stated no, they have not observed staff falsify records. During interviews with Residents R1-R12, were asked if they have any concerns regarding staff falsifying records, twelve (12) out of twelve (12) stated no, they have no concerns regarding staff falsifying records. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated. An exit interview was conducted with Ace Huyhn, Executive Director, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 11-AS-20260424164701

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87303(a) · Plan of correction due date: Jul 29, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met based on interviews and observations, LPA observed on 04/30/2026, in room 245 the handle on the closet door was broken and the shower head spayed outside the shower, which poses a health and safety riskthe state’s words, verbatim · CDSS document, Jul 15, 2026

Plan of correction: During a visit on 06/02/2026, LPA observed the handle and shower head were replaced. Administrator

Allegation investigated: Resident call light is in disrepair.

On July 08, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted an initial unannounced complaint visit. Ace Huynh, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation, a collection of documents, and a tour of the facility. A review of Personnel Report LIC 500 (dated 06/02/26), Resident Roster (dated 007/02/26), Faciltiy Visitor Log (dated 06/01/26 - 06/30/26), Maintenance Request Report (dated 03/1/26 - 07/07/26), Resident #1 (R1's) Medical Assessment for Residential Care Facilities LIC 602A (dated 05/01/26), Appraisal/Needs and Services Plan LiC 625 (dated 06/03/26), Incident Report LIC 624 (dated 06/02/26 & 06/04/26) and other pertinent records associated with this complaint. Interviews conducted with Resident #1-5, Staff #1-#3 and Witness #1. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: ALLEGATION: Resident call light is in disrepair. It is alleged that the call light for Resident #1 (R1) is in disrepair. For the past month, the call light has not been functioning properly on weekends. Although it has been fixed each week, it continues to work inconsistently. It is important to note that (R1) is at high risk of falling and requires a functioning call light for safety. No further details have been provided. On July 8, 2026, between 09:50 AM and 11:30 AM, the Department interviewed resident members identified as Resident #1 through Resident #5 (R1-R5). Four (4) out of five (5) could not support this claim. (R2-R5) reported no issues or concerns regarding their call lights. They stated that when maintenance is needed, the response and repair time is timely. (R1) stated that the call light is operational. Although it was down a couple of times, it has been repaired and is now working. (R1) mentioned that it has been functioning well for over a week and a half. (R2), who shares a room with (R1), stated that (R2) has never experienced any issues with (R2’s) call light system and that it served as a useful option for (R1) when (R1’s) call light was inoperable. However, (R2) noted that (R1) tends to pull the cord horizontally, which can cause the entire call box system to come off the wall. (R2) explained that the proper way to use the system is to pull the cord downward to avoid dislodging it. On July 08, 2026, between 09:30 AM and 3:35 PM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of three (3) staff members could not support this claim. (S1–S3) all asserted that Resident #1 (R1) has a functional call light system. (S1) indicated that (S1) became aware of the issue on July 2, 2026, when (S2) received a call about (R1's) call light system being dislodged from the wall and inoperable. (S2) reported that (S2) performed minor repairs on June 19, 2026, to (R1's) call light system, followed by a subsequent service on June 30, 2026, when the call light was found broken. There might have been one time before June 19, 2026, when it was dispatched on the walkie talkie as an urgent request and might have not been logged on the Maintenance Request Report. Services were completed on the same day. Additionally, (S2) claimed that no other service orders were placed apart from those two occasions. (S3) was on duty on June 7, 14, 21, and 28, 2026, when concerns were raised about (R1's) call light system functioning properly. Although it was being tested only, it was never reported as non-operational, and no maintenance order for repairs was required. If the situation calls for it, (S3) will promptly place an order for repairs to ensure everything is in top condition. On July 6, 2026, between 8:14 AM and 8:40 AM, the Department conducted an interview with witness #1 (W1). (W1) noticed that the call box was malfunctioning around June 3-4, 2026, after (R1) had pulled it off the wall while seeking assistance. On June 7,2026, (W1) found the call box hanging off the wall again and reported it to the front desk, which informed them that repairs were in progress. (W1) repeatedly observed the call box hanging off the wall and reported it each time. By June 28, 2026, the call mechanism had been tampered with and was no longer usable. The Department inspected room #132 (R1's room) and evaluated the call light system. The wall-mounted system was found to be functioning properly. A care staff member responded within 2 minutes after the call light was activated. Further inspection of the call light system in room #132 (R2) confirmed it was operable as well. In addition, the call light systems in the following rooms were inspected and tested: #101, #104, #134, #137, #139, #141, #142, #206, #208, #213, #217, #228, and #229. All 30 call light systems were found to be in working condition. A review of the Facility Visitor Log Report (dated 06/01/26 to 06/30/26), revealed inaccuracies in the reporting of visit dates from (W1). Additionally, a review of the Facility Maintenance Request Report for the same period confirmed that services were performed on (R1's) call light system on June 19, 2026, and June 30, 2026. The analysis showed that of (68) work orders, (60) were completed within 24 hours, resulting in an 88.24% completion rate. Based on the information gathered, there is insufficient evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. No deficiencies cited. An exit interview was conducted with Ace Huynh, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Jul 8, 2026 · control 11-AS-20260630170230

Type of visit: Case Management - Incident

On July 07, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit to the facility following an incident reported by the facility that occurred on June 21, 2026. During the visit, the LPA met with Ace Huynh, Executive Director, to explain the purpose of the visit. The El Segundo Regional Office Adult and Senior Care received an Unusual Incident Report (LIC 624) on June 27, 2026, stating that Resident #1 (R1) had been given the incorrect medication. On June 21, 2026, at approximately 5 PM, the medication technician mistakenly administered in error to (R1) Buspirone, Hydrocodone, Metformin, and Metoprolol to (R1) in error. The Department found that the facility was not in compliance with Title 22 Regulations and issued citations as follows: 87465(c)(2) Incidental Medical and Dental Care Services. The investigation revealed that the facility failed to comply with Title 22 regulations. The LPA reviewed (R1’s) Physician's Report (LIC 602A) (dated 12/27/24), Appraisal/Needs and Services Plan LIC 625 (dated 06/13/26), and Medication List (dated 07/08/26), which identified that (R1) needs assistance with medication administration and Buspirone, Hydrocodone, Metformin, and Metoprolol are not prescribed by (R1's) physician. Based on interviews, observations, and record reviews, the licensee was found in violation of the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies have been issued, and an exit interview was conducted with Ace Huynh, Executive Director. A copy of this report is provided, along with the appeal rights.the state’s words, verbatim · CDSS document, Jul 8, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jul 9, 2026

87465)(c)(2) Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need .. facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on the records review, staff administered (R1) Buspirone, Hydrocodone, Metformin, and Metoprolol in error. The facility reported a medication not prescribed to (R1). This violation poses/posed an immediate risk to persons in care.the state’s words, verbatim · CDSS document, Jul 8, 2026

Plan of correction: Licensee shall provide medication administration retraining. This training shall be provided by pharmacy and/or registered nurse. Submit proof of training by POC due.07/09/26.

Allegation investigated: Staff are not safeguarding residents medications.

On 07/07/26 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Co-Executive Director Anita Csukardi as the purpose of today’s visit was explained. The investigation consisted of the following: On 07/07/26 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1-3 (R1-R3) Emergency ID form, pre-appraisal,Physicians reports, needs and service plans, medication list, and Medication Administration Records (MAR) for the months of June 2026-July 2026. On 07/07/26 from 10:00am- 11:31am LPA conducted a review of medications for residents #1-7 (R1-R7). On 07/07/26 from 1pm- 1:45pm LPA conducted interviews with resident #1-10 (R1-R10), and from interviews with staff #1-4 (s1-S4). The investigation revealed the following: Allegation: Staff are not safeguarding residents medications. Substantiated It is alleged that residents’ medication goes missing daily with no explanation. On 07/07/26 LPA conducted interviews with R1-R10 regarding the allegation above. 7 of the 10 residents denied the allegation above and reported having no concerns with the staff who handle their medication(s). Additionally, 6 or 10 resident reported that they have never been told that their medication are unavailable. 1 of the 10 residents interviewed reported that there medications have been unavailable but reports it was due to pharmacy availability. 3 of the 10 residents interviewed reported being unaware if they take medications while currently receiving care at the facility. On 07/07/26 LPA conducted interviews with On 07/07/26 from 10:00am- 11:31am LPA conducted a records review of the June 2026 and July 2026 medications administration records (MARs) for R1-R7. During the records review LPA observed that for July 2026 there were 16 medication documentation errors that affected 4 residents. The review showed missing initials for medications assigned to R1- Famotidine 20mg 8am- documented as refused but still in the pack for July 4th, 2026 Famotidine 20mg 4pm- documented as refused but are not in the bubble pack for July 1st-3rd 2026, Fluoxetine HCL 20mg- July 3rd, 2026 and July 7th, 2026 documented as refused but not in the bubble pack, July 6th, 2026 documented as given, then documented in the back that resident refused. LPA observed the following for R2, Carbamazepine 8am am- July 2nd, 2026 documented given but in the bubble pack, Levetiracetam 8am July 2nd 2026 documented given but in the bubble pack, Tamsulosin 8am July 2nd, 2026 documented given but in the bubble pack. LPA observed the following for R4, Amitriptyline HCL 100mg 8 pm July 1st, 2026 documented as given but in the bubble pack, Atorvastatin 40 mg 8pm July 1st, 2026 documented as given but in the bubble pack Senna 8.6 mg 8pm July 1st, 2026 documented as given but in the bubble pack. LPA observed the following for R5 Besylate 2.5 mg 8am July 2nd, 2026 documented given but in the bubble pack, Benztropine MES 1pm 8am July 2nd, 2026 documented given but in the bubble pack, Benztropine MES 1pm 4 pm July 2nd, 2026 not signed out and not in the bubble pack, Divalproex DOS 500 mg 10pm out of bubble pack on 07/1/26, 07/3/26, 07/4/26 and on 07/5/26 but not signed out, Folic Acid 1mg 8am July 2nd, 2026 not documentation but inside bubble pack, Metformin 1000 mg 8am July 2nd, 2026 signed out but in the bubble pack, Metformin 1000 mg 4 pm July 2nd, 2026 not signed out and not in the bubble pack. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. Exit interview provided, appeal rights explained, and a copy of this report was provided. It is alleged that facility staff play mind games with the residents by manipulating them. On 07/07/26 LPA conducted interviews with R1-R10 regarding the allegation above. 10 of the 10 residents interviewed denied the allegation above and reported feeling respected by the facility staff. On 07/07/26 LPA conducted interviews with S1-S4 regarding the allegation above. 4 of 4 staff interviewed denied the allegation above, and reported having good interactions with residents in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 11-AS-20260629143423

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6)(A-F) · Plan of correction due date: Jul 21, 2026

(h)The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained...(A-F) records for centrally stored medications...based on records review the Department identified that for July 2026 there were 16 medication documentation errors that affected 4 residents, indicating medications were not documented as required which poses a potential health and safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: Executive Director will retrain all medication staff on MAR documentation requirements in order to get into compliance with title 22 regulation. A weekly MAR review will be implemented to ensure all entries are completed correctly with signatures and correct dates tht match. LPA to receive proof by POC due that the med room staff was retrained. Training materials, staff sign in sheet, and a documented from Executive Director self certifying the review and understandment of the regulation being cited. Lizeth.villegas@dss.ca.gov

Allegation investigated: Facility staff did not meet residents’ care needs, resulting in resident obtaining multiple UTI’s Resident sustained multiple bruises due to staff neglect. Facility staff did not ensure that residents have clean linen. Facility staff did not provide adequate laundry service Facility is not providing adequate food service resulting in resident weight loss. Facility staff did not respond to resident's call button in a timely manner.

On 07/07/2026 at 08:45am, the department made an unannounced visit at this facility to conduct an subsequent visit to reveal the investigation findings for the allegations above. During today’s visit, the department met with Catherine Dacara (Assistant Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 04/01/2026, the department interviewed Administrator (A1), Staff (S1 - S7) Residents (R1- R10), between the hours of 09:27am - 2:33pm. LPA requested copies of Staff Roster (dated 03/19/2026), Resident Roster (dated 03/25/2026), Resident 1 (R1): LIC 601: Identification & Emergency Information (date 10/30/2024); LIC 602: Physician Report for Residential Care Facilities for the Elderly (dated 08/04/2025), LIC 603: Preplacement Appraisal Information (dated 10/14/2024); LIC 625: Needs & Service Appraisal (dated 02/12/2026), Admission Agreement (dated 10/31/2024) Medication Administration Record (MAR) (dated January 2026 - March 2026) Internal Resident Incident Report (dated 01/21/2026, 11/23/2025, 10/11/2025, & 07/08/2025), Weight Record (March 2026) Power of Attorney (dated 05/11/2024), Resident Laundry Schedule for March 2026 and Spring 4 Week Food Menu Cycle. Unsubstantiated The investigation revealed the following: Allegation: Facility staff did not meet resident’s care needs, resulting in resident obtaining multiple UTIs. It was alleged that for several months, a resident had not been provided with adequate hygiene and incontinence care. A resident was reportedly found soiled on multiple occasions, not changed. It was further alleged that a resident developed multiple urinary tract infections due to untimely hygiene care. On 04/01/2026 between the hours of 9:27am – 9:50am, the Department interviewed Administrator (A1) in regards to the allegation. A1 denied the allegation and stated being unaware of any UTIs occurring while the resident was in care. A1 reported that a physician visited the resident the prior week but did not leave notes or orders. A1 stated the facility’s protocol for UTI prevention includes encouraging hydration, contacting the physician, and following any orders provided. A1 stated that residents receiving incontinence care are changed regularly in the morning, noon, night, and overnight, or upon request, with documentation maintained in ADL logs. A1 stated no incident reports or nursing notes were completed because no physician orders for labs or treatment were issued. On 04/01/2026, between 10:00am -11:50am, LPA interviewed seven (7) staff in regards to the allegation. 3 out of 7 staff denied the allegation. 2 out of 7 staff confirmed the allegation and expressed observing odor and pain. 2 out of 7 staff did not confirm nor deny that allegation of one(1) who mentioned only being aware of R1's UTI during the resident last hospital visit. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents in regards to the allegation. 7 of 10 residents denied the allegation and expressed no concerns with hygiene or care needs. 3 of 10 resident did not confirm nor deny the allegation and reported sometimes waiting for assistance. On 05/18/2026, between the hours of 3:00pm - 4:00pm, the Department conducted a record review and observed the LIC 602A Medical Assessment documented a “recent UTI – resolved” prior to admission, with notation that nitrofurantoin had been completed and no urinary symptoms were present at the time of assessment. The Department reviewed the resident’s Medication Administration Records (MARs) for all months in care and found no physician orders, MAR entries, or medication administration related to UTI treatment, antibiotics, or diagnostic testing such as urinalysis or urine culture. The Department reviewed all physician orders on file and found no orders for laboratory testing, diagnostic evaluation, or treatment related to UTIs. The Department reviewed the resident’s ADL logs, which documented routine incontinence care but did not contain entries indicating missed care, delayed care, or concerns related to urinary symptoms. The Department reviewed the Needs and Services Plan, which documented scheduled toileting every 2–3 hours and as needed, hydration encouragement, and incontinence care requirements. The Department reviewed all incident reports, and found no documentation of UTIs, suspected UTIs, changes in condition related to urinary symptoms, or communication with the authorized representative regarding UTIs. No documentation was found indicating multiple UTIs or unmet hygiene care needs. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Resident sustained multiple bruises due to staff neglect. It was alleged that a resident was observed with bruising on the forearm and hand that staff could not explain. It was further alleged that the bruising may have resulted from rough handling or neglect during care. On 04/01/2026 between the hours of 9:27am - 9:50am, the Department interviewed A1 in regards to the allegation. A1 denied the allegation and stated not being aware of any bruising, no incident reports were completed, and no concerns were brought to A1's attention. A1 stated that per protocol, the LVN assesses bruising and reports findings to the physician. On 04/01/2026, between 10:00am -11:50am, the Department interviewed seven (7) staff. 6 out 7 staff denied the allegation and reported no rough handling or observed inappropriate care. 1 out of 7 staff did not confirm nor deny that allegation, yet S2 reported seeing a mark on the resident’s arm but did not know the cause. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents. 9 out of 10 residents denied being handled roughly or observing rough handling. 1 out of 10 residents did not confirm nor deny the allegation but reported staff were rough during cleaning of their private area. On 05/18/2026, between the hours of 3:00pm - 4:00pm, the Department conducted a record review and observed the following: no incident reports documented bruising, discoloration, skin tears, or unexplained marks. The Department reviewed the LIC 602A Medical Assessment, which documented a history of skin breakdown but did not identify bruising or unexplained injuries. The Department reviewed communication logs and found no documentation of staff reporting bruising, unexplained injuries, or neglect related to skin integrity. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Facility staff did not ensure that residents have clean linen. It was alleged that the resident’s bedding was left soiled and not changed in a timely manner. On 04/01/2026 between 9:27am - 9:50am, the Department interviewed A1 in regards to the allegation. A1 denied the allegation and stated not being aware of any issues regarding soiled bedding. A1 stated linens are changed daily and immediately if soiled. On 04/01/2026, between 10:00am -11:50am, the Department interviewed seven (7) staff. 2 out of 7 staff confirmed the allegation and stated finding soiled bedding at times but states it changed immediately. 5 out of 7 staff denied the allegation and reported no delays in linen changes. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents. 1 out of 10 resident confirmed the allegation and reported that bedding was not changed promptly sometimes. 9 out of 10 residents denied the allegation and had no concerns with linen changes. On 05/18/2026, between the hours of 3:00pm - 4:00pm, the Department conducted a records review and observed the following: on page 2 of the Admission Agreement and Basic Services (signed on 10/30/2024) states that the facility provides clean bed and bath linens weekly or more often if needed. Upon further review, no incident reports, no communication logs, and no internal notes were found with concerns regarding soiled bedding, missed linen changes, or lack of clean linens. No documentation was found indicating feces on bedding, urine on sheets, or extended periods without clean linens for R1. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Facility staff did not provide adequate laundry service. It was alleged that the resident’s clothing was not washed regularly and remained soiled for extended periods. On 04/01/2026 between 9:27am - 9:50am, the Department interviewed A1 in regards to the allegation. A1 denied the allegation and stated not being aware of any concerns regarding unwashed clothing. A1 stated laundry is washed daily, with caregivers providing additional laundry support on Sundays. On 04/01/2026, between 10:00am - 11:50am, the Department interviewed seven (7) staff in regards to the allegation 7 out of 7 staff denied the allegation and mentioned that laundry is completed on assigned days and heavily soiled items are washed immediately. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents in regards to the allegation. 9 out of 10 residents denied with no concerns with laundry service. 1 out 10 residents was unaware of the allegation and stated they don't because they travel a lot . On 05/18/2026, between the hours of 3:00pm - 4:00pm, the Department conducted a records reviewed and observe Resident's Laundry Service for the month of March indicates R1's laundry day of the week was on Mondays. The LIC 500 Personnel Report, which listed designated (2) laundry staff who are assigned specifically to provide laundry services. The Department reviewed communication logs and incident reports and found no documentation of concerns regarding unwashed clothing, delays in laundry service, or extended periods without clean garments. No documentation was found indicating inadequate laundry service. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Facility is not providing adequate food service resulting in resident weight loss. It was alleged that a resident experienced weight loss due to inadequate food services. It was reported that meals were not consistently consumed and that staff did not ensure adequate food intake. On 04/01/2026 between 9:27am - 9:50am, the Department interview A1 regarding the allegation. A1 denied the allegation and stated there was no documented weight loss and no special diet per LIC 602. A1 stated no concerns were raised by the family and no physician or dietitian was consulted. On 04/01/2026, between 10:00am - 11:50am, the Department interviewed seven (7) staff in regards to the allegation. 6 out of 7 staff denied the allegation. 1 out of 7 staff did not confirm nor deny the allegation and reported the resident sometimes does not finish meals but stated concerns are reported to the nurse. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents in regards to the allegation. 2 out of 10 resident confirmed the allegation, of which one resident mention weight loss, while the other resident mentioned not receiving enough food and missing meals. 7 out 10 residents denied the allegation and had no concerns with food service. Of the 8 residents who denied the allegation ; 1 resident mentioned losing weight but did not attribute it to food service. 1 out of 10 resident did not confirm nor deny the allegation but mentioned sometimes not receiving enough food. On 05/18/2026, between the hours of 3:00pm - 4:00pm, the Department conducted a records review and observed the LIC 625 Appraisal/Needs & Service Plan documents R1 is on a NAS diet with thin liquids but according to the LIC 602A Physician's Report for RCFE documented that the resident was not on a special diet and required “No Added Salt” with thin liquids. The Department reviewed the March 2026 weight log, which documented three consecutive refusals (“Refused x3”) for scheduled weigh-ins by R1. No weight loss was documented. On 07/07/2026 between the hours of 12:30pm - 12:45pm, the Department reviewed the facility's four-week menu cycle utilized during Spring 2025. Although the menus are labeled "Spring 2022" and "Spring 2023," facility Administrator indicated these menus were the menus in use during Spring 2025. The menus reflected planned daily breakfast, lunch, dinner, and evening snacks, including a variety of proteins, fruits, vegetables, grains, dairy products, and beverages. Breakfast meals included items such as eggs, oatmeal, pancakes, waffles, French toast, breakfast meats, toast, cereal, fruit juice, coffee, tea, and milk. Lunch and dinner menus included a variety of entrees consisting of chicken, turkey, beef, pork, fish, tuna, and pasta dishes, accompanied by vegetables, rice, potatoes, beans, salads, soups, bread, fresh fruit, and desserts. Evening snacks included items such as yogurt, pudding, muffins, granola bars, fruit, crackers, cookies, ice cream, and nutritional beverages Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation : Facility staff did not respond to resident’s call button in a timely manner. It was alleged that staff failed to respond promptly when the resident activated the call button and left without prompt assistance when using the call bell, with delays reported up to 30 minutes. On 04/01/2026 between 9:27am - 9:50am, the Department interview A1 regarding the allegation. A1 denied the allegation and stated not being aware of any delays and ensure staff responds right away. A1 stated no response logs are maintained. On 04/01/2026, between 10:00am - 11:50am, the Department interviewed seven (7) staff in regards to the allegation. 6 out of 7 staff denied the allegation. 1 out of 7 staff did not confirm nor deny the allegation & reported that call light delays occur when caregivers are assisting other residents. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents in regards to the allegation. 5 out of 10 confirmed the allegation & reported delayed call light response with R2 mentioning waiting two hours at one time. 4 out of 10 residents denied and stated they do not use the call button. 1 out 10 residents did not confirm nor deny the allegation but mentioned a time period of 10 -15 minutes wait. On 04/01/2026 at 2:34pm, the Department conducted a call light inspection in room 245. At 2:41pm, facility staff entered room 245 to respond to the activated call light, resulting in a total response time of 7 minutes. On 07/07/2026 between 2:02pm – 2:23pm, the Department continued conducting call light inspections and observed the following: at 2:02pm, the call light was activated in room 137 and answered at 2:06pm, resulting in a four-minute response time. At 2:08pm, the call light was activated in room 115. At 2:09pm, two (2) staff walked by and did not acknowledge the call light. The call light was answered at 2:10pm by another staff, resulting in a two-minute response time. At 2:11pm, the call light was activated in room 130. At 2:13pm, two staff walked by and did not acknowledge the call light. At 2:14pm, a third staff walked by and did not address the call light. Between 2:15pm – 2:21pm, two additional staff walked by and did not address the call light. Between 2:11pm – 2:21pm, the call light in room 130 remained unanswered, resulting in a ten-minute period with no staff response. At 2:22pm, a staff informed a caregiver that the resident in room 102 needed a diaper change. The caregiver stated they were attending to two other residents and asked the staff to notify someone at the front desk. At 2:23pm, another caregiver entered room 102 with diapers to assist the resident with the diaper change, resulting in a one-minute response time. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Catherine Dacara (Assistant Administrator) and copy of this report was provided. Allegation : Facility staff did not provide communication with authorized representative. It was alleged that the facility failed to communicate with the authorized representative regarding the resident’s care and condition. On 04/01/2026 between 9:27am - 9:50am, the Department interview A1 regarding the allegation. A1 denied the allegation and stated not being aware of any concerns. A1 stated multiple staff communicate with families as needed. On 04/01/2026, between 10:00am - 11:50am, the Department interviewed seven (7) staff in regards to the allegation. 7 out of 7 staff denied the allegation and stated they would refer the representative to the Administrator, med tech, or front desk. On 04/01/2026, between the hours of 2:24pm - 3:05pm, the Department interviewed ten (10) residents in regards to the allegation. 8 of out 10 residents denied the allegation and expressed no concerns with communication. Several residents independently manage their own communication or do not have family. 2 out of 10 residents did not confirm nor deny the allegation and mentioned having no family (R8) and or does not communicate with their family (R4). On 05/18/2026, between the hours of 3:00pm - 4:00pm, the Department conducted a records review and observed the following: R1 has a POA, according to a document titled Power of Attorney for California (dated on 05/11/2024). This POA is also mentioned on the LIC 601 has the person responsible for final affairs, payment for care and legal guardian if any and this is also indicated on LIC 603 that POA is the person who manages R1’s finances. On 07/07/2026 between 11:45am – 1:00pm, the Department conducted further review of four (4) internal resident incident reports dated (2) on 07/08/2025, 11/23/2025, and 01/21/2026. The incident report dated 07/08/2025 documented that R1 was sent to the hospital and the written narrative stated that the POA was notified; however, the “Responsible Party” section reflected “No” for contact made. The incident report dated 07/08/2025 documented R1’s return from the hospital and indicated that discharge paperwork was scanned to GPDocs, the pharmacy, and the former office desk manager, and that the POA was notified; however, the “Responsible Party” section again reflected “No” for contact made. The incident reports dated on 10/11/2025 of an unwitnessed fall, on 11/23/2025 R1 screaming and shaking and on 01/21/2026 documented a witnessed fall in which 911 was called; however, the “Responsible Party” section reflected “No” for contact made. Based on the 4 incident reports, the Department observed that “No” was consistently checked for contact made to the responsible party, indicating that the authorized representative was not contacted at the time of each incident. The Department did not observe supplemental documentation indicating that communication occurred outside of the incident reports. Based on observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Catherine Dacara (Assistant Administrator) and a copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Jul 7, 2026 · control 11-AS-20260327155037

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Jul 21, 2026

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services including ongoing evaluations... This requirement was not met as incident reports dated 07/08/2025, 10/11/2025, 11/23/2025, and 01/21/2026 showed “No” contact made with R1’s authorized representative, with no documentation of communication. This poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Jul 7, 2026

Plan of correction: The Administrator shall retrain staff on required notification procedures for authorized representatives by ensuring responsible parties are notified of all incidents and requests, with documentation completed accordingly. The facility shall submit proof of training to the Department via email at Zina.Brown@dss.ca.gov by the POC due date.

Allegation investigated: Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. Staff does not ensure resident's hygienic care needs are met. Staff does not ensure resident's incontinence care needs are met. Staff did not allow resident back to facility after hospital stay.

*This report supersedes the report dated 04/24/2026 to add additional information and interviews.* On 07/1/2026, at 9:15am, the department conducted a subsequent complaint visit to the facility and was greeted by Ace Huynh, Executive Director. The department explained the purpose of this visit was to amend the prior complaint with additional information and interviews. The investigation consisted of the following: On 04/01/2026, the department conducted an initial complaint visit to gather facility files. On 04/24/2026 from 11:00am-2:00pm, the department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4), residents (R2-R10). R1 was not available for interview because they are no longer at the facility and has cognitive issues. On 06/08/2026 the department interviewed witness (W1); resident (R1s) representative. The department received the following documents: Report Continued on LIC909-C Unsubstantiated Staff Roster (Dated: 03/19/2026), Resident Roster (Dated: 03/25/2026), Identification & Emergency Information (Dated: 02/02/2026), Physician Report (Dated: 12/08/2025), Preplacement Appraisal Information (Dated 02/02/2026), Needs & Service Appraisal (Dated: 04/01/2026), Admission Agreement (Dated 02/02/2026), Shower Schedule (Last Updated 03/06/2026), Shower Log (for March 2026) and Internal Resident Incident Reports (Dated: 03/12/2026, 03/23/2026 & 03/25/2026), and Medication Administration Record (Dated: February 2026 - March 2026) from the facility. The investigation revealed the following: Allegation #1-Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. The details of the complaint alleged that resident (R1) had two unwitnessed falls, with no injuries in the facility. It was reported that the staff did not provide adequate supervision for the resident. On 04/24/2026 from 11:00am-2:00pm, the department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4), residents (R2-R10), and on 06/08/2026 the department interviewed witness (W1) regarding the allegation. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. 4 of 4 staff denied the allegation that Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. All staff stated that they do provide adequate supervision for the residents in the facility. Staff also stated that there is a call button in each resident’s room that they can push if they need assistance or are having trouble walking. They further stated that the residents are checked on frequently throughout the day and night and to their knowledge (R1) never had a fall in the facility. The department interviewed residents (R2-R10) about the allegation and 8 of 10 residents that were interviewed stated that they believe the staff does provide adequate care and supervision for the residents in the facility. Those residents further stated that they are satisfied with the care and supervision and feel safe living in the facility. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. The department interviewed witness (W1), and they stated that the staff did not monitor the resident correctly and felt that they wouldn’t have fallen if they were monitored better. The department reviewed Internal Resident Incident Reports (Dated: 03/12/2026, 03/23/2026 & 03/25/2026) and observed that the incident reports were not fall related. There is no documentation that (R1) had any falls. The department reviewed the Staff Roster (Dated: 03/19/2026) and observed that the facility has sufficient staff to provide adequate supervision for the residents. The department also reviewed the Preplacement Appraisal Information (Dated 02/02/2026) and observed that (R1) was able to walk without any physical assistance and does not utilize assistive devices for mobility, despite having a cane available. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report Continued on LIC9099-C Allegation #2- Staff does not ensure resident's hygienic care needs are met. The details of the complaint alleged that the facility staff did not ensure the residents’ (R1) hygiene care needs were met. It was reported that hygiene requests from the family were not addressed. On 04/24/2026 from 11:00am-2:00pm, the department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4), residents (R2-R10), and on 06/08/2026 the department interviewed witness (W1) regarding the allegations. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. 3 of 4 staff denied the allegation that Staff does not ensure resident's hygienic care needs are met. The majority of the staff stated that the residents’ hygienic care needs were being met. Staff further stated that (R1) was able to care for their own hygiene needs with little assistance from the staff but needed reminders from the staff. Staff stated that they reminded (R1) often and tried to assist (R1) but (R1) would get agitated and scream for them to stop. While 1 staff stated that the resident did require some assistance and would often refuse and get agitated if they tried to assist them. The department interviewed residents (R2-R10) about the allegation and 9 of 10 residents that were interviewed stated that the facility staff does ensure that their hygiene needs are met but added that they are primarily independent and care for their own needs. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. The department interviewed witness (W1), and they stated that the facility staff did not make sure that (R1s) hygiene (shower/grooming) needs were met as requested. The department reviewed the Needs & Service Appraisal (Dated: 04/01/2026) and observed that (R1) needed assistance with bathing and grooming but was able to care for their toileting needs by themselves without assistance. The department reviewed the Shower Schedule (Last Updated 03/06/2026) and Shower Log (for March 2026) and observed that (R1) was on a schedule but some days it was documented that (R1) refused to shower and refused assistance. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that Staff does not ensure resident's hygienic care needs are met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report Continued On LIC9099-C Allegation #3- Staff does not ensure resident's incontinence care needs are met. The details of the complaint alleged that the facility staff did not ensure that resident (R1) incontinent care needs were met. It was reported that (R1) had redness in their groin area which they suggested was suggestive of infrequent brief changes. On 04/24/2026 from 11:00am-2:00pm, the department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4), residents (R2-R10), on 06/08/2026 the department interviewed witness (W1) regarding the allegation. On 7/1/26 the department reinterviewed staff about the allegation. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. 3 of 4 staff denied the allegation that Staff does not ensure resident's incontinence care needs are met. The majority of the staff stated that the residents’ needs were being met. While 1 staff said they needed some assistance sometime but could generally care for their own toileting needs. All staff stated they had no knowledge of any redness in (R1s) groin area. All staff stated that residents who need assistance with incontinence care is conducted every two hours or as needed depending on the resident’s needs. All staff stated that (R1) did not need incontinent care. The department interviewed residents (R2-R10) about the allegation and 9 of 10 residents that were interviewed stated that the staff does ensure that their care needs are met. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. The department interviewed witness (W1), and they stated that the facility staff did not make sure that (R1) incontinence care needs were being met. W1 stated that R1 was not changed often and had dried feces in their adult briefs and believed their groin area was red because of infrequent brief changes. The department reviewed the Needs & Service Appraisal (Dated: 04/01/2026), Physician Report (Dated: 12/08/2025), and Preplacement Appraisal Information (Dated 02/02/2026) and observed that the resident was able to care for their toileting needs by themselves without assistance. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that Staff does not ensure resident's incontinence care needs are met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Report Continued on LIC9099-C Allegation #4- Staff did not allow resident back to facility after hospital stay. The details of the complaint alleged that the facility did not allow resident back after hospital stay. It was reported that the family member of the resident did not want to return the resident to the facility because they didn’t think the resident was properly cared for. On 04/24/2026 from 11:00am-2:00pm, the department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4), residents (R2-R10), and on 06/08/2026 the department interviewed witness (W1) regarding the allegations. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. 4 of 4 staff denied the allegation that Staff did not allow resident back to facility after hospital stay. Staff (S1) stated that the family member of the resident came on 03/24/2026 to take the resident to the hospital for evaluation and never brought the resident back to the facility. S1 also stated on that day, the family member removed all of the residents’ belongings from the facility. S1 further stated that there wasn’t a valid reason that the resident could not return to the facility, and no one said otherwise. S2-S4 stated that they had no knowledge of a reason that the resident would not be allowed to return to the facility. The department did not find any documentation or communication that would have denied the resident from returning to the facility. R1 was not available for interview because they are no longer at the facility and has cognitive issues. However, witness (W1) was available to speak on their behalf as their representative. The department interviewed witness (W1), and they stated that the facility did not refuse to allow R1 back. However, they felt that R1 would be safer in a different facility and chose to take R1 elsewhere. Based on interviews conducted, there is insufficient evidence to support the allegation that Staff did not allow resident back to facility after hospital stay. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued for this complaint investigation. An exit interview was conducted with Ace Huynh, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Jul 1, 2026 · control 11-AS-20260325144642

Type of visit: Case Management - Incident

On June 15, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit to the facility following an incident reported by the facility that occurred on June 6, 2026. During the visit, the LPA met with Anita Csukardi & Ace Huynh, Executive Directors to explain the purpose of the inspection. The El Segundo Regional Office Adult and Senior Care received an Unusual Incident Report (LIC 624) on June 8, 2026, stating that Resident #1 (R1) had been given the wrong medication. On June 6, 2026, at 4 PM, the medication technician mistakenly verified only (R1's) last name without confirming the correct resident. Consequently, (R1) was administered medications intended for another resident with the same last name. As a result, both Metformin and Senna were given to (R1) in error, leading to hospitalization in the emergency room. The Department found that the facility was not in compliance with Title 22 Regulations and issued citations as follows: 87465(c)(2) Incidental Medical and Dental Care Services. The investigation revealed that the facility failed to comply with Title 22 regulations. The LPA reviewed (R1’s) Physicians Report (LIC 602A) (dated 07/27/23) and Medication List (dated 06/15/26), which confirmed that (R1) was not prescribed Metformin by (R1's) physician. Based on interviews, observations, and record reviews, the licensee was found in violation of the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies have been issued, and an exit interview was conducted with Ace Huynh, Executive Director. A copy of this report is provided, along with the appeal rights.the state’s words, verbatim · CDSS document, Jun 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465)(c)(2) · Plan of correction due date: Jun 16, 2026

87465)(c)(2) Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on the records review, facility staff did not verify the medication record and administered medication Metform that was not prescribed to (R1). The facility reported a medication error: administering the wrong medications intended for another resident with the same last name. This violation poses/posed an immediate risk to persons in care.the state’s words, verbatim · CDSS document, Jun 15, 2026

Plan of correction: Licensee shall provide medication administration in-service training to all staff that dispense medications. This training shall be provided by pharmacy and/or registered nurse. Submit proof of training by POC due.06/16/26. Citation was cleared during the visit. Medication training took place on 06/10/26 with a registered nurse.

Allegation investigated: Facility did not maintain a safe and healthful environment for the resident.

This report supersedes the report created on 03/18/2026. An additional report will be provided addressing the remaining allegations investigated. The findings regarding the loud television and resulting sleep disruption remain unchanged. On 06/09/2026, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced complaint visit. LPA met with Administrator Catherine Dacara. The investigation consisted of the following: On 03/18/2026, LPA Anguiano interviewed fourteen (14) residents (R1–R14) and five (5) staff members (S1–S5), conducted observations, and collected records. Records obtained included internal incident reports for R1 and R2, an LIC 500 dated 03/12/2026, staff roster, resident roster dated 03/05/2026, and an internal resident incident report for R5 with documentation of a house rules reminder provided. LPA also reviewed four (4) resident files, including admission agreements, physician’s reports, and appraisal/reappraisal documents. The investigation revealed the following: Please see report continuation on (LIC9099-C) Substantiated Regarding the allegation, “Facility did not maintain a safe and healthful environment for the resident,” it was alleged that a resident was subjected to ongoing noise disturbances due to a roommate’s loud television at night, resulting in sleep disruption. Records review revealed internal incident reports dated 03/12/2026 and 03/13/2026 documenting concerns regarding loud television use and roommate conflict between R1 and R2. Documentation indicated that R1 reported concerns regarding television volume and difficulty sleeping. Records also indicated that staff provided reminders to R2 regarding house rules, including lowering television volume and use of headphones at night. However, the facility did not provide additional requested documentation, including behavior logs, complaint logs, or other records demonstrating ongoing monitoring, follow-up actions, or effective resolution of the roommate conflict. Resident interviews revealed that R1 reported concerns regarding loud television volume at night and disruption of sleep. Staff interviews revealed ongoing roommate conflict between R1 and R2 involving television volume, different sleep schedules, and sleep disruption. Staff further reported that incident reports were completed, the issue was brought to administration, and staff attempted verbal interventions including reminders, counseling, mediation, and review of house rules. S1 reported addressing the concern by counseling the resident, reviewing house rules, and offering a room change. However, both residents declined relocation and staff reported the concern remained ongoing at the time of the investigation. Observations revealed that residents were observed in their rooms and common areas, and the facility appeared calm during the visit. Based on interviews conducted, observations made, and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation that the facility did not maintain a safe and healthful environment for the resident due to ongoing noise disturbance and sleep disruption is Substantiated. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.1(a)(2), Personal Rights of Residents in All Facilities. A citation is being issued on the attached (LIC9099-D). An exit interview was conducted with the Administrator. A copy of this report and appeal rights were provided to the Administrator. The investigation revealed the following: Regarding the allegation that a resident attempted to run over another resident with a wheelchair, interviews conducted with residents and staff did not corroborate the allegation. Staff interviewed denied knowledge of physical aggression or wheelchair aggression between R1 and R2. S1 stated this concern had not been previously reported. Records reviewed did not contain incident reports, behavior logs, or other documentation supporting the allegation. During the visit, LPA did not observe physical aggression between residents. Regarding the allegation that a resident yelled at another resident, interviews conducted with residents and staff did not corroborate the allegation. Staff interviewed denied knowledge of yelling between R1 and R2. S1 stated this concern had not been previously reported. Records reviewed did not contain incident reports, behavior logs, or other documentation supporting the allegation. During the visit, LPA did not observe yelling or active conflict between residents. Regarding the allegation that a resident used abusive language toward another resident, interviews conducted with residents and staff did not corroborate the allegation. Staff interviewed denied knowledge of abusive language between R1 and R2. S1 stated this concern had not been previously reported. Records reviewed did not contain incident reports, behavior logs, or other documentation supporting the allegation. During the visit, LPA did not observe abusive language or active conflict between residents. Based on interviews conducted, observations made, and records reviewed, although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the allegations are Unsubstantiated. No deficiencies were cited regarding these allegations. An exit interview was conducted with the Administrator. A copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 9, 2026 · control 11-AS-20260311163742

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 10, 2026

87468.1 Personal Rights of Residents in All Facilities(a)...in all residential care facilities for the elderly...all of the following personal rights:(2)To be accorded safe...accommodations...This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee failed to ensure R1’s personal rights were protected. R1 experienced repeated sleep disruption due to R2’s loud television. This poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 9, 2026

Plan of correction: Licensee agreed to find a better room for R1 in order to help R1's personal rights by due date and email LPA: jose.anguiano@dss.ca.gov

Allegation investigated: Staff did not distribute residents' medications as prescribed Staff do not provide a comfortable environment for residents in care

On 06/04/26 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. California Department of Social Services (CDSS) was met by staff one, Ace Huynh - Administrator (S1), and the purpose of the visit was explained. CDSS was assisted by Davila Alvarez (S2) and toured the facility. The investigation consisted of the following: Between 9:00AM and 1:00PM CDSS interviewed ten (10) out of one-hundred and nine (109) residents (R1-R10) and four (4) out of fifty-five (55) staff (S1-S4). CDSS collected documents listed as follows: Resident roster (Dated: 06/03/26), Staff roster (Dated: 06/02/26), Admission Agreement of resident one (R1) (Dated: 02/08/22), medical transport of resident 11 (R11) and medications administration record (MAR) of R1 and R12 for the month of May, 2026 (05/2026). The investigation revealed the following: Regarding the allegation “Staff did not distribute residents' medications as prescribed”, it is being alleged that on 5/25/2026, the facility was short staffed and that medications were not delivered to all residents in care. Report continues, please see LIC9099-C. Unsubstantiated Record reviews revealed the following: During the month of May (05/2026) CDSS reviewed two (2) MARs and there were zero (0) discrepancies observed. Interviews revealed the following: Nine (9) out of ten (10) (R2-R10) residents and all four staff (S1-S4) have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation “Staff do not provide a comfortable environment for residents in care”, it is being alleged that another resident speaks too loudly on a daily basis and staff have spoken to this resident, yet the volume of their voice remains loud. Record reviews have revealed that, within house rules, the grievance procedures are listed. Interviews revealed the following: Six (6) out of ten (10) (R4-R8 and R10) residents and all four staff (S1-S4) have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with staff one, Ace Huynh, and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 11-AS-20260529151706

Allegation investigated: Facility staff mismanage residents’ medications

**This report supersedes the report delivered on 05/13/2026 to include additional information to the findings** On 06/03/2026 at 8:00am, the department conducted an subsequent visit to deliver the investigation findings at this facility for the allegation listed above. During today’s visit, the department met with Catherine Dacara (Assistant Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 04/07/2026 between the hours of 8:40am - 1:33 pm, the department interviewed Administrator (A1), Staff (S1 - S5), Residents (R1 - R10). The department also requested and obtained the following documents: Staff Roster (dated 03/19/2026), Resident Roster (dated 04/06/2026), Employee Schedule (dated 03/29/2026 - 04/04/2026), Visitor Log (dated 04/02/2026),2 Resident Records for R1 & R2 which include: See LIC 9099-C Substantiated LIC 601: Identification & Emergency Information (R1 dated 03/09/2026 & R2 dated 02/26/2025), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (R1 dated 08/21/2025 & R2 dated 02/07/2025), LIC 603: Preplacement Appraisal Information (R1 dated 08/27/2025 & R2 dated 02/07/2025), Admission Agreement (R1 dated 09/19/2025 & R2 dated 02/28/2025, R1's New Resident Account Set Up (dated 09/19/2025), R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) . The investigation revealed the following: Allegation: Facility staff mismanage residents’ medications. It was alleged that residents’ medications were not administered as prescribed and that documentation was incomplete. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated medtechs assist with self-administered medications when LVNs are unavailable. A1 reported she was not aware of any missed doses or medication errors. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Four (4) out of five (5) staff denied the allegation. One (1) staff was unaware. Staff reported they were not aware of missed doses and stated they notify the med-tech or charge nurse if unable to administer medications. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed ten (10) residents regarding the allegation. One (1) out of ten (10) residents confirmed the allegation. One (1) out of ten (10) was unsure of the allegation. Eight (8) out of ten (10) denied the allegation. Of the one (1) resident who confirmed the allegation, the resident reported missed doses. Of the one (1) resident who was unsure mentioned being not sure of their medication management. On 05/13/2026 between 10:00am – 11:00am, the Department conducted a records review of the April and May 2026 Medication Administration Records (MARs) and identified 42 undocumented medication administrations affecting eight (8) residents. The review showed missing initials for medications assigned to R1, including 6 missed doses of Carvedilol, 3 of Duloxetine, 14 of Furosemide, and 9 of Gabapentin on various dates in April 2026; R2 had 2 missed doses of Sacubitril/Valsartan, 2 of Magnesium Oxide, 2 of Vitamin C, and 1 multivitamin dose between April 10–18, 2026; R3 had 2 missed doses of AmoxClav, 1 of Olanzapine, and 1 Lidocaine patch between April 6–15, 2026; R4 had 2 missed doses of Polyethylene Glycol, 3 of Amlodipine, and 2 of Atorvastatin between April 12–20, 2026; R5 had 1 missed dose each of Benazepril, Eliquis, and Refresh Tears on April 9, 13, and 17, 2026; R6 had 2 missed doses of Divalproex, 2 of Vitamin D3, 3 of Docusate Sodium, 4 of Famotidine, 1 of Omega-3 Ethyl Esters, and 1 of Buspirone between April 5–22, 2026; R7 had 20 missed doses of Lantus Solostar, 3 of Metformin, and 2 of Xiidra throughout April 2026; and R8 had 2 missed doses of Levetiracetam and 1 missed dose each of Lisinopril, Sertraline, Acetazolamide, Bisacodyl, Ipratropium-Albuterol, Isosorbide Dinitrate, Jardiance, and Triamcinolone between April 7–25, 2026. The Department also observed nine (9) medications remaining inside bubble packs despite being initialed as administered, with no documentation explaining the discrepancies. Based on the Department's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Catherine Dacara (Assistant Administrator) a copy of this report was provided with appeal rights. LIC 601: Identification & Emergency Information (R1 dated 03/09/2026 & R2 dated 02/26/2025), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (R1 dated 08/21/2025 & R2 dated 02/07/2025), LIC 603: Preplacement Appraisal Information (R1 dated 08/27/2025 & R2 dated 02/07/2025), Admission Agreement (R1 dated 09/19/2025 & R2 dated 02/28/2025, R1's New Resident Account Set Up (dated 09/19/2025), R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) . The Investigation revealed the following: Allegation: Facility staff do not ensure that residents’ toileting needs are met. It was alleged that residents were not receiving timely assistance with toileting and incontinence care due to chronic understaffing, resulting in delays in responding to care needs and insufficient break coverage. On 04/07/2026 between the hours of 8:40am - 8:52am, the Department interviewed A1 in regards to the allegation. A1 denied the allegation, stated not being informed of any resident left soiled or any staff refusing assistance due to being on break. A1 explained that the facility uses a break schedule to ensure coverage and stated not being present during the reported incident and did not receive follow-up information. On 04/07/2026 between the hours of 11:55am - 1:33pm, the Department interviewed 5 staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they had not observed a resident being left soiled, had not refused assistance due to being on break, and stated that another caregiver is assigned to provide coverage when a staff member is on break. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents was aware of the allegation. Nine (9) out of ten (10) residents denied the allegation. Residents reported they independently manage toileting or receive timely assistance. One resident reported a single instance where staff stated they were on break in regards to the delay in responding to care needs. On 05/13/2026 between the hours of 10:00am - 11:00am, the Department conducted a records review of resident assessments and facility documentation and did not observe any records indicating unmet toileting needs or delays in incontinence care. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Facility staff did not treat residents with dignity and respect. It was alleged that staff entered rooms without knocking, spoke rudely to residents, and refused to provide their names. On 04/07/2026 between 8:40am -8:52am, the Department interviewed the Administrator (A1) regarding the allegation. A1 denied the allegation and mentioned not being informed of staff entering rooms without knocking, speaking rudely to residents, or refusing to provide their names. A1 stated staff are expected to knock before entering and identify themselves when asked, and no complaints of disrespectful conduct had been reported. On 06/03/2026 between 9:24am - 9:42am, the Department re-interviewed A1 to obtain additional information in regards to the allegation. A1 denied receiving any reports of staff entering rooms without knocking, speaking rudely to residents or visitors, refusing to provide their names, or making inappropriate statements. A1 stated staff are trained to uphold resident Personal Rights, including respectful communication and proper room entry procedures. A1 reported that R1 approached her the day after 04/02/2026 to apologize for R1's visitor’s behavior such as being rude towards the staff. A1 stated she spoke with the involved staff (S4), reviewed expectations regarding respectful communication, and reinforced de-escalation procedures. A1 reported no residents had expressed concerns about staff conduct or indicated a desire to move out due to staff behavior. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they knock before entering resident rooms, do not speak to residents in a rude manner, and provide their names when requested. Staff stated they were not aware of any incidents involving rude tone or refusal to identify themselves. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. Two (2) of ten (10) residents confirmed the allegation. Eight (8) of ten (10) residents denied the allegation. Two residents reported incidents involving rude tone or failure to knock; the remaining residents reported staff knock before entering and treat them respectfully. On 05/13/2026 between the hours of 10:00am – 11:00am, the Department conducted a records review of facility policies, resident rights documentation, and internal records and did not observe any documentation indicating staff failed to treat residents with dignity or respect. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Facility staff do not ensure residents’ medical needs are being met. It was alleged that residents were not receiving ordered physical therapy or medical services. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated not being aware of any resident failing to receive ordered physical therapy or medical services. A1 stated the facility follows up with therapy providers when services are missed and had not received reports of unmet medical needs. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Four (4) out of five (5) staff denied the allegation. One (1) out of five (5) staff was unaware of the allegation. Staff reported they had not observed residents missing medical services and stated they notify the LVN or med-tech when residents report concerns. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents confirmed the allegation. Nine (9) of ten (10) residents denied the allegation. One resident reported not receiving physical therapy; other residents reported receiving medical services as ordered or stated delays were due to insurance authorization rather than facility action. On 05/13/2026 between the hours of 10:00am – 11:00am, the Department conducted a records review of LIC 602s, LIC 603s, and medical documentation and did not observe any records indicating missed medical services or lack of follow up by the facility. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff do not ensure food served is of good quality. It was alleged that the food served to residents was of poor quality and did not meet nutritional needs, and that inadequate staffing and oversight contributed to inconsistent meal preparation and insufficient attention to dietary requirements. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated menus are created monthly and reviewed for nutritional adequacy. A1 reported not receiving complaints regarding food quality. On 04/07/2026 between the hours of 11:55am – 1:33 pm, the Department interviewed five (5) staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they had not received complaints regarding food quality and stated meals are prepared according to posted menus. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents confirmed the allegation. Nine (9) of ten (10) residents denied the allegation. One resident reported dissatisfaction with food quality; other residents reported meals were satisfactory. On 05/13/2026 between the hours of 10:00am – 11:00am, the Department conducted a records review of the facility’s posted Spring 2026 menus for Weeks 1, 3, and 4. The Department observed that the menus were dated, organized, and reflected balanced meals including proteins, vegetables, starches, fruits, and desserts. Breakfast menus included hot cereals, eggs, pancakes, and juice options. Lunch and dinner menus included soups, salads, meats, vegetables, and desserts. The Department observed that the menus aligned with the facility’s Admission Agreement requirement to provide three nutritious meals daily and accommodate special diets. No documentation was found indicating that meals served failed to meet nutritional standards or that residents were served food inconsistent with posted menus or dietary requirements. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Catherine Dacara and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 3, 2026 · control 11-AS-20260403094947

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 4, 2026

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medication as needed Based on observation and record review, the Department identified eight (8) residents and nine (9) medications remaining in bubble packs despite being initialed as administered, posing a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2026

Plan of correction: The Administrator will complete an immediate medication audit & ensure all medications are administered & documented correctly. Also Administrator will provide proof of scheduled in-service training from a contracted pharmacy on proper administration of medication & proper MAR documentation... for all staff who handle meds. Proof of the completed medication audit in detail and scheduled date and time for the in-service training with contracted pharmacy on proper medication administration by the POC due date to LPA Brown at Zina.Brown@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6)(A–F) · Plan of correction due date: Jun 24, 2026

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring a record of centrally stored prescription medications for each resident is maintained ...(A-F) records for centrally stored medication... Based on record review, the Department identified 42 undocumented medication administrations affecting eight (8) residents, indicating medications were not documented as required, which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2026

Plan of correction: The Administrator will retrain all medication staff on MAR documentation requirements under 87465(h)(6)(A–F). A weekly MAR review will be implemented to ensure all entries are complete, accurate & must be signed & dated daily. The administrator will submit proof of completed retraining for... MAR documentation requirements & weekly MAR review entries are conducted & must be reviewed by being signed & dated for confirmation of review being completed by the POC due date and email proof to LPA Brown at Zina.Brown@dss.ca.gov

Allegation investigated: Staff do not ensure that resident's transportation needs are being met

***Please note that this amended Complaint Investigation Report LIC9099 and LIC9099-C dated June 25, 2026, will supersede the original LIC9099 dated June 3, 2026, clarification.*** On Wednesday, June 3, 2026, Licensing Program Analyst (LPA) Pamela Bunker conducted an initial visit to gather information regarding the above allegation. LPA met with Ace Huynh, Executive Director, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On June 3, 2026, the following documents were reviewed and obtained as part of the investigation: Personnel Report (dated 06/02/26), Resident Roster (dated 03/02/26), Admission Agreement (dated 01/23/26), Identification and Emergency Information (dated 02/17/26), Physician’s Report (dated 07/30/25), Medical Assessment (dated 12/31/25), Medication Administration Records (MARs) (06/01/26 -Present), Resident Appraisal & Needs and Services Plan (dated 12/31/25), Functional Capability Assessment (dated 12/31/25), Preplacement Appraisal Information (dated 12/31/25), Personal Rights (dated 01/23/26), Consent Forms (dated 01/23/26), Personal Property and Valuable (dated 01/30/26). See continued LIC9099-C page 2. Unsubstantiated Continued LIC9099-C page 2. The investigation revealed the following: Allegation: Staff do not ensure that residents' transportation needs are being met. On 06/03/2026, between 10:00 a.m. and 3:30 p.m., the Department interviewed Staff #1 through Staff #3 (S1–S3). All three staff members (3 out of 3) stated that the facility ensures residents' transportation needs are met. Staff reported that residents may schedule transportation services through the front desk receptionists for use of the facility van, and staff also assist residents in arranging transportation through Access Services and CalVA Car. 3 out of 3 staff members stated that residents are required to sign up in advance for transportation to medical appointments. Staff explained that once transportation requests are submitted, the front desk notifies administration, and nursing staff are also informed when transportation is needed for medical appointments to ensure proper coordination of care. All three staff members stated that residents are not denied transportation services and denied the allegation that the facility fails to meet residents' transportation needs. On 06/03/2026, between 1:00 p.m. and 3:30 p.m., and on 06/25/2026, between 11:00 a.m. and 12:00 p.m., the Department interviewed Residents #1 through #10 (R1–R10) regarding the above allegation. 9 out of 10 residents interviewed stated that staff ensure their transportation needs are met and reported no issues obtaining transportation to medical appointments or other scheduled destinations. 9 out of 10 residents stated that transportation services are available when requested and that staff assist them as needed. 1 out of 10 residents stated that staff is currently assisting them with obtaining transportation services through Access Services and LA Care to help meet their transportation needs. The resident did not express any concerns regarding staff’s efforts and acknowledged that staff are actively working to coordinate the necessary services. 10 out of 10 residents stated that staff follow their individual needs and service plans, and their care needs are being met. 9 out of 10 residents stated that they have not experienced any problems related to transportation. 9 out of 10 residents interviewed denied the allegation that staff fail to ensure residents’ transportation needs are being met. See continued LIC9099-C page 3. Continued LIC9099-C page 3 The Department reviewed the resident’s Physician’s Report (dated 07/30/25), Medical Assessment (dated 12/31/25), Resident Appraisal/Needs and Services Plan (dated 12/31/25), Functional Capability Assessment (dated 12/31/25), and Pre-placement Appraisal Information (dated 12/31/25). There was no indication that the resident had been seen by physical therapy (PT). Documentation reflects that the resident had no scheduled PT appointments. Based on interviews, available evidence, observations, information received, and records reviewed, there was not sufficient evidence to support the allegation. Although the allegation may have occurred or may be valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099 and LIC9099-C was provided to Ace Huynh, Executive Director. No deficiencies were cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Jun 3, 2026 · control 11-AS-20260526112802

Allegation investigated: Facility staff are not assisting resident with obtaining healthcare

On 06/02/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint visit to the facility listed above. LPA met with Ace Huynh, Administrator, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation revealed the following: During today’s visit, LPA interviewed Staff S4-S7 and delivered findings. During a subsequent visit conducted on 04/30/2026, LPA inspected the facility, interviewed Staff S3, interviewed Residents R1-R12, and received and reviewed Internal Resident Incident Reports, Besht Wellness Group Progress Notes (dated 10/27/2025, 12/15/2026, 12/18/2025 . During an initial visit conducted on 03/05/2026, LPA interviewed Staff S1 and S2 and received documents. The following documents were received and reviewed: Staff Roster, Resident Roster, Physician’s Report (dated 03/27/2026), Needs and Service Plan (dated 02/15/2026), Physician’s Orders, and Admission Agreement (dated 04/04/2025). The investigation revealed the following: Unsubstantiated Allegation: Facility staff are not assisting resident with obtaining health care The allegation alleges that a resident wants physical therapy, a new wheelchair, and a medical procedure done and she has not received it. During record review, LPA received and reviewed the Admission Agreement (dated 04/03/2025) that lists under Basic Service the following, On page 1, number 3 states “Notification to resident’s family, physician, and other appropriate person/agency of resident’s needs. And on page 2, number 6 states “Plan, arrange and/or provide for transportation to medical and dental appointments within a 7-mile radius of facility." Physician’s Report for Residential Care Facilities for the Elderly (dated 03/27/2025) that indicates R1 has a Motor Impairment/Paralysis that causes hemiplegia and hemiparesis. Additionally, LPA received and reviewed Progress Notes from Besht Wellness (dated 12/18/2025) that under Plan lists the following: Referral to home health physical and occupational therapy for ongoing rehabilitation needs. Order for durable medial equipment: replacement or repair of motorized wheelchair. Referral to obstetrics and gynecology for intrauterine device replacement as previously requested. LPA observed an order for home health for physical therapy/occupational therapy on 10/28/25 and 12/18/25. During the facility visit, LPA observed R1 utilizing an electric wheelchair. R1 stated that it was working fine During interviews with Staff S1-S7, were asked if there is staff who assist residents with arranging medical appointments or procedures, seven (7) out of seven (7) stated if a resident requires assistance making a doctor’s appointment, staff in the medication room or the front desk are able to assist. Additionally, Staff S1- S7 were asked if staff assist residents with acquiring assistive devices or outside services, seven (7) out of seven (7) stated if there is an order from the doctor, they will assist with acquiring it or if the resident or family request we can notify their physician to see about getting an order. During interviews with Residents R1-R12, were asked if staff assist them with arranging medical appointments or procedures, twelve (12) out of twelve (12) stated yes, staff are there to assist them with arranging appointments and transportation, if needed. Additionally, Residents R1-R12 were asked if staff assist them with receiving outside services and/or acquiring assistive devices, twelve (12) out of twelve (12) stated yes, staff are there to assist with receiving outside services and/or acquiring assistive devices, if need. During an interview with R1, they specified the issue has been with their physician and have since gotten a new doctor. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is/are unsubstantiated. LPA did not observe or cite any deficiencies. An exit interview was conducted with Administrator, Ace Huynh, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 11-AS-20260226154701

Allegation investigated: The facility did not ensure that resident was provided with comfortable, safe, and sanitary living accommodations.

On 05/29/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with the Executive Director, Ace Huynh and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 05/20/2026, an interview was conducted. On 05/22/2026, interviews were conducted and records were reviewed. Interviews conducted consisted of Witness 1 (W1), Staff 1 (S1) to Staff 6 (S6) and Resident 2 (R2) to Resident 9 (R9). Facility records were reviewed which consisted of Personnel Report dated 05/01/2026 and Resident Roster. Resident 1’s (R1) records were reviewed which consisted of Admission Agreement, Physicians Report dated 4/24/2023, Appraisal/Needs And Services Plan (ANS) dated 01/30/2025, Friendly Reminder letter dated 02/20/2025, five (5) Internal Resident Incident Reports ranging from 01/27/2025 to 02/17/2026. On 05/29/2026, R1’s room was toured. Substantiated Investigation revealed the following: Allegation: “The facility did not ensure that resident was provided with comfortable, safe, and sanitary living accommodations.” It is being alleged that staff allowed R1’s belongings and unsanitary items to accumulate in resident’s room. On 05/22/2026 at around 9:30 AM, R1’s room was toured and the following was observed: the room floor was filled with miscellaneous items such as boxes, picture frames, bags of stuff, bags of food supplies, toys, art supplies, house hold supplies, there is a medical bed with a half bed rail, large black bags filled, wheelchair, microwave, toiletries, and other items. It was difficult to maneuver around the bedroom; there was a small narrow path that led to the bed; it was not possible to open the bedroom window because the floor was covered with miscellaneous items (as mentioned above). R1’s bathroom was toured and the following was observed: the bathroom bathtub/shower was filled with clothing items and other miscellaneous supplies. The shower curtain rod was used as a closet rod that holds about forty-seven (47) hangers with long sleeve t-shirts, sweaters, sweatpants, etc. The bathroom sink was filled with dirty dishes. Vermin droppings and dead vermin were observed in the bathroom. On 05/29/2026, R1’s room was toured and two (2) kitchen knives were observed out. (Several pictures of R1’s room were taken and video footage). Interviews conducted with W1 revealed the following: W1 agreed with the allegation. W1 explained that the facility has not addressed R1’s hoarding; furthermore, W1 states that they have witnessed one (1) to four (4) portable urinal bottles filled with urine at one time on several occasions. Interviews conducted with R2 to R9 revealed the following: Five (5) out of eight (8) residents agreed with the allegation. Residents indicated that R1 was a “pack rat,” “hoarder,” and they had observed cups filled with urine. Three (3) out of eight (8) residents could not corroborate towards the allegation (residents had not seen R1’s room). Interviews conducted with Staff 1 (S1) to Staff 6 (S6) revealed the following: Six (6) out of six (6) staff agreed that R1 has a hoarding problem which makes it difficult for R1 to remove items from their room. Staff indicated that R1 uses a wheelchair, is a large person, and were unsure how R1 maneuvered in their room. Furthermore, staff indicated that it was difficult to work inside R1’s room due to it being difficult to ambulate in the room. Moreover, staff indicated that they had observed portable urinals filled with urine. Additionally, staff indicated that R1 was unable to shower in their bathroom because it was filled with clothing items. Staff indicated since the date they began working in the facility R1’s room has been like this (filled with boxes, art supplies, etc.). Staff were unaware if Unusual Incident Reports and Adult Protective Services (APS SOC341) reports were submitted to the department. Staff were unaware if there was a specific detailed plan in place to decrease the number of items R1 had. R1’s records reviewed revealed the following: Admission Agreement was not signed nor dated by R1 nor facility staff but stated that date of Admission was 04/25/17; on page 11 under “9. Clutter No hoarding or clutter is allowed in the units. Blocking the walkways, exit areas, and air/heat unit is a safety hazard.”; R1 is “Self-Responsible.” Physicians Report dated 04/24/2023 (report not signed by R1), stated that R1 needs assistance with bathing, grooming, toileting needs, and is non-ambulatory due to both mental and physical condition. Internal Resident Incident Report dated 01/27/2025, stated that the facility contacted R1’s family about R1 being a fall risk and room being a fire hazard; family indicated they are aware of R1’s “hoarding in the past.” Appraisal/Needs And Services Plan (ANS) dated 01/30/2025 was not signed by R1 nor facility staff; document stated that R1 required assistance with Activities of Daily Living (ADLs); it stated that on 01/08/2025, “staff reported that the resident’s room had become excessively cluttered, making it difficult to move around safely. The resident also reported seeing roaches in the room.”; under “Physical/Health” it stated “Environmental/Safety Needs” “Provide a constant supervision and assistance maintaining a clean, safe, and uncluttered living space” and “all staff” will be involved daily. Internal Resident Incident Report dated 02/06/2025, indicated that R1 was hospitalized and not in the facility. Friendly Reminder letter dated 02/20/2025, stated that R1 was not complying with the facilities House Rules and/or policies, referenced House Rule 9, and stated that R1 had until 03/20/2025 to clear out the room; the letter went on to explain that “The room is extremely cluttered. This poses a fire risk and makes it difficult for our staff to assist R1”; furthermore, it indicated failure to resolve will lead to the beginning of eviction proceedings. Internal Resident Incident Report dated 03/11/2025, described R1’s room as a fire hazard. Internal Resident Incident Report dated 03/22/2025, indicated that R1’s room still needs to be de-cluttered. Internal Resident Incident Report dated 02/17/2026, indicated that R1 went to the hospital. Substantiated: Based on observations, interviews and record reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Ace Huynh.the state’s words, verbatim · CDSS document, May 29, 2026 · control 11-AS-20260519135515

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: May 30, 2026

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on observations, interviews, and record review, the licensee did not comply with the section cited above, in not ensuring that R1's room was free of excessive items, vermin, and vermin droppings. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 29, 2026

Plan of correction: The Executive Director has agreed to create a plan with R1 to maintain R1’s room free of clutter, human waste, and vermin. A plan to maintain R1’s room and bathroom free of clutter, human waste, and vermin will be emailed to Socorro.Leandro@dss.ca.gov. Progress of R1's room will be submitted to the Department on a weekly basis up until 07/03/2026. Pictures of R1's room/bathroom along with an Unusual Incident/Injury Report (UIR) will be faxed to the Departments at 424-544-1016.

Type of visit: Case Management - Deficiencies

On 05/29/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit. The purpose of this visit is to deliver deficiencies observed on 05/22/2026 during a complaint investigation visit control number 11-AS-20260519135515. LPA met with the Executive Director, Ace Huynh and the purpose of the visit was explained. LPA was granted entry to the facility. Deficiencies observed on 05/22/2026 were as follows: · The facility did not submit Unusual Incident/Injury Reports (UIRs) for Resident 1(R1). o Internal Resident Incident Report dated 02/06/2025, indicated that R1 was hospitalized and not in the facility. o Friendly Reminder letter dated 02/20/2025, stated that R1 was not complying with the facilities House Rules and/or policies and stated that R1 had until 03/20/2025 to clear out the room; the letter went on to explain that “The room is extremely cluttered. This poses a fire risk and makes it difficult for our staff to assist R1”; furthermore, it indicated failure to resolve will lead to the beginning of eviction proceedings. o Internal Resident Incident Report dated 03/11/2025, described R1’s room as a fire hazard. o Internal Resident Incident Report dated 03/22/2025, indicated that R1’s room still needs to be de-cluttered. o Internal Resident Incident Report dated 02/17/2026, indicated that R1 went to the hospital and was diagnosed with shingles. · The facility did not have a yearly Appraisal and Needs Services Plan [ANS) also known as a reappraisal] for R1. o R1’s ANS dated 01/30/2025 was not signed by R1 nor facility staff. o The facility did not have an ANS for R1 for the year 2026. · The facility did not have a yearly updated Physicians Report (e.g. annual medical routine visit) for R1. o R1’s Physicians Report was dated 04/24/2023. o There was no documentation explaining as to why R1 did not receive an annual medical routine visit for 2024, 2025, nor 2026. Deficiencies are being cited based on record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Ace Huynh.the state’s words, verbatim · CDSS document, May 29, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jun 19, 2026

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidence by: Based on record review, the licensee did not comply with the section cited above in not submitting Unusual Incident to the department for incidents with Resident 1 on 2/20/2025, 3/20/2025, 3/11/2025, 3/22/2025, and 2/17/2025. This posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2026

Plan of correction: The Executive Director has agreed to retrain staff on Reporting Requirements. Email trainings to Socorro.Leandro@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Jun 16, 2026

Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidence by: Based on record review, the licensee did not comply with the section cited above in not having a yearly reappraisal for Resident 1 (R1). This posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2026

Plan of correction: The Executive Director has agreed to create an updated reappraisal with R1 and email updated reappraisal to Socorro.Leandro@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(h)(1-3) · Plan of correction due date: Jun 16, 2026

Reappraisals (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. (2) Documentation of a resident's refusal to receive an annual routine visit, or if applicable, their representative's refusal on their behalf, shall be added to the resident's record. (3) If a resident refuses to receive an annual routine visit, or if applicable, their representative refuses an annual routine visit on their behalf, but later agrees to one, documentation of the annual routine visit shall be added to the resident’s record. This requirement is not met as evidence by: Based on record review, the licensee did not comply with the section cited above in not having a documented annual medical routine visit for R1. This posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 29, 2026

Plan of correction: On 5/29/2026, the Executive Director provided LPA with an updated physician's report for R1.

Allegation investigated: Staff mismanaged resident medication

**This report supersedes the report delivered on 12/17/2025 to include additional information to the findings** On 05/20/2026 at 08:55am, the Department conducted a subsequent visit at this facility to deliver the complaint findings for the allegations above. During today’s visit, the Department met with Catherine Dacara (Asssistant Administrator) and the purpose of the visit was explained. The investigation consisted of the following: On 11/13/2025, the Department conducted interviews with Administrator (A1), Staff (S1-S10) & Residents (R1 - R10) between the hours of 8:29am - 2:30pm. The Department also requested and received the following documents: Staff Roster (dated 11/07/2025), Resident Roster (dated 11/01/2025), Resident #1's personnel record such as LIC 503 Pre-Placement Appraisal (dated 09/28/2022), LIC 602: Physician Report (dated 07/27/2023), Admission Agreement (dated 08/01/2024) & Dietary Preference (dated 10/25/2022), Fall Menu Week 3 (10/2025 & 11/ 2025), staff training & Medication Administration Record for R1 - R10 (for 10/2025 - 11/2025) . Substantiated The investigation revealed the following: Allegation: Staff mismanaged resident medication It was alleged that for the last 3 months a resident medications have been passed out late. On 11/13/2025 between the hours of 11:12am - 11:22am, the Department interviewed A1 who denied the allegation and stated the facility uses a medication cart for medtech to administer the medication to the residents. A1 also stated the facility just suspended two (2) medtech for lack of performance and Technical Support Program (TSP) provided by the Department of Social Service Community Care Licensing came to the facility about two weeks ago to assist with medication training. On 11/13/2025, between 9:15am - 1:21 pm, , the Department interviewed 9 staff regarding the allegation. 2 of 9 staff confirmed the allegation and stated due to short staff and or stopping to help assist another resident there have been challenges with timely medication administration. 2 of 9 staff denied the allegation and stated not rushing to administrator medication quickly to avoid making a mistake while another staff stated it's hasn't been any challenges with timely medication administration. 5 of 9 staff were unaware and or have no knowledge of the allegation due to their assigned job roles such a receptionist, caregiver, and activities director. On 11/13/2025, between 8:29am- 2:00pm, LPA interviewed 10 residents: 4 of 10 residents confirmed and stated by R1 that medication were for 3 months while other residents such as R3, R7 and R9 stated their medication being given late or missed once before. 3 of 10 residents denied and stated never experienced receiving their medication being given late nor missed. 3 of 10 residents did not confirm nor deny the allegation due to R6 stating no comment while R8 stated not remembering and R10 have not having any knowledge of their medication being give late or missed. On 11/19/2025, between the hours of 9am - 11am, LPA conducted medication review for 10 residents (R1 - R10) and observed the following: Medication Administration Record (MAR) for November 2025 indicated the medtechs administered medication by initial & timestamp. However medication is still observed to be in the bubble for Resident 1 (R1) 8pm Pregabalin 150mg on 11/1, 11/04, 11//11 and 11/18, Resident 1 (R1) 6:30am Pantoprazole SD DR 40 on 11/01 , Resident 5 (R5) 8pm Rosuvastatin Calcium 10 MG on 11/09, Resident 5 (R5) 6:30am Pantoprazole SD DR 40 MG on 11/01 and Resident 9 (R9) 8pm Atorvastatin 40 MG on 11/13, 11/14 and 11/15 Based on the Departments observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights. The investigation revealed the following: Allegation: Facility does not have a certified Administrator It was alleged that the facility does not have a certified Administrator since Michael Mendoza. On 11/13/2025 between the hours of 11:12am - 11:22am, the Department interviewed A1 who stated Melissa Flores is currently acting as the facility Administrator and is not sure how long she's been in the position. A1 stated she has a Administrator certification. On 11/13/2025, between 9:15am - 1:21 pm, the Department interviewed 9 staff regarding the allegation. 9 of 9 staff denied the allegation and stated Jennifer Rivas has been acting as the facility Administrator for a couple months. On 11/13/2025, between 8:29am- 2:00pm, the Department interviewed 10 residents regarding the allegation. 1 of 10 resident denied the allegation and stated Jennifer Rivas is the current Administrator of the facility. 9 of 10 are unaware of the allegation. On 11/17/2025, between the hours of 2:20pm - 2:30pm, the Department conducted a records review and observed the following: The previous Administrator for the facility was Michael Mendoza. Upon the departure of Michael Mendoza, the facility had Melissa Flores acting as the Administrator who held a Administrator Certification effective 08/11/2023 - 08/11/2025. On 11/7/2025, the Department received an email from Jennifer Rivas who provided her Proof of Completion for Certification Program for 740 - Residential Care Facility for the Elderly effective as of 02/23/2024 - 02/23/2026. Unfounded: This agency has investigated the complaint alleging (for the allegation above). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. Exit interview conducted with Catherine Dacara (Assistant Administrator) and a copy of this report was provided. The investigation revealed the following: Allegation: Staff do not ensure resident diapering needs are met It was alleged that residents are not getting their diapers changed in a timely manner. On 11/13/2025 between the hours of 11:12am - 11:22am, the Department interviewed A1 denied the allegation and stated staff conduct rounds to ensure resident who need diaper changes are assigned promptly. On 11/13/2025, between 9:15am - 1:21 pm, the Department interviewed 9 staff regarding the allegation. 7 of 9 staff denied the allegation and stated upon the call light going off, caregiver are radio over the walkie-talkies to assist the residents and also resident are changed every 2-3 hours or upon the residents’ request. 2 of 9 staff did not confirm nor deny the allegation but stated at time sometimes when the facility is short staff it does affect how quickly the resident receive diapering care needs. On 11/13/2025, between 8:29am- 2:00pm, the Department interviewed 10 residents regarding the allegation. 2 of 10 residents denied the allegation and stated that they are in fact incontinent but expressed the staff check and change them, once in the morning and once in the night or 3 times in the afternoon and 2 times in the middle of the night. 7 of 10 residents did not confirm nor deny and state that they are not wearing diapers because they are not incontinent 1 of 10 residents had no knowledge of the allegation and stated no comment at the time of the interview. On 12/16/2025, between 1:30pm -2:30pm, the Department conducted a records review and observed the following: The facility has 35 incontinent residents. According to incontinence logs for September through November 2025, 33 residents received incontinence care, including bowel movements, toileting, supervised toileting for safety, showers, wet or dry briefs, or care was refused. Care was documented at various times throughout the day and night, ranging from overnight (NOC) to hourly intervals between 1:00am and 11:00pm Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff are not adequately trained. It was alleged that there are many staff members who are not trained. On 11/13/2025, between the hours of 11:12am - 11:22am, LPA interviewed A1, who denied the allegation and stated that in-service training for staff is conducted once a month, and this month's training will address fall risk. On11/13/2025 between 9:15am - 1:21pm, the Department interviewed 9 staff regarding the allegation. 9 of 9 staff denied the allegation and stated they receive in-service training on a regular basis. On 11/13/2025, between 8:20am - 2:00pm, the Department 10 residents: 8 of 10 residents denied the allegation and stated the staff know what they are doing when helping residents and have not noticed a difference between newer staff and those who currently work or formerly worked at the facility. 2 of 10 residents did not confirm nor deny the allegation; R6 stated "no comment," while R8 stated doesn't think much about it because they don't know which staff are new and that does not involve them. On 12/16/2025, between 8:35am - 11:15am, the Department conducted a records review and observed that the facility conducted twenty-nine (29) in-service trainings between January 28, 2025 and September 29, 2025. Each training included a sign-in sheet acknowledging staff participation and understanding of the material presented. Topics covered during these training included new employee orientation; sexual harassment (1 hour); workplace violence (1 hour); injury and illness prevention; bloodborne pathogens (30 minutes); missing resident response procedures; dementia and memory care practices (5 hours); activities of daily living and personal care; medication administration; infection control (3 hours); residents’ rights and mandated reporting; fall and elopement safety; housekeeping and food safety practices; activity programming; customer service (3 hours); and applicable facility policies and procedures. On 05/18/2026, between 11:00am -12:00pm, the Department conducted an additional records review (requested training on multiple dates such as 04/03, 04/17, 05/13) of personnel files for A1 and S1–S10 which included training certificates, medication training documentation, shadow training logs, and facility in-service sign-in sheets. The review revealed that all eleven (11) staff had completed the required New Employee 20-Hour Training, with completion dates ranging from 2021–2025. Nine (9) staff had current Sexual Harassment Prevention Training, and six (6) staff completed Workplace Violence Prevention Training in 2024–2025. Four (4) staff completed the 8-hour Medication Technician Training, and three (3) staff completed the full Basic Medication Training Course supported by 16-hour medication shadow-training logs documenting instruction in medication ordering, storage, documentation, medication passing, refusal procedures, and communication. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff do not ensure that resident's with special dietary needs are adequately fed It was alleged that residents who require a special diet are not accommodated. On 11/13/2025 between the hours of 11:12am - 11:22am, the Department interviewed A1 denied the allegation and stated that residents with special diets or food allergies are identified on a list created by the front desk, which is posted in the kitchen. A1 also stated that if a resident cannot eat what is being served, an alternative menu is offered. However, if the resident does not want anything from the alternative menu, the facility will ask the resident what they prefer and will try to accommodate their request as much as possible. Between 9:15am - 1:21 pm, the Department interviewed 10 staff: 10 of 10 staff denied the allegation and stated the facility has documentation such a binder on file and the whiteboard located in the kitchen which list the residents special diets and food allergies. Staff also states the facility has other options such as sandwich, chicken, yogurt , Jello, rice pudding and fruit as alternative food. Between 8:29am - 2:00pm, the Department interviewed 10 residents: 1 of 10 residents confirmed the allegation and stated the facility does not handle their dietary preferences at all with no healthy alternative options provided as a result of purchasing their own food for the last two years. 8 of 10 residents denied the allegation and stated not asking for something specific and did not experience being served food they couldn't eat. 1 of 10 resident did not confirm nor deny the allegation and stated being allergic but the facility doesn't give them avocados. However one time the resident was served veal and can't eat veal. On 11/26/2026 between the hours of 11:16am - 11:25am, the Department conducted a record review a observed the following: Resident 1 (R1) LIC 602A Physicians Report for Residential Care Facilities for the Elderly (RCFE) - (dated 07/27/2023 page 3 of 6 states under the physical health status e. special diet is checked no. Also, the GPLB Resident Summary Sheet (spreadsheet), stated that the facility requested Resident 1 (R1) Physician Report on 08/19/2025. Resident 1 (R1) provided a Rx from Vannarith So, MD Internal Medicine (dated 12/21/2023) states patient (R1) is lactose intolerance, intolerance to bell pepper and allergic to bleach. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Catherine Dacara (Assistant Administrator) and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 20, 2026 · control 11-AS-20251104162513

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 3, 2026

Incidental Medical & Dental Care (a) A plan for incidental medical care shall be developed by each facility. The plan shall encourage routine medical care & assist in obtaining care, by compliance with..: (4) the licensee shall assist residents with self-administered medication as needed This requirement was not met as evidenced by interviews, observations, and record review showing medications for R1, R5, and R9 were not administered as prescribed. However, LPA observed medications not given but signed out, posing a health and safety risk to residents.the state’s words, verbatim · CDSS document, May 20, 2026

Plan of correction: The Administrator will have a licensed Pharmacist provide additional medication training for all the medtech and the LVN will conduct daily audits for Medication Administration for the next 30 days. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

Allegation investigated: Facility staff mismanage residents’ medications.

On 05/13/2026 at 8:15am, the Department conducted an subsequent visit to deliver the investigation findings at this facility for the allegation listed above. During today’s visit, the department met with Catherine Dacara (Assistant Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 04/07/2026 between the hours of 8:40am - 1:33pm, the Department interviewed Administrator (A1), Staff (S1 - S5), Residents (R1 - R10). The department also requested and obtained the following documents: Staff Roster (dated 03/19/2026), Resident Roster (dated 04/06/2026), Employee Schedule (dated 03/29/2026 - 04/04/2026), Visitor Log (dated 04/02/2026),2 Resident Records for R1 & R2 which include: LIC 601: Identification & Emergency Information (R1 dated 03/09/2026 & R2 dated 02/26/2025), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (R1 dated 08/21/2025 & R2 dated 02/07/2025), LIC 603: Preplacement Appraisal Information (R1 dated 08/27/2025 & R2 dated 02/07/2025), Admission Agreement (R1 dated 09/19/2025 & R2 dated 02/28/2025, R1's New Resident Account Set Up (dated 09/19/2025) . .Report continues on LIC 9099-C Substantiated R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) . The investigation revealed the following: Allegation: Facility staff mismanage residents’ medications. It was alleged that residents’ medications were not administered as prescribed and that documentation was incomplete. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated med-techs assist with self-administered medications when LVNs are unavailable. A1 reported not being aware of any missed doses or medication errors. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Four (4) out of five (5) staff denied the allegation. One (1) staff was unaware. Staff reported they were not aware of missed doses and stated they notify the med-tech or charge nurse if unable to administer medications. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents confirmed the allegation. One (1) out ten (1) resident was unsure of the allegation. Eight (8) out of ten (10) denied the allegation. One resident reported missed doses; another resident was unsure of their medication management. On 05/13/2026 between the hours of 10:10am – 11:00am, the Department conducted a records review of the April and May 2026 Medication Administration Records (MARs) and observed multiple missing staff initials indicating undocumented medication administration for several residents. The Department also observed medications remaining inside bubble packs despite being initialed as administered. Missing initials were noted for daily medications which include, diabetic medications, antihypertensives, anticoagulants, and ophthalmic treatments. These discrepancies were observed for multiple residents on multiple dates, and no documentation was found to explain the missing initials or unadministered medications. Based on the Department's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights. R1's LIC 9172 Functional Capability Assessment (dated 08/27/2025), R1's Concise Care Group (dated 08/06/2025), R1's Patient Chart (not dated), Besht Wellness (dated 03/05/2026), R1's Appraisal/Need & Service Plan (dated 12/19/2025), R1's Invoice for Monthly Room Charge (September 2025 -April 2026) R2's Internal Resident Incident Report (dated 09/26/2025) and R1's & R2's ALl Order Administered/ Medication List (January 2026- June 2026) . The Investigation revealed the following Allegation: Facility staff do not ensure that residents’ toileting needs are met. It was alleged that residents were not receiving timely assistance with toileting and incontinence care due to chronic understaffing, resulting in delays in responding to care needs and insufficient break coverage. On 04/07/2026 between the hours of 8:40am - 8:52am, the Department interviewed A1 in regards to the allegation. A1 denied the allegation, stated not being informed of any resident left soiled or any staff refusing assistance due to being on break. A1 explained that the facility uses a break schedule to ensure coverage and stated not being present during the reported incident and did not receive follow-up information. On 04/07/2026 between the hours of 11:55am - 1:33pm, the Department interviewed 5 staff regarding the allegation. five (5) staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they had not observed a resident left soiled, had not refused assistance due to being on break, and stated that another caregiver is assigned to provide coverage when a staff member is on break. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents was aware of the allegation. Nine (9) out of ten (10) residents denied the allegation. Residents reported they independently manage toileting or receive timely assistance. One resident reported a single instance where staff stated they were on break in regards to the delay in responding to care needs. On 05/13/2026 between the hours of 10am - 11am, the Department conducted a records review of resident assessments and facility documentation and did not observe any records indicating unmet toileting needs or delays in incontinence care. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Facility staff did not treat residents with dignity and respect. It was alleged that staff entered rooms without knocking, spoke rudely to residents, and refused to provide their names. On 04/07/2026 between the hours of 8:40am – 8:52am the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated not being informed of any staff entering rooms without knocking, speaking rudely to residents, or refusing to provide their names. A1 stated staff are required to knock before entering rooms and provide their names when asked, and A1 did not receive any complaints regarding disrespectful conduct. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they knock before entering resident rooms, do not speak to residents in a rude manner, and provide their names when requested. Staff stated they were not aware of any incidents involving rude tone or refusal to identify themselves. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. Two (2) of ten (10) residents confirmed the allegation. Eight (8) of ten (10) residents denied the allegation. Two residents reported incidents involving rude tone or failure to knock; the remaining residents reported staff knock before entering and treat them respectfully. On 05/13/2026 between the hours of 10:00 AM – 11:00 AM, the Department conducted a records review of facility policies, resident rights documentation, and internal records and did not observe any documentation indicating staff failed to treat residents with dignity or respect. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Facility staff do not ensure residents’ medical needs are being met. It was alleged that residents were not receiving ordered physical therapy or medical services. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated not being aware of any resident failing to receive ordered physical therapy or medical services. A1 stated the facility follows up with therapy providers when services are missed and had not received reports of unmet medical needs. On 04/07/2026 between the hours of 11:55am – 1:33pm, the Department interviewed five (5) staff regarding the allegation. Four (4) out of five (5) staff denied the allegation. One (1) out of five (5) staff was unaware of the allegation. Staff reported they had not observed residents missing medical services and stated they notify the LVN or med-tech when residents report concerns. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents confirmed the allegation. Nine (9) of ten (10) residents denied the allegation. One resident reported not receiving physical therapy; other residents reported receiving medical services as ordered or stated delays were due to insurance authorization rather than facility action. On 05/13/2026 between the hours of 10:00am – 11:00am, the Department conducted a records review of LIC 602s, LIC 603s, and medical documentation and did not observe any records indicating missed medical services or lack of follow up by the facility. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff do not ensure food served is of good quality. It was alleged that the food served to residents was of poor quality and did not meet nutritional needs, and that inadequate staffing and oversight contributed to inconsistent meal preparation and insufficient attention to dietary requirements. On 04/07/2026 between the hours of 8:40am – 8:52am, the Department interviewed A1 regarding the allegation. A1 denied the allegation and stated menus are created monthly and reviewed for nutritional adequacy. A1 reported not receiving complaints regarding food quality. On 04/07/2026 between the hours of 11:55am – 1:33 pm, the Department interviewed five (5) staff regarding the allegation. Five (5) out of five (5) staff denied the allegation. Staff reported they had not received complaints regarding food quality and stated meals are prepared according to posted menus. On 04/07/2026 between the hours of 9:00am – 11:52am, the Department interviewed ten (10) residents regarding the allegation. One (1) of ten (10) residents confirmed the allegation. Nine (9) of ten (10) residents denied the allegation. One resident reported dissatisfaction with food quality; other residents reported meals were satisfactory. On 05/13/2026 between the hours of 10:00am – 11:00am, the Department conducted a records review of the facility’s posted Spring 2026 menus for Weeks 1, 3, and 4. The Department observed that the menus were dated, organized, and reflected balanced meals including proteins, vegetables, starches, fruits, and desserts. Breakfast menus included hot cereals, eggs, pancakes, and juice options. Lunch and dinner menus included soups, salads, meats, vegetables, and desserts. The Department observed that the menus aligned with the facility’s Admission Agreement requirement to provide three nutritious meals daily and accommodate special diets. No documentation was found indicating that meals served failed to meet nutritional standards or that residents were served food inconsistent with posted menus or dietary requirements. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Catherine Dacara and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 13, 2026 · control 11-AS-20260403094947

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 6, 2026

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medication as needed Based on observation and record review: The Department observed medications remaining inside bubble packs despite being initialed as administered and or not being initialed on the MAR which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: The Administrator will arrange an in‑service medication‑management training with the facility’s contracted pharmacy for all medication‑assisting staff. Training will include proper MAR documentation and ensuring medications are initialed at the time of administration. The Administrator will submit proof of completed pharmacy in-service training to the Department by the due date.

Allegation investigated: Staff does not treat resident with dignity or respect. Staff does not accord resident privacy in the restroom.

On May 13, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted an initial unannounced complaint visit. Catherine Dacara, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegations mentioned above. The investigation included interviews, inspection of the facility, and a collection of documents. A review of Personnel Report LIC 500 (dated 05/01/26), Register of Faciltiy Residents Roster (dated 04/06/26), Admission Agreement, (dated 08/01/24), Identification and Emergency Information (dated 09/18/24), Physicians Report LIC 602A (dated 04/10/26), Resident Appraisal LIC 603A (dated 05/30/22) and other pertinent records associated with this complaint. Interviews conducted with Resident #1 - #10 (R1-R10), and Staff #1- #7 (S1-S7) and an inspection of (R1's) room #220. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff does not treat resident with dignity or respect. Allegation #2: Staff does not accord resident privacy in the restroom. The complaint alleges that the staff does not treat Resident #1 (R1) with the dignity, respect, and privacy (R1) deserve while in care. Reports indicate that staff members, specifically Staff #5 (S5) and Staff #6 (S6), harassed (R1) by yelling profanities at them in front of other residents during an incident. Furthermore, there are concerns about (R1's) privacy being violated by Staff #7 (S7), who entered (R1's) room while (R1) was in the bathroom, failing to provide adequate privacy. It has also been reported that (S7) spoke harshly about (R1) in (S7's) native language. These concerns have been brought to the management's attention, but no action has been taken to address the behavior. No additional details regarding this matter are provided. Resident #1 (R1) was admitted to Glen Park in Long Beach on October 25, 2022, based on the facility’s Admissions Agreement (dated 08/01/24). (R1) is responsible for self-admission to this facility. On May 11, 2026, and May 12, 2026, between 11:20 AM and 03:40 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Nine (9) out of the ten (10) residents could not support both claims. (R2-R10) were complimentary of all staff, including Staff #5 (S5), Staff #6 (S6), and Staff #7 (S7). All of them stated that they are treated with dignity and respect; no employee has ever addressed them disrespectfully. Furthermore, the staff honors residents' privacy by announcing their arrival before entering a resident's room and will only enter with the resident's permission. (R1) had concerns about how (S5), (S6), and (S7) addressed (R1) during recent incidents on March 28, 2026, and April 15, 2026. In both occurrences, (R1)’s rights were breached when (S5), (S6), and (S7) displayed disrespectful behavior and used offensive language while making derogatory remarks about (R1). (R1) claims that these concerns were raised with management, but notes that no action has been taken. On May 11, 2026, May 12, 2026, and May 13, 2026, between 09:45 AM and 3:59 PM, the Department interviewed staff members identified as Staff #1 through Staff #7 (S1-S7). Seven (7) out of seven (7) staff members could not validate this claim. Staff #5 (S5), Staff #6 (S6), and Staff #7(S7) all denied the allegations of violating (R1’s) rights, asserting that they never made any derogatory remarks to (R1). (Evaluation Report continues LIC 9099-C) They indicated that (R1) has exceptionally high expectations and is resistant to receiving guidance from any staff. This often leads to a shift from positive interactions to negative ones. Staff #7 (S7) specifically stated that the claim regarding (R1) intruding on privacy rights is false; the incident never occurred. Staff #3 (S3) indicated that management has implemented proactive steps regarding the incidents that occurred on March 28, 2026, and April 15, 2026. An internal inquiry was conducted, including analysis of surveillance footage from March 28, 2026. The inquiry found insufficient evidence to ascertain whether the staff had infringed on (R1’s) rights. A review of (R1’s) Admission Agreement (dated 08/01/24), Physicians Report LIC 602A (dated 07/27/23), and Resident Appraisal LIC 603A (dated 03/10/26), and Personal Rights LIC 613 (dated 08/01/24) revealed (R1's) medical diagnosis profoundly impacts (R1’s) thought processes and belief system, intricately shaping (R1) perspective and understanding. Further review of Internal Staff Incident Report (dated 03/30/26), Internal Resident Incident Repot (dated 03/28/26 and 04/15/26) confirmed that the facility had conduced internal investigation on both incidents. Additional review of (R1’s) Medication Orders (dated 05/12/26) (R1) is prescribed (18) medications and (9) out of the (18) have side effects of inducing manic symptoms, depression, fatigue, and disturbance (ref National Institute of Health). During the visit on May 11, 2026 through May 13, 2026, the Department identified that the facility promotes the rights and safety of its residents. Posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. Based on the information gathered, there is not enough evidence to support the allegations mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated. Exit interview conducted with Executive Director CATHERINE DACARA, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 13, 2026 · control 11-AS-20260504125345

Type of visit: Case Management - Deficiencies

On 05/13/2025 at 8;15am, the Department conducted an unannounced Case Management Deficiencies visit. During at 8:30 AM, the Department met with Catherine Dacara (Assistant Administrator) and explain the purpose of the visit. On 04/03/2026, upon the Department issuing a Technical Violation for 87465(a)(4) with a due date of 04/17/2026, the Department also requested that the facility submit employee training records from hire date to present by the end of the week of 04/03/2026 in relation to Complaint Control #11-AS-20251104162513. On 04/17/2026 at 5:55 PM, the Department received an email from the facility’s Assistant Administrator containing a PDF attachment titled Allegiance Valley Pharmacy Audited and Reviewed Medication Management Program Training dated 04/15/2026. On 05/11/2026 at 8:00am via email and on 05/13/2026 at 8:30am in person, the Department requested for staff training records from hire date to present related to Complaint Control #11-AS-20251104162513. The facility did not provide the requested documentation until 12:00 PM. Upon review, the training records submitted reflected training years 2021–2026, but did not include training records from previous employers for staff listed on the LIC 811, as requested As a result, according to the California Code of Regulations (Title 22, Division 6, Chapter 8) the facility did not comply with Title 22, Section 87412(f)(1), which states: All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. The facility failed to make provide personnel training records upon request in a timely manner An exit interview was conducted with Assistant Administrator Catherine Dacara. A copy of this report with appeal right were provided.the state’s words, verbatim · CDSS document, May 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(f)(1) · Plan of correction due date: May 13, 2026

Personnel Records: All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. . .information is otherwise readily available in another document or format. Based on observation and record review, the facility did not provide staff training upon request in a timely manner for staff from hire date to present. This posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 13, 2026

Plan of correction: Facility will submit all staff training records for the employees listed on the LIC811 from Complaint Control #11-AS-20251104162513. and submit the plan of correction by due date and email proof to LPA Brown at Zina.Brown@dss.ca.gov

Allegation investigated: Staff withheld resident's funds.

On May 12, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted a subsequent unannounced complaint visit. Anita Csukardi, Executive Director, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, inspection of the facility, and a collection of documents. A review of Personnel Report LIC 500 (dated 05/01/26), Register of Faciltiy Residents Roster (dated 04/06/26), Admission Agreement, (dated 06/30/26), Identification and Emergency Information (dated 02/17/26), Medical Assessment LIC 602A (dated 12/30/25), Resident Appraisal LIC 603A (dated 12/31/25) and other pertinent records associated with this complaint. Interviews conducted with Resident#1 through #10 (R1-R10), Staff #1 through Staff #3 (S1-S3) and Witness #1 (W1). (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff withheld resident's funds. The complaint alleges that the staff is withholding funds from Resident #1 (R1). It is reported that (R1) has a trust fund account intended for a family member, but the administrator has denied (R1) access to those funds. No additional details regarding this matter are provided. Resident #1 (R1) was admitted to Glen Park in Long Beach on January 22, 2026, based on the facility’s Admissions Agreement (dated 01/23/26). (R1) is responsible for self-admission to this facility. On May 11, 2026, between 11:20 AM and 01:00 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Nine (9) out of the ten (10) residents could not support this claim. Four (4) of the ten (10) are independent and can manage their own finances. Three (3) of the ten (10) have other family members handling their finances, while two (2) out of the ten (10) cannot manage their finances themselves. (R1) claimed to have an $11,000 trust fund that the facility is withholding. However, (R1) had no information or documentation regarding this trust fund. (R1) was unaware of the trust fund's origin and could not provide further details. The only information (R1) had was that there was a trust fund, and (R1) wanted to grant access to these funds to a family member. (R1) did not have legal documentation arranged that holds and manages assets—such as money, stocks, or real estate—for a beneficiary on behalf of a grantor, managed by a trustee. On May 11, 2026, between 09:45 AM and 01:30 PM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Two (2) out of (3) three staff members reported that (R1) has personal funds being managed by the facility. (S1) indicated that Glen Park serves as the payee for (R1’s) Supplemental Security Income (SSI). Basic services are paid directly to Glen Park, and any remaining funds are deposited into (R1’s) resident's account. Both (S1) and (S2) stated that since (R1) is self-responsible and does not have the power of attorney or conservator managing (R1’s) finances, Glen Park functions as the payee for (R1’s) (SSI). (S1) and (S2) stated that they informed (R1) that (R1) needed to complete a facility form to withdraw funds and for accounting tracking. This information may have led to (R1's) current misunderstanding of the situation. However, (S1-S3) were unaware of any issues regarding (R1's) lack of understanding of the process. (Evaluation Report continue LIC 9099-C) (S1) stated that the facility is not being defiant or refusing to provide (R1) with access to personal funds. The funds established by the facility are for any leftover money from (R1’s) (SSI) and Personal and Incidental (P&I) expenses, a term that (R1) does not understand. The management informed (R1) that a process exists: the Check Request form and the Payable Distribution Letter must be completed to distribute funds. On May 11, 2026, between 12:00 PM and 12:15 PM, the Department interviewed a family member identified as Witness #1 (W1). (W1) stated that (W1) was not aware of any trust account in the name of (R1). Furthermore, W1 mentioned that when family members passed away over 30 years ago, there was no trust account for (R1) that (W1) was aware of. A review of (R1’s) Admission Agreement (dated June 30, 2026), Identification and Emergency Information (dated 02/17/26), Medical Assessment LIC 602A (dated 12/30/25), and Resident Appraisal LIC 603A (dated 12/31/25) revealed that (R1) is self responsible but cannot manage their own financial resources. A copy of (R1’s) Record of Resident’s Safeguarded Cash Resources LIC 405 (dated 05/12/26) detailed the date, description, initial deposit, withdrawal, balance, signature, and transaction number, confirming that (R1) has a trust account with a positive balance. Further review of the facility's Check Request form (dated 05/12/26) and Payable Distribution Letter confirmed that the facility has a process in place that must be followed to access (R1's) finances. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. An exit interview was conducted with Anita Csukardi, and copies of the reports were provided.the state’s words, verbatim · CDSS document, May 12, 2026 · control 11-AS-20260507123904

Allegation investigated: Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. Staff does not ensure resident's hygienic care needs are met. Staff does not ensure resident's incontinence care needs are met. Staff did not allow resident back to facility after hospital stay.

On 04/24/2026, at 11:00am, the department conducted a subsequent complaint visit to the facility and was greeted by Ace Huynh, Executive Director, and Cathrine Dacara, Assistant Administrator. The department explained the purpose of this visit was to gather information about the complaint, interview staff and residents, and deliver findings for the allegations mentioned above. The investigation consisted of the following: On 04/01/2026, the department conducted an initial complaint visit to gather facility files. On 04/24/2026 from 11:00am-2:00pm, the department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4) and residents (R1-R10). The department received the following documents: Staff Roster (Dated: 03/19/2026), Resident Roster (Dated: 03/25/2026), Identification & Emergency Information (Dated: 02/02/2026), Physician Report (Dated: 12/08/2025), Preplacement Appraisal Information (Dated 02/02/2026), Needs & Service Appraisal (Dated: 04/01/2026), Admission Agreement (Dated 02/02/2026), Shower Schedule (Last Updated 03/06/2026), Shower Log (for March 2026) and Internal Resident Incident Reports (Dated: 03/12/2026, 03/23/2026 & 03/25/2026).... Report Continued On LIC9099-C Unsubstantiated On 4/24/2026, from 11:00am-2:00pm, the department interviewed staff (S1-S4) regarding the allegation. 4 of 4 staff denied the allegation that Staff did not allow resident back to facility after hospital stay. Staff (S1) stated that the family member of the resident came on 03/24/2026 to take the resident to the hospital for evaluation and never brought the resident back to the facility. S1 also stated on that day, the family member removed all of the residents’ belongings from the facility. S1 further stated that there wasn’t a valid reason that the resident could not return to the facility, and no one said otherwise. S2-S4 stated that they had no knowledge of a reason that the resident would not be allowed to return to the facility. Based on interviews conducted, there is insufficient evidence to support the allegation that Staff did not allow resident back to facility after hospital stay. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No citations were issued for this complaint investigation. An exit interview was conducted with Ace Huynh, Executive Director, and a hard copy of this Complaint Investigation Report was provided. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that the facility staff does ensure that their hygiene needs are met but added that they are primarily independent and care for their own needs. The department reviewed the Needs & Service Appraisal (Dated: 04/01/2026), Physician Report (Dated: 12/08/2025), and Shower Log (for March 2026) and observed that the resident was able to bathe, dress, groom, and care for their toileting needs by themselves without assistance. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that Staff does not ensure resident's hygienic care needs are met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #3- Staff does not ensure resident's incontinence care needs are met. The details of the complaint alleged that the facility staff did not ensure the residents’ incontinent care needs were met. On 4/24/2026, from 11:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that Staff does not ensure resident's incontinence care needs are met. All staff stated that the residents’ needs were being met. 3 of 4 staff denied the resident needed incontinence care while 1 staff said they needed some assistance sometime but could generally care for their own toileting needs. The department interviewed residents (R1-R10) about the allegation and 9 of 10 residents that were interviewed stated that the staff does ensure that their care needs are being met. The department reviewed the Needs & Service Appraisal (Dated: 04/01/2026), and Physician Report (Dated: 12/08/2025) and observed that the resident was able to care for their toileting needs by themselves without assistance. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that Staff does not ensure resident's incontinence care needs are met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #4- Staff did not allow resident back to facility after hospital stay. The details of the complaint alleged that the facility did not allow resident back after hospital stay. It was reported that the family member of the resident did not want to return the resident to the facility because they didn’t think the resident was properly cared for. Report Continued On LIC9099-C and Medication Administration Record (Dated: February 2026 - March 2026) from the facility. The investigation revealed the following: Allegation #1- Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. The details of the complaint alleged that the resident had two unwitnessed falls, with no injuries in the facility. It was reported that the staff did not provide adequate supervision for the resident. On 4/24/2026, from 11:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 4 of 4 staff denied the allegation that Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. All staff stated that they do provide adequate supervision for the residents in the facility. Staff also stated that there is a call button in each resident’s room that they can push if they need assistance or are having trouble walking. They further stated that the residents are checked on frequently throughout the day and night. The department interviewed residents (R1-R10) about the allegation and 8 of 10 residents that were interviewed stated that they believe the staff does provide adequate care and supervision for the residents in the facility. Those residents further stated that they are satisfied with the care and supervision and feel safe living in the facility. The department reviewed Internal Resident Incident Reports (Dated: 03/12/2026, 03/23/2026 & 03/25/2026) and Staff Roster (Dated: 03/19/2026) and observed that the incidents were documented and reported and that the facility has sufficient staff to provide adequate supervision to the residents. The department also reviewed the Physician Report (Dated: 12/08/2025) and observed the resident had no motor impairments or paralysis. Based on interviews conducted and records reviewed, there is insufficient evidence to support the allegation that Staff did not provide adequate supervision, resulting in resident sustaining multiple unwitnessed falls. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #2- Staff does not ensure resident's hygienic care needs are met. The details of the complaint alleged that the facility staff did not ensure the residents’ hygiene care needs were met. On 4/24/2026, from 11:00am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R10) regarding the allegation. 3 of 4 staff denied the allegation that Staff does not ensure resident's hygienic care needs are met. The majority of the staff stated that the residents’ hygienic care needs were being met. Staff further stated that the resident was able to care for their own hygiene needs with little assistance from the staff. While 1 staff stated that the resident did require some assistance and would often refuse and get agitated if they tried to assist them. Report Continued On LIC9099-Cthe state’s words, verbatim · CDSS document, Apr 24, 2026 · control 11-AS-20260325144642

Allegation investigated: Facility illegally evicted a resident in care.

On 4/23/2026, at 9:30am, the department conducted an initial complaint visit to the facility and was greeted by Ace Huynh, Executive Director, and Cathrine Dacara, Assistant Administrator. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff and resident, and deliver findings regarding the allegation mentioned above. The investigation consisted of the following: The department investigated the allegation mentioned in this complaint and conducted interviews with staff (S1-S3) and witness (W1). The department received the following documents: Resident Roster (Date: 03/02/2026), Staff Roster (Dated: 04/22/2026), ID Emergency Information (Dated: 04/25/2024), Physician’s Report (Dated: 04/30/2025), Admission Agreement (Dated: 04/25/2024), and Resident Appraisal (Dated: 04/25/2024) from the facility. The investigation revealed the following: Allegation- Facility illegally evicted a resident in care. Report Continued On LIC9099-C Unsubstantiated The details of the complaint alleged that the resident went to the hospital and that the facility would not allow the resident to return due to the resident needing to use a Continuous Positive Airway Pressure (CPAP) machine used for Chronic Obstructive Pulmonary Disease (COPD). It was reported that the facility is evicting the resident and discriminating against the resident because of the diagnosis. On 4/23/26, from 9:30am-12:00pm, the department interviewed staff (S1-S3) and witness (W1) regarding the allegation. 3 of 3 staff denied the allegation that the Facility illegally evicted a resident in care. All staff stated that the facility has not issued an eviction notice nor is the resident being evicted. They all state that the resident went into the hospital because they were having breathing problems. While at the hospital the resident was prescribed a Bilevel Positive Airway Pressure (BIPAP) machine which assists with breathing by delivering, via a mask, higher air pressure during inhalation and lower pressure during exhalation. S2 stated that according to the residents’ Physicians Report they can’t manage their own medication, treatment, or equipment and that is why they have not accepted the resident back. S2 stated that once the resident no longer needs the equipment they are welcomed to come back to the facility. The department interviewed witness (W1) about the allegation and (W1) stated that they were informed that the resident would not be able to come back to the facility while they were using the BIPAP machine because their Physicians report stated they could not manage the machine on their own. The department asked if the resident or (W1) has received an eviction notice written or verbal, they stated they have not. The department reviewed the Physician’s Report (Dated: 04/30/2025) and observed that the report states the patient cannot manage their own treatment, medication, or equipment (page 2 Physicians Report). The department reviewed the facility records for the resident and did not observe an eviction notice or eviction notes for the resident. Based on interviews and records that were reviewed, there is insufficient evidence to support the allegation that the Facility illegally evicted a resident in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were found and no citations were issued for this complaint investigation. An exit interview was conducted with Ace Huynh, Executive Director, and a hard copy of this Complaint Investigation Report was provided.the state’s words, verbatim · CDSS document, Apr 24, 2026 · control 11-AS-20260416134102

Allegation investigated: Staff does not prevent resident from smoking inside the facility.

*This report does not supersede the previous report dated 10/24/2025 but is used to clarify findings*. On 04/23/2026 at approximately 01:40 PM Licensing Program Analyst (LPA) Troy Watson made a subsequent unannounced visit to deliver findings to the facility listed above. LPA Watson was greeted by the Assistant Administrator, Catherine Dacara, and explained the purpose of the visit. LPA was granted entry into the facility. The investigation consisted of the following:On 10/24/2025 between 08:01 AM – 04:56 PM the department requested, obtained, and reviewed the following documents: Resident Roster (10/08/25), Staff Roster (10/01/25), Smoking Policy (01/18/23), Staff Schedule (10/19/25 – 10/25/25), Unusual Incident Report (10/09/25 – 10/10/25) CONTINUED ON LIC9099-C Unsubstantiated Psychiatric Emergency Team Assessment (10/10/25), and Placement for Evaluation and Treatment documentation (10/10/25). On 10/24/2025 between 08:01 AM – 04:56 PM the department conducted interviews with Staff #1 – #5 (S1–S5) and Resident #2 – #11 (R2–R11). An attempt to interview Resident #1 (R1) was made, but the resident was no longer at the facility and could not be contacted. LPA Watson toured the facility with the Assistant Administrator, Catherine Dacara, and found the facility clean and in good repair. The investigation revealed the following: Allegation: Staff do not prevent residents from smoking inside the facility. It was alleged that staff failed to prevent residents from smoking inside the facility, resulting in R1 reportedly igniting their shirt while smoking in their bedroom, creating a fire hazard and risk of injury. On 10/24/2025 between 08:01 AM – 04:56 PM LPA Watson interviewed Staff #1 – #5 (S1–S5). Out of those interviewed, 5 out of 5 staff denied the above allegation. On 10/24/2025 LPA Watson interviewed Residents #2 – #11 (R2–R11). Out of those interviewed, 10 out of 10 denied the above allegation. On 10/24/2025 between 08:01 AM – 04:56 PM the department conducted an interview with the Assistant Administrator, Catherine Dacara (S1), and they were asked the question: does staff prevent residents from smoking inside the facility? S1 answered that residents and staff are not permitted to smoke inside the facility, and that a designated smoking patio outside the facility is provided for this purpose. The facility enforces its posted house rules prohibiting smoking on the premises, and staff assist residents by holding their cigarettes to ensure compliance and safety. LPA Watson reviewed the Smoking Policy records, and it showed on pg. 1, section 8, under Procedures that “There will be designated times for supervised smoking set by the administration.” A review of the Unusual Incident Report dated 10/09/25 – 10/10/25 revealed that R1 was witnessed on 10/09/25 at approximately 7:00 AM trying to set his shirt on fire using a lighter and attempted to put it out with a broom, causing heavy smoke inside his room. Further review of the Unusual Incident Report also showed that R1 told staff fireworks were shot into his room and caused the smoke, but there was no evidence or proof of fireworks being recovered from that incident. The Department reviewed R1’s file and did not find any other similar incidents. CONTINUED ON LIC9099-C Based on record reviews, staff and client interviews, and observations, there is insufficient evidence to support the allegation: “Staff do not prevent residents from smoking inside the facility.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. An exit interview was conducted with the Assistant Administrator, Catherine Dacara, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 11-AS-20251017130143

Allegation investigated: Staff does not prevent resident from smoking inside the facility.

*This report does not supersede the previous report dated 10/24/2025 but is used to clarify findings. * On 02/11/2026 at approximately 1:02 PM Licensing Program Analyst (LPA) Troy Watson made a subsequent unannounced visit to the facility listed above. LPA Watson was greeted by the Assistant Administrator Catherine Dacara and explained the purpose of the visit. LPA was granted entry into the facility. The investigation consisted of the following: On 10/24/2025 between 08:01 AM – 04:56 PM the department requested, obtained, and reviewed the following documents: Resident Roster (10/08/25), Staff Roster (10/01/25), Smoking Policy (01/18/23), Staff Schedule (10/19/25 – 10/25/25), Unusual Incident Report (10/09/25 – 10/10/25), CONTINUED IN LIC9099-C Unsubstantiated Psychiatric Emergency Team Assessment (10/10/25), and Placement for Evaluation and Treatment documentation (10/10/25). On 10/24/2025 between 08:01 AM – 04:56 PM the department conducted interviews with Staff #1 – #5 (S1–S5) and Resident #2 – #11 (R2–R11). An attempt to interview Resident #1 (R1) was made, but the resident was no longer at the facility and could not be contacted. LPA Watson toured the facility with the Assistant Administrator, Catherine Dacara, and found the facility clean and in good repair. The investigation revealed the following: Allegation: Staff do not prevent residents from smoking inside the facility. It was alleged that staff failed to prevent residents from smoking inside the facility, resulting in R1 reportedly igniting their shirt while smoking in their bedroom, creating a fire hazard and risk of injury. On 10/24/2025 between 08:01 AM – 04:56 PM LPA Watson interviewed Staff #1 – #5 (S1–S5). Of those interviewed, 5 out of 5 staff denied the above allegation. On 10/24/2025 LPA Watson interviewed Residents #2 – #11 (R2–R11). Of those interviewed, 10 out of 10 denied the above allegation. On 10/24/2025 between 08:01 AM – 04:56 PM the department conducted an interview with the Assistant Administrator, Catherine Dacara (S1) and they were asked the question, does staff prevent residents from smoking inside the facility? S1 answered that residents and staff are not permitted to smoke inside the facility, and that a designated smoking patio outside the facility is provided for this purpose. The facility enforces its posted house rules prohibiting smoking on the premises, and staff assist residents by holding their cigarettes to ensure compliance and safety. LPA Watson reviewed the Smoking Policy records, and it showed on pg. 1, section 8, under Procedures that “There will be designated times for supervised smoking set by the administration.” A review of the Unusual Incident Report dated 10/09/25 – 10/10/25 revealed that R1 was witnessed on 10/09/25 at approximately 7:00 AM trying to set his shirt on fire using a lighter and attempted to put it out with a broom, causing heavy smoke inside his room. Further review of the Unusual Incident Report also showed that R1 told staff fireworks shot into his room and caused the smoke, but there was no evidence or proof of fireworks being recovered from that incident. The Department reviewed R1;s file and did not find any other similar incidents. CONTINUED ON LIC9099-C Based on record reviews, staff and client interviews, and observations, there is insufficient evidence to support the allegation: “Staff do not prevent residents from smoking inside the facility.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. An exit interview was conducted with the Assistant Administrator, Catherine Dacara and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 22, 2026 · control 11-AS-20251017130143

Type of visit: Case Management - Incident

On 04/03/2025 at 9:10 am, the Department conducted an unannounced case management incident visit. The department met with Catherine Dacara (Administrator) and Ace Huynh (Executive Director) and explained the purpose of the visit. On 03/20/2026 at 3:58 pm., On Duty Office of the Day LPA Gibbs received a telephone call from Administrator Catherine Dacara, who reported that medications were missing from the facility’s medication room and noted a Medtech is suspected of involvement. LPA Gibbs requested that an incident report be faxed to the Department. The department received the LIC 624 Unusual Incident/Injury Report (dated 03/13/2026) on March 20, 2026 at 10:05pm. On 04/03/2026 between the hours of 9:25am - 9:30am, the Department reviewed a copy of the LIC 624 Unusual Incident/Injury Report (dated 03/13/2026) which states the following at around 2:16pm, the Staff 1 (S1) who is a LVN received a text message from Staff 2 (S2) who is a medtech mentioned PRN Oxycodone is missing for Resident 1 (R1). When S1 spoke with Staff 3 (S3) who is also a medtech from the previous shift, mentioned to S1 that medicine was placed in the NARC box. R1 was informed along with Welbe Pace. On 04/03/2026 between the hours of 10:45am - 11:41am, the department conducted a medication review for 7 residents & observed the following: the department did not discover any missing medication. Due to insufficient information available at this time, the case management incidents needs further investigation. An exit interview was conducted with Catherine Dacara (Administrator) and a copy of this report with a technical violation was provided.the state’s words, verbatim · CDSS document, Apr 3, 2026

Allegation investigated: Facility did not maintain a safe and healthful environment for the resident.

On 03/18/2026, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced complaint visit. LPA met with Administrator Catherine Dacara. The investigation consisted of the following: On 03/18/2026, LPA Anguiano interviewed 14 residents (R1–R14) and 5 staff (S1–S5), conducted observations, and collected records. Records obtained included internal incident reports for R1 and R2, an LIC 500 dated 03/12/2026, staff roster, resident roster dated 03/05/2026, and an internal resident incident report for R5 with documentation of a house rules reminder provided. LPA also reviewed four resident files (S1–S4), including admission agreements, physician’s reports, and appraisal/reappraisal documents. The investigation revealed the following: Observations revealed that residents were observed in their rooms and common areas, and the facility appeared calm, with most residents engaging appropriately. Please see (LIC9099-C) for report continuation. Substantiated No active conflict was observed at the time of the visit. Records review revealed the following: Records for R1 indicate a diagnosis of end-stage renal failure requiring ongoing dialysis treatment and that R1 requires assistance with activities of daily living and supervision, including night supervision. Records for R2 indicate physical impairment requiring assistance with activities of daily living. LPA reviewed internal incident reports dated 03/12/2026 and 03/13/2026 documenting complaints regarding loud television use and roommate conflict between R1 and R2. Documentation indicates that R1 reported an inability to sleep due to the volume of the television, and staff provided reminders to R2 regarding house rules, including lowering the volume and using headphones at night. However, the facility did not provide additional requested documentation, including behavior logs, complaint logs, or records demonstrating ongoing monitoring, follow-up actions, or resolution of the roommate conflict. Records reviewed support the allegation, as the documentation confirms the reported concern and demonstrates that interventions were limited to reminders, without evidence of effective resolution, despite the resident’s medical condition requiring adequate rest and supervision. Regarding the allegation, “Facility did not maintain a safe and healthful environment for the resident,” it is being alleged that a resident was subjected to ongoing roommate conflict, including noise disturbances, lack of shared space access, and disruption of sleep, and that staff failed to ensure effective resolution of the situation. Interviews conducted revealed the following: Four residents (R1–R4) reported concerns supporting the allegation, while 10 out of 14 residents reported no concerns. Residents who reported concerns described ongoing roommate conflict involving loud television use at night, lack of respect, and misuse of shared space, as well as feeling unsafe due to roommate conflict and experiencing ongoing issues involving noise, hygiene concerns, and unresolved conflict lasting approximately six months. Interviews with 5 staff (S1–S5) supported the allegation, as staff confirmed that the roommate conflict between R1 and R2 has been ongoing for several months. Staff reported that R1 requires rest due to dialysis treatment, while R2 maintains a conflicting sleep schedule and uses the television at a high volume. Staff further reported that incident reports were completed and the issue was brought to administration, and that staff attempted verbal interventions such as reminders and mediation. S1 reported addressing the concern by counseling the resident, reviewing house rules, and offering a room change; however, both residents declined relocation, and the issue remained ongoing at the time of the investigation. Additional statements indicated that R1 may have difficulty reporting concerns due to language barriers. Please see (LIC9099-C) for report continuation. Based on the evidence gathered, interviews conducted, observations, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation “Facility did not maintain a safe and healthful environment for the resident” is found to be substantiated. The facility identified the roommate conflict and implemented initial interventions; however, those actions were not effective, and the issue continued to impact the resident’s health and well-being. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87307(d)(2). A citation is being issued on the attached (LIC 9099D). An exit interview was conducted, and a copy of this report, along with appeal rights, was provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 11-AS-20260311163742

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(2) · Plan of correction due date: Apr 1, 2026

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Based on interviews, observations, and records review, the licensee failed to ensure a safe and healthful environment for R1, as the resident was subjected to ongoing roommate conflict, including noise disturbances and disruption of sleep, despite having a medical condition requiring dialysis and rest. Staff were aware of the issue for several months and completed incident reports; however, the facility failed to implement timely and effective corrective action to resolve the situation. This violation poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: PLAN OF CORRECTION (POC): Licensee agrees to submit a Plan of Correction to LPA Jose Anguiano by due date and emailed to: Jose.Anguiano@dss.ca.gov

Allegation investigated: Staff does not treat residents with dignity and respect. Staff do not accord resident privacy. Staff unable to communicate with resident due to language barrier.

On 03/09/2026 at 8:40am, Licensing Program Analyst (LPA) Zina Brown conducted an subsequent visit at this facility to deliver the complaint investigation findings for the allegations above. During today’s visit, LPA met with Wendy Wheeler (Retirement Counselor) and explained the purpose of the visit. The investigation consisted of the following: On 02/19/2026 at 8:21am, Licensing Program Analysts (LPA) Zina Brown conducted interviews with Administrator (A1), Staff (S1-S10) & Residents (R1-R10), between the hours of 8:31am - 1:00pm and requested the following documentation: Staff Roster (dated 01/26/2026), Resident Roster (dated 02/18/2026) , Resident 1's (R1), records such as Admission Agreement (dated 10/15/2019) LIC 601: Identification & Emergency Information (not dated), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (not dated) , LIC 603: Preplacement Appraisal Information (dated 10/03/2019), and Medication Administration Record (December 2025). Unsubstantiated The investigation consisted of the following: Allegation: Staff does not treat residents with dignity and respect It was alleged that facility staff does not treat residents with dignity and respect. During breakfast time one of the younger staff workers spoke to the resident in a disrespectful manner. On 02/19/2026 between the hours of 8:31am - 8:42am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and indicated that the facility has not recently received any complaints regarding how staff speak to residents. A1 stated having no knowledge of any incidents where staff spoke to residents in a disrespectful manner. A1 mentioned if a staff member speaks disrespectfully to a resident, the facility would first arrange for a 1-on-1 meeting with staff, second talk to the resident to listen to their concern, third provide training to all staff, fourth take disciplinary action, and fifth remove the staff from that unit as a change of face. On 02/19/2026 between the hours of 9:26am - 11:43am, LPA conducted 5 staff interviews regarding the allegation. 5 of 5 staff denied the allegation and indicated they have not received complaints from residents or their families about how staff speak to residents, are not aware of any incidents where staff spoke to residents in a disrespectful manner, and would report such incidents to the Administrator and complete an incident report. On 02/19/2026 between the hours of 12:28pm - 2:30pm, LPA conducted 10 resident interviews regarding the allegation. 3 of 10 residents confirmed the allegation and indicated staff do not speak to them nicely all the time, staff have spoken to them in a rude or disrespectful way a few times or every once in a blue moon or staff do not treat them with respect all the time, and they have witnessed or heard staff speak rudely to other residents. Of the 3 residents who confirmed the allegation ; 1 of the residents indicated they have seen staff speak rudely to other residents. 7 of 10 residents denied the allegation and indicated staff speak to them nicely, no staff member has ever spoken to them in a rude or disrespectful way, staff treat them with respect, and they have not seen staff speak rudely to other residents. On 02/27/2026, between the hours of 2:25pm - 2:30pm, The Department had not received nor had on file any LIC 624 Unusual Incident/Injury Report, nor any reports or notes that alleged a staff spoke to a resident in a disrespectful manner. Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff do not accord resident privacy It was alleged that facility staff do not accord residents privacy. A staff worker came into the resident's room without knocking, used their key, and walked right in. On 02/19/2026 between the hours of 8:31am - 8:42am, LPA interviewed A1 regarding the allegation. A1 denied the allegation and disclosed the facility's policy about entering residents' rooms requires staff to knock before entering, identify themselves, asking for permission first, and explain the purpose of entering the room. If the resident doesn't want staff to enter, then staff has to respect that. A1 stated always knocks before entering a resident's room all the time and identifying herself. A1 indicated never receiving any complaints about staff entering residents' rooms without knocking. A1 mentioned staff has received training on respecting residents' privacy. On 02/19/2026 between the hours of 9:26am -11:43am, LPA conducted 5 staff interviews regarding the allegation. 1 of 5 staff confirmed the allegation and disclosed entering a resident's room without knocking first which resident have made complaints about. 4 of 5 staff denied the allegation and indicated the facility's policy about entering residents' rooms is to always knock first before going in, they knock before entering a resident's room, they have not entered a resident's room without knocking first, and they have received training on respecting residents' privacy. On 02/19/2026 between the hours of 12:28pm - 2:30pm, LPA conducted 10 resident interviews regarding the allegation. 4 of 10 residents confirmed the allegation and indicated staff do not knock on their door before coming into their room or only occasionally, staff have walked into their room without knocking, and they do not feel they have privacy in their room. Of the four (4) residents who confirmed the allegation, one (1) resident reported having to place a 160 pound chair against their door and cover themselves with a sheet or towel because staff entered the room without knocking, while the resident was disrobed at that time. Another resident stated that staff had to create a sign for their door because staff would otherwise walk in without announcing themselves. 2 of 10 residents did not confirm nor deny the allegation and stated they don't know if staff knock on their door before coming into their room or if staff have walked into their room without knocking. 4 of 10 residents denied the allegation and indicated staff knock on their door before coming into their room most of the time or always, staff have not walked into their room without knocking, and they feel they have privacy in their room. On 02/27/2026, between the hours of 2:25pm - 2:30pm, LPA conducted a records review & observed the following:The Department had not received nor had on file any LIC 624 Unusual Incident/Injury Report, nor any reports or notes related to a staff member entering a residents room without knocking before walking into the residents room. Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff unable to communicate with resident due to language barrier It was alleged that facility staff is unable to communicate with the resident due to a language barrier. A staff worker has a hard time understanding the resident because the staff speaks their language a lot. When the resident complained to the staff worker, the staff worker told the resident that they did not understand the resident and that the resident needs to write theirs concerns on paper which staff would look into it. On 02/19/2026 between the hours of 8:31am - 8:42am, LPA interviewed A1 regarding the allegation. A1 was aware of the allegation and mentioned at times the facility has had difficulty understanding or communicating with specific residents. A1 disclosed if a resident speaks to staff and they don't understand them, staff call the receptionist to have another staff who can interpret and at the same time use the Google Translator app. A1 stated residents have complained that staff don't understand them, and when that happens, A1 sends a request for another staff to translate. A1 mentioned training has been provided on how to communicate with residents who speak different languages. On 02/19/2026 between the hours of 9:26am -11:43am, LPA conducted 5 staff interviews regarding the allegation. 5 of 5 staff denied and stated that they have receive training on how to communicate with residents who speak different languages. However, all staff indicated if a resident speaks to them and they don't understand, they get assistance from another caregiver who speaks the same language as the resident or inform the Administrator. Staff noted residents have not complained that they don't understand them. Staff disclosed some residents are difficult to understand due to dementia but not due to language barriers. On 02/19/2026 between the hours of 12:28pm - 2:30pm, LPA conducted 10 resident interviews regarding the allegation. 3 of 10 residents confirmed the allegation and indicated they have had trouble getting staff to understand what they need or want. Of the 3 residents who confirmed the allegation, 1 resident stated staff have an foreign accents such as Spanish, West Indies, British, or Creole with staff answering questions with part English mixed with another language, and they don't understand staff most of the time. This same resident also mentioned nothing gets done if the staff doesn't understand. Since staff members doesn't understand, it results in yelling or displays of authority—yet the Administrator refuses to address these underlying communication problems .1 of 10 resident did not confirm nor deny the allegation and noted they have had trouble getting staff to understand what they need or want, but also indicated they make sure they are understood. 6 of 10 residents denied the allegation and indicated they have not had trouble getting staff to understand what they need or want. The resident also mentioned no staff member has told them they don't understand them and staff understand them when they ask for help and or have witness staff finding solutions. Report continues on LIC 9099-C On 02/27/2026, between the hours of 2:25pm - 2:30pm, the LPA conducted a records review and observed the following: The Department had not received nor had on file any LIC 624 Unusual Incident/Injury Report, nor any reports or notes related to the alleged language barriers between the resident and staff. Unsubstantiated: Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Wendy Wheeler (Retirement Counselor) and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 9, 2026 · control 11-AS-20260210101503

Allegation investigated: Staff did not ensure resident medication was taken as prescribed

On 03/04/2026 around 12:00 PM, Licensing Program Analyst (LPA) Jose Anguiano conducted an subsequent unannounced complaint visit. LPA met with Administrator Catherine Decara. The investigation consisted of the following: On 01/22/2026, during the visit, LPA interviewed 11 residents (R1–R11) and 8 staff members (S1–S8). LPA collected the staff roster for the week of 01/18/2026 to 01/24/2026, the resident roster dated 01/20/2026, and Medication Administration Records (MARs) for two residents (R1–R2) for November 2025, December 2025, and January 2026. LPA also reviewed the facility’s Plan of Operation and Personnel Policies. On 03/04/2026, LPA collected a sample medication/treatment administration record for March 2026 for R2 and the MARs for December 2025 and January 2026 for R1. Investigation revealed the following: Regarding the allegation “Staff did not ensure resident medication was taken as prescribed,” it is being alleged that Resident (R1) time-sensitive medications were consistently administered later than prescribed. Please see report continuation on LIC9099-C Substantiated Interviews Conducted revealed: Staff (1-6) confirmed the facility’s medication scanner was functioning properly from January 2026 to present date. R1 stated that routine medications are often not administered on time. Staff (S1–S6) confirmed that MAR entries include the medication name, dosage, administration time, and staff initials, stamped at the time of administration. Observations: LPA observed a demonstration by five staff members (S1–S5) of the medication scanner scanning a sample resident medication. The printed timestamp accurately reflected the time, date, and medication description at the time the sample was conducted. Records Review: MARs for R1 from December 2025 and January 2026 indicate multiple routine medications were administered 1–2 hours after the prescribed time. The scanner demonstration confirmed equipment is operational, eliminating equipment malfunction as a justification for late administration as previously stated. Based on the evidence gathered, interviews conducted, observations, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation is SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, §87465, Incidental Medical and Dental Care. A citation is being issued on the attached LIC-9099D. An exit interview, a copy of this report, and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, Mar 4, 2026 · control 11-AS-20260114115021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 11, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility.The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by Based on observation, records, and interviews, the facility failed to ensure that routine, time-sensitive medications for Resident R1 were administered at the prescribed times. This violation poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 4, 2026

Plan of correction: Administrator agreed to send LPA a plan of correction on due date. jose.anguiano@dss.ca.gov

Allegation investigated: Resident is not provided with proper housekeeping services

On 02/25/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegation. LPA met with Marketing Director and the purpose of the visit was explained. LPA spoke with Administrator Assistant Catherine Espino Dacara over the phone. Investigation consisted of the following: On 02/25/2025, LPA obtained Personnel Report (01/20/2026), Register of Residents, and GPLB Housekeeping Daily Task List. LPA interviewed Residents #1 - #9, Staff #1 - #4, #7 - #9 and observed Residents’ bedrooms. Note: LPA left a voicemail for Staff #5 - #6. Investigation revealed the following: Regarding the allegation, “Resident is not provided with proper housekeeping services,” it is being alleged Resident #1 (R1) room has only been cleaned once in February 2026. Record review of Facility Program and Admission Agreement revealed residents will receive cleaning of resident’s room. Continue to LIC9099-C. Unsubstantiated Review of Personnel Report revealed four housekeepers of which two – four housekeepers are working on the same day. Review of facility housekeeping daily task lists revealed staff are to restock towels, toilet paper and take out trash, daily. It also revealed staff are to sweep under the bed, mop, and vacuum floors including the bathroom, dust, disinfect, clean toilets and sinks, and check for pest control. The facility is divided into three zones and R1 lives in zone two. Seven out of eight resident interviews (R1 – R7, R9) indicated housekeeping services are provided daily or every other day. Seven out of seven staff interviews (S1 – S4, S7 - S9) indicated housekeeping services are provided daily or every other day. S2, S4, and S9 indicated R1 does not like S2 to clean R1’s room. S7 indicated R1 likes particular people to clean R1’s room. S1/The Administrator Assistant indicated another housekeeper will clean R1’s room when S2 is working in zone two. S1 indicated R1 will complain that no one has cleaned R1’s room even after S1 sent a staff member or S3 to the room. LPA observed resident rooms (219 - 222, 226 – 228) to be clean and observed housekeepers cleaning. LPA observed R1’s room to be clean. Regarding the allegation, “Resident is not provided with proper housekeeping services,” based on record reviews, interviews, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to Administrator Assistant Catherine Espino Dacara.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 11-AS-20260219120149

Allegation investigated: Staff leave residents behind locked doors. Staff are not qualified to care and supervise residents.

On 02/25/2026, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegations. LPA met with Administrator Assistant Catherine Dacara and the purpose of the visit was explained. Investigation consisted of the following: On 12/31/2025, LPA obtained Personnel Report (12/09/25), Register of Residents (12/19/25), and Staff Schedule (12/21/25 – 01/03/26). On 01/08/26, LPA interviewed Staff #1 – 3, 5, 6, 7, received emergency contact for residents in memory care, and toured the facility. On 02/23/26, LPA interviewed Witnesses 1, 3, 4, and 6 over the phone. On 02/25/26, LPA interviewed Staff #8 - #9 and Witness #11. Note: LPA left a voicemail for Staff #4 and Witnesses 2, 5, 7 – 10. Investigation revealed the following: Regarding the allegation, “Staff leave residents behind locked doors,” it is being alleged memory care residents are locked behind door with only one employee... Continue to LIC9099-C. Unsubstantiated after midnight and during the day to provide care and supervision. It is also alleged that staff does not have enough supplies to perform their jobs and there isn’t any front desk coverage after midnight for emergency personnel entrance and for families to reach memory care residents. Record review of Fire Inspection allows for the facility to have locked doors in the memory care unit. Review of staff schedule (12/21/25 - 12/27/25) revealed one staff worked in memory care during the PM and NOC shift on 12/21/25, 12/27/25. One staff worked in memory care on 12/22/25 (2:30 PM - 11:00 PM). One staff worked in memory care on 12/23/25 - 01/02/26 (11:00 PM - 7:30 AM). Review of staff schedule (12/28/25 – 01/03/26) revealed one staff worked in memory care during the PM and NOC shift on 12/28/25 - 12/29/25, 01/03/26. One staff worked in memory care on 12/30/25 - 01/02/26 (11:00 PM - 7:30 AM). Two out of three staff interviews (S1, S3, S6) indicated there are two staff working in memory care and rounds are conducted every two hours or less. S5 and S7 indicated working with another staff member in zone one (assisted living on the first floor). S1 indicated there are eleven residents in memory care (zone three). S6 indicated most residents are sleep around 8:00pm. Five out of five staff interviews (S1, S3, S5 - S7) indicated there is enough supplies for caregivers. Five out of five staff interviews (S1, S3, S5 – S7) indicated someone works at the front desk after midnight who is able to grant access to emergency personnel and transfer phone calls from families to memory care. S8 indicated there is always a caregiver working the front desk overnight and use radios to inform of incoming phone calls. Three out of three Memory Care Emergency Contact (W3 - W4, W6) indicated care and supervision is provided to residents in memory care. Four out of four Memory Care Emergency Contact (W1, W3-W4, W6) indicated they have not tried to call the facility after 10pm. On 01/08/26 (9:40 AM – 10:00 AM), LPA toured and observed a locked door device that requires a key scan to enter the Memory Care Unit. The area also included an aiphone that rings to the front desk. Memory Care has a phone in the common room and in the office. The phone in the common room was tested and the front desk answered. While at the front desk, LPA and staff tested memory care's radio and a caregiver responded. LPA also observed the Paging System at the front desk. Staff was able to make an announcement that went throughout the building. LPA also observed supplies for the caregivers to access them. No deficiencies cited. Continue to LIC9099-C. Regarding the allegation, “Staff are not qualified to care and supervise residents,” it is alleged the facility’s nurse was fired and the position is being covered by an unqualified employee. Interview with Administrator Assistant indicated the facility has contracts with three nurse agencies and a Licensed Vocational Nurse (LVN) is in the facility from 6:00 AM – 5:00 PM. S6 indicated there are two LVNs on staff and a third-party nurse comes out. Three out of three staff interviews (S2 – S3, S6) indicated residents receive visits from the LVNs. S9 indicated S9 worked with that third-party agency before getting hired at the facility. S9 is primarily responsible for residents’ insulin injections, attending to falls, taking vitals, and assessing residents with changes of conditions. Interview with third-party agency (Witness #11) indicated they provided professional services (LVNs, RNs, MedTech, and Caregivers) to the Licensee in December 2025. Regarding the allegation, “Staff are not qualified to care and supervise residents” based on interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to the Administrator Assistant Catherine Dacara.the state’s words, verbatim · CDSS document, Feb 25, 2026 · control 11-AS-20251223135226

Allegation investigated: Staff do not ensure resident's personal hygiene needs are being met.

On 02/23/2026 at 8:35am, Licensing Program Analyst (LPA) Zina Brown conducted an subsequent investigation complaint visit at this facility to deliver the findings for the allegation above. During today’s visit, LPA met with Catherine Dacara (Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 02/19/2026, Licensing Program Analysts (LPA) Zina Brown conducted interviews with Administrator (A1), Staff (S1-S5) & Residents (R1-R10), between the hours of 8:42am - 2:11pm and requested the following documentation: Staff Roster (dated 01/26/2026), Resident Roster (dated 02/18/2026), Staff Schedule(02/08/2026 - 02/21/2026), Resident 1's (R1) records such as Admission Agreement (dated 07/04/2025), LIC 601: Identification & Emergency Information (dated 07/05/2025), LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (dated 06/18/2025) , LIC 603: Preplacement Appraisal Information (dated 07/04/2025), Medication Administration Record for R1 (December 2025), LIC 625 Appraisal/Needs & Service Plan (dated 09/23/1950), Shower Log (December 2025 -February 2026), Resident Tracking Log (February 2026). Substantiated The investigation revealed the following: Allegation: Staff do not ensure resident's personal hygiene needs are being met. It was alleged that facility staff do not ensure the resident's personal hygiene needs are being met. The resident stated the last time they received a bed bath from facility staff was around 2 or 3 months ago. The resident mentioned that it has been around 1 year since receiving an actual shower. It was also reported that facility staff do not assist with personal hygiene which the resident needs assistance with. On 02/19/2026 between the hours of 8:42am - 8:49am, LPA interviewed A1 regarding the allegation. A1 denied the allegation. A1 stated the resident is scheduled to receive showers at least twice per week per the Admission Agreement, but indicated the resident often receives bed baths instead, reportedly twice a week, and that hygiene care is provided daily by direct care staff. A1 stated she does not personally assist with hygiene care, but that staff assist the resident with changing clothes, incontinence care, and brushing teeth on a daily basis. A1 acknowledged that deviations from showering may occur due to resident refusal or health-related issues (e.g., pain preventing movement). A1 reported that the facility maintains records of bathing and hygiene care, and that staff are responsible for documenting care and reporting when hygiene supplies are low, at which point the family is notified or the facility provides items if needed. On 02/19/2026 between the hours of 9:21am -11:38am, LPA interviewed 5 staff in regards to the allegation. 2 of 5 staff confirmed the allegation and stated Resident 1 (R1) has been refusing showers since last year and cannot remember the last time R1 received a shower. Staff stated R1 gets bed baths usually twice a week but has been refusing. 1 of 5 staff did not confirm nor deny the allegation and stated the resident gets showers 3 days a week or upon request from the resident, and last month upon being assigned to the unit where R1 resides, personal hygiene assistance would be about 3 times a week. 2 of 5 staff were unaware of the allegation and stated they work in the memory care unit and do not assist R1 with showering or personal hygiene needs. Staff mentioned the facility keeps records using communication logs and shower sheets when residents are bathed or showered, and caregivers have to sign a shower sheet and document in the Activities of Daily Living (ADL) book. Investigation findings continue on LIC 9099-C On 02/19/2026 between the hours of 12:01pm - 2:11pm, LPA interviewed 10 residents in regards to the allegation. 2 of 10 residents confirmed the allegation. 1 of the 2 residents stated the last time they received assistance with a shower from staff is like months to a year. The resident stated it is not really often and once caregivers see the residents can independently take care of themselves, then no care is provided by staff even though the facility is supposed to provide care which is mentioned in their contract (Admission Agreement). Of the 2 resident who confirmed the the allegation mentioned staff are too slow with assisting and or never come, so they have to take their own shower because they cannot trust nor put their care in the hands of the caregivers. 1 of 10 residents did not confirm nor deny the allegation and stated staff help with changing and assist with their catheter, and about two weeks ago they had a bed bath. The resident stated they never refused bed baths/showers but would like a bed bath at least twice a week. 7 of 10 residents denied the allegation and stated they take their own showers independently, never ask for help since they do this themselves, take care of their own personal hygiene, and do not ask staff for help because they are independent. On 02/23/2026 between the hours of 8:30am - 11:00am, LPA conducted a records review and observed the following: According to the LIC 602A Physician's Report (dated 06/18/2024), page 5 of 9, Section 2 (Capacity for Self-Care), the resident is marked No for being able to bathe, dress, or groom self. Similarly, the LIC 603 Pre-Placement Appraisal Information (dated 07/04/2024) indicates Yes for needing help with bathing, hair care, and personal hygiene. Furthermore, the Admission Agreement under Section 3 (Basic Services), Item 8, specifies assistance with the following activities: a. dressing, c. toileting, d. bathing (twice weekly), and e. grooming. The shower logs for the month of February revealed R1's showers days are marked for Tuesdays and Thursday in the Spa Room. On the Resident Tracking Sheet (February 2026) for R1's during the AM, PM and NOC Shift it revealed: During the hours of 7am, 9am, 11am, 1pm, 3pm, 5pm, 7pm, 9pm, 10:30pm, 12am, 2am, 4am, 6am that S on the key which means for Supervised Safety was provided to the R1 on 02/01 - 02/05, 02/09 - 02/14, 02/17 - 02/18, 02/28 - 02/29. The following dates had no initials 02/06 - 02/08, 02/15 - 02/19 - 02/22. The facility did not provide written documentation of R1 refusing a shower and or bed bath. Investigation findings continue on LIC 9099-C The facility’s direct care staffing schedules from 02/08/2026 - 02/21/2026, stated the following: During the week of (02/08–02/14), the AM shift utilized 5 to 7 caregivers, the PM shift maintained 5 to 6 caregivers, and the NOC shift utilized 3 to 4 caregivers. Memory care coverage during this period consisted of 1 to 2 caregivers per shift. During the week of (02/15/2026 – 02/21/2026), staffing levels fluctuated, with the AM shift utilizing 4 to 7 caregivers and the PM shift utilizing 5 to 7 caregivers. The NOC shift had 2 caregivers on 02/16, 02/17, and 02/21. While memory care usually maintained 2 caregivers during the day, it dropped to 1 caregiver during the PM shift on 02/21 and remained at 1 caregiver for the majority of the NOC shifts throughout both weeks. Substantiated: Based on LPA's observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Catherine Dacara (Administrator) and a copy of this report was provided with appeal rightsthe state’s words, verbatim · CDSS document, Feb 23, 2026 · control 11-AS-20260217155337

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Mar 2, 2026

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met by: Based on interviews & records review, the facility did not have any written refusals of showers for R1 on file nor could staff provide an exact date of the last time R1 received a shower and or bed bath.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: The Administrator will conduct training on personal rights and the necessary reporting requirements for CDSS CCL. Additionally, the Administrator will implement an internal data sheet to track resident refusals of ADLs. The administrator submit proof of training and internal data sheet for resident refusals of ADLs by the plan of correction due date and email proof to LPA Brown at Zina.Brown@dss.ca.gov

Allegation investigated: Staff does not prevent resident from smoking inside the facility.

*This report does not supersede the previous report dated 10/24/2025 but is used to clarify findings. * On 02/11/2026 at approximately 1:02 PM Licensing Program Analyst (LPA) Troy Watson made a subsequent unannounced visit to the facility listed above. LPA Watson was greeted by the Assistant Administrator Catherine Dacara and explained the purpose of the visit. LPA was granted entry into the facility. The investigation consisted of the following: On 10/24/2025 between 08:01 AM – 04:56 PM the department requested, obtained, and reviewed the following documents: Resident Roster (10/08/25), Staff Roster (10/01/25), Smoking Policy (01/18/23), Staff Schedule (10/19/25 – 10/25/25), Unusual Incident Report (10/09/25 – 10/10/25), Psychiatric Emergency Team Assessment (10/10/25), and Placement for Evaluation and Treatment documentation (10/10/25). CONTINUED ON LIC9099-C Unsubstantiated On 10/24/2025 between 08:01 AM – 04:56 PM the department conducted interviews with Staff #1 – #5 (S1–S5) and Resident #2 – #11 (R2–R11). An attempt to interview Resident #1 (R1) was made, but the resident was no longer at the facility and could not be contacted. LPA Watson toured the facility with the Assistant Administrator, Catherine Dacara, and found the facility clean and in good repair. The investigation revealed the following: Allegation: Staff do not prevent residents from smoking inside the facility It was alleged that staff failed to prevent residents from smoking inside the facility, resulting in R1 reportedly igniting their shirt while smoking in their bedroom, creating a fire hazard and risk of injury. On 10/24/2025 between 08:01 AM – 04:56 PM LPA Watson interviewed Staff #1 – #5 (S1–S5). Of those interviewed, 5 out of 5 staff denied the above allegation. On 10/24/2025 LPA Watson interviewed Residents #2– #11 (R2– R11). Of those interviewed, 10 out of 10 denied the above allegation. On 10/24/2025 between 08:01 AM – 04:56 PM the department conducted an interview with the Assistant Administrator, Catherine Dacara (S1) and they were asked the question, does staff prevent residents from smoking inside the facility? S1 answered that residents and staff are not permitted to smoke inside the facility, and that a designated smoking patio outside the facility is provided for this purpose. The facility enforces its posted house rules prohibiting smoking on the premises, and staff assist residents by holding their cigarettes to ensure compliance and safety. LPA Watson reviewed the Smoking Policy records, and it showed on pg.1, section 8, under Procedures that “There will be designated times for supervised smoking set by the administration.” A review of the Unusual Incident Report dated 10/09/25 – 10/10/25 revealed that R1 was witnessed on 10/09/25 at approximately 7:00 AM trying to set his shirt on fire using a lighter and attempted to put it out with a broom, causing heavy smoke inside his room.Further review of the Unusual Incident Report also showed that R1 told staff fireworks shot into his room and caused the smoke, but there was no evidence or proof of fireworks being recovered from that incident. Based on record reviews, staff and client interviews, and observations, there is insufficient evidence to support the allegation: “Staff do not prevent residents from smoking inside the facility.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. An exit interview was conducted with the Assistant Administrator, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 11-AS-20251017130143

Allegation investigated: Licensee did not follow proper eviction procedures for resident.

*On 02/05/2026, Licensing Program Analyst (LPA), Socorro Leandro conducted a subsequent visit to deliver an amended complaint investigation report and re-issue an updated Title 22 Regulation being cited. This report supersedes the report dated 10/08/2025. The purpose of this report is to update the citation provided on 10/08/2025 but the finding remains substantiated.* Investigation consisted of the following: On 09/22/2025, Resident 1 (R1's) records were gathered. On 10/06/2025, R1 and Staff 1 (S1) were interviewed and R1’s records were gathered. On 10/07/2025, R1’s records were reviewed which consisted of New Resident Alert; Admission Agreement dated 04/04/2025; Identification and Emergency Information; Thirty Day Notice to Quit dated 05/07/2025; L.A. Superior Court, Long Beach, Eviction Restoration Notice dated 10/06/2025; and emails between the Department and the Facility were reviewed. On 10/08/2025, LPA Leandro conducted an unannounced subsequent complaint investigation visit. On 02/05/2026, LPA Leandro conducted an unannounced subsequent complaint investigation visit and met with the Interim Executive Director, Catherine Dacara, and explained tthe purpose of the visit. Substantiated Investigation revealed the following: Allegation: “Licensee did not follow proper eviction procedures for resident”, it is being alleged that the facility did not follow proper eviction procedures for R1. Interviews conducted revealed the following: According to S1 the facility did follow proper eviction procedures. According to R1 the facility did not follow proper eviction procedures, furthermore, R1 indicated that they do not read or understand the English language, additionally, R1 indicated that they received their Eviction Notice in English and not in their native language. R1’s records reviewed revealed the following: the New Resident Alert states R1 “only speaks Spanish.” The Thirty Day Notice to Quit dated 05/07/2025 indicates that R1 did not follow general policies of the facility [referring to CCR87224(a)(3)] but did not describe how R1 did not follow said general policies of the facility, furthermore, the document indicates that R1 is not an appropriate fit for the facility [referring to CCR87224(a)(4)] but did not conduct/provide a reappraisal of R1 as stated in regulation CCR87224(a)(4) and explain how R1 is not an appropriate fit for the facility. Substantiated: Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, plans of corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Interim Executive Director, Catherine Dacara .the state’s words, verbatim · CDSS document, Feb 5, 2026 · control 11-AS-20250919141527

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: Feb 20, 2026

87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement is not met as evidenced by: Based on interviews and records review the licensee did not comply with the section cited above in the 30-day notice issued by the licensee on 05/07/2025 did not state specific facts on why R1 was not an appropriate fit for the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2026

Plan of correction: The Interim Executive Director, Catherine Dacara has agreed to re-read CCR 87224 Eviction Procedures (d), create a plan to stay in compliance with CCR’s Eviction Procedures, and to retrain staff on eviction procedures and email proof of corrections. Email to: Socorro.Leandro@dss.ca.gov Zina.Brown@dss.ca.gov Janae.Hammond@dss.ca.gov

Allegation investigated: Staff members worked while under the influence of alcohol.

On 1/29/2026, LPA Alfonso Iniguez conducted an unannounced initial complaint visit. LPA Iniguez met Catherine Dacara/Assistant Administrator. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Assistant Administrator Interview (A#1), Staff Interviews (S#1-S#6) and Residents Interviews (R#1-R#7) .LPA gathered the following documents: copy of facility resident roster dated : 1/29/26, copy of facility staff roster or LIC 500 dated: 1/9/2026, copy of facility employee conduct dated:1/29/26, copy of facility meeting sign-in sheet dated: 1/20/26. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Allegation: Staff members worked while under the influence of alcohol. The details of the complaint alleged that (S#1) and (S#2) are drinking alcohol while working at the facility. On January 29, 2026, at approximately 1:00 PM during the records review, LPA Iniguez examined the facility’s employee conduct policy dated January 29, 2026. The policy lists, as grounds for discipline or termination, reporting to work intoxicated or under the influence of alcohol or non-prescribed drugs, and bringing or using alcoholic beverages on facility property or while conducting company business offsite, unless authorized. LPA Iniguez also reviewed the facility meeting sign-in sheet from January 20, 2026, which confirms that all staff attended a mandatory in-service meeting where the code of conduct was discussed. On January 29, 2026, at approximately 10:00 AM during an interview with the assistant administrator (A#1), she stated that (S#1) and (S#2) were not observed consuming alcohol during work hours. In addition, (A#1) explained that the facility has policies and procedures regarding staff consuming alcohol or being under the influence while on duty, which are clearly outlined in the employee code of conduct and reinforced through regular in-service training. Additionally, (A#1) confirmed that there have been no prior concerns, complaints, or disciplinary actions involving (S#1) or (S#2) related to alcohol use or inappropriate workplace conduct. On January 29, 2026, at approximately 10:30 AM, during an interview with staff members (S#1) and (S#2), they stated that they had not consumed any alcohol during work hours. In addition, both staff confirmed they are aware of the facility’s policy regarding alcohol use while on duty and explained that they understand drinking while at work is strictly prohibited. Additionally, (S#1 and S#2) stated that they have never consumed alcohol during work hours in the past and have never been involved in any similar incidents at the facility. Evaluation Report continues LIC 9099-C On January 29, 2026, at approximately 11:00 AM, during an interview with facility staff members (S#3 through S#6), (4) out of (4) staff members stated that they had never observed S#1 or S#2 consuming alcohol or appearing under the influence during work hours. They further indicated that they are not aware of any incidents or conversations among staff regarding alcohol use while on duty. Additionally, (4) out of (4) staff confirmed that they have no concerns about staff conduct or behavior that could affect the safety and well-being of clients. On January 29, 2026, at approximately 12:00 PM, during interviews with residents (R#1 through R#7), (7) out of (7) residents stated that they have never noticed any staff members drinking alcohol or appearing to be under the influence while working. They further indicated that they have not observed any unusual behavior from staff that made them feel uncomfortable or concerned. Additionally, (7) out of (7) residents expressed that they feel staff are attentive and able to provide care and supervision at all times, and they feel safe in the facility. During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Catherine Dacara/Assistant Administrator.the state’s words, verbatim · CDSS document, Jan 29, 2026 · control 11-AS-20260122094156

Allegation investigated: Staff sexually abused resident in care

On 1/22/2026, at 1:35pm, Licensing Program Analyst (LPA) Zina Brown conducted an subsequent unannounced complaint investigation in order to deliver investigation findings for the allegation listed above.During today’s visit, LPA met with Catherine Dacara (Assistant Administrator), and explained the purpose of the visit. The investigation consisted of the following: LPA requested copies of the staff roster (dated 10/01/2025), resident roster (dated 10/08/2025), Resident #1 (R1's) documents such as LIC 601: Identification and Emergency Form (dated 02/26/2025), LIC 602: Physician Report (dated 02/07/2025), LIC 603: Preplacement Appraisal Information, Functional Capability Assessment, Medication Administration Record (August 2025 - October 2025), Staff #1 (S1) documents such as LIC 501: Personnel Record/Job Application, Job Description (for Direct Care Staff), Interview Statement (dated 08/14/2025), ID/Driver License (Employment Authorization valid 08/02/2024 - 08/01/2028), Training Complete, Suspension Notification (dated 08/14/2025), Termination Statement (dated 08/25/2025), Report Receipt/Application for Release of Report from Long Beach Police Department. The complaint was referred to the department Investigation Bureau for further investigation. The department obtained the Long Beach Police Department Report, Interviewed the Administrator (A1), Staff #1- Staff #3 (S1-S3), Interviewed Resident #1 (R1) and Witness #1 (W1). Substantiated The investigation revealed the following: Allegation: Facility staff sexual abused resident in care. The department interviewed A1 regarding the allegation. A1 stated S1 was terminated from the facility for job performance issues, inappropriate interactions with residents, and inappropriate communications with fellow staff members. A1 stated R1 reported to staff members that S1 kissed R1 on the neck and chest and touched himself through his pants while in front of R1. The department interviewed S1–S3 regarding the allegation. One out of three staff interviewed denied the allegation, stating he was always professional and never displayed any inappropriate behaviors, such as kissing residents or touching himself while employed at the facility. Two out of the three staff interviewed confirmed being aware of S1’s inappropriate interactions with residents, which consisted of kissing residents on the cheek or chest and touching himself in front of residents. The department interviewed Witness #1, and W1 stated S1 was employed by the facility but was quickly terminated for inappropriate interactions with a resident, as well as job performance issues. W1 stated the inappropriate interaction with a resident occurred when S1 was found lying in a resident’s bed next to the resident while on his phone. The department interviewed R1 regarding the allegation, and R1 confirmed the allegation and disclosed S1 kissed R1 on the cheek and chest and touched himself through his pants. R1 further stated S1 hugged R1 every time S1 saw R1, and all of S1’s inappropriate behaviors made the resident uncomfortable. The department obtained a copy of the Long Beach Police Department report, which contains statements from facility staff regarding S1’s inappropriate behaviors. The department reviewed S1’s termination documents from Glen Park at Long Beach and another facility, both of which list similar reasons for S1’s termination, including inappropriate interactions with residents. Based on interviews conducted and records reviewed the department finds enough evidence to support that S1 sexually abused R1. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted with Catherine Dacara (Assistant Administrator) and copy of this report was provided with appeal rights.the state’s words, verbatim · CDSS document, Jan 22, 2026 · control 11-AS-20251007143756

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jan 23, 2026

Personal Rights of Residents: (3) To be free from punishment, humiliation, intimidation, abuse, or actions of a punitive nature, such as withholding money or interfering with daily living functions. This requirement was not met as evidenced by: Based on interview & records review, facility Staff 1 (S1) sexually abused Resident 1 (R1) by kissing R1 on the neck & touching their own groin area in front of R1. This violation poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 22, 2026

Plan of correction: Licensee/Administrator shall ensure a training for all staff on Title 22, Section 87468.1 “Personal Rights” is conducted & send the sign in sheets and training materials to the CCLD by the Plan of Correction (POC) due to the attention of: Zina.Brown@dss.ca.gov

Type of visit: Case Management - Other

On 01/22/2026, Licensing Program Analysts (LPA) Zina Brown conducted an unannounced Case Management visit to Glen Park at Long Beach. The purpose of today’s visit is to serve an ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY for staff #1. LPA met with Catherine Dacara (Assistant Administrator) and explained the purpose of today’s visit. An investigation conducted by the California Department of Social Services determined that staff #1 violated California Code of Regulations Title 22 for the resident's personal rights. Government Code 11522 was also issued, informing the licensee that an excluded person may petition for reinstatement to the Department one year after the effective date of the exclusion order. LPA delivered copies of the immediate exclusion letters for the following facility to Catherine Dacara (Assistant Administrator). Staff #1 (S1) was not present at the facility at the time of the visit. Staff #1 was mailed the Immediate Exclusion Order letter and Government Code 11522. The Assistant Administrator was read the Immediate Exclusion from Facility Order and acknowledged understanding the immediate exclusion order and that the mentioned staff is not allowed to be physically present in the facility. An exit interview was conducted with Catherine Dacara (Assistant Administrator) and copies of Order to Licensee/Facility of Immediate Exclusion from Facility and Government Code 11522 were provided. The report was signed by Catherine Dacara (Assistant Administrator) and copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 22, 2026

Allegation investigated: Staff are mishandling the residents medications

On 01/15/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent complaint visit to the facility listed above. LPA met with Assistant Administrator, Catherine Dacara, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit, LPA interviewed a Resident and delivered findings for the complaint. During a subsequent visit conducted on 12/04/2025, LPA conducted a medication review for eight (8) residents, observed lunch service, and received and reviewed the following documents Medication Administration Records (MAR) for December 2025, Weekly Menus for four (4) weeks, Sanitation and Food Safety Checklist for Assisted Living by RDs for Healthcare INC (dated 11/072025, 10/03/2025, and 09/05/2025), and invoices from Sysco for November and December 2025. During the initial visit on 10/21/2025, LPA inspected the facility, interviewed Staff S1-S8, interviewed Residents R1-R10, conducted a narcotic medication count, and received and reviewed the Staff Roster, Resident Roster, Resident Diabetic List, Physician’s Report for R1-R10, In-Service Training Log, Substantiated Medication Management Program verification, med tech Certification of Completion in Basic Medication Training, and med tech Basic Medication Shadow Training Logs. The following additional documents were requested and are to be emailed to LPA Unusual Incident Reports (URI), Physician’s Orders, Needs and Service Plan, and Medication Administration Records (MAR). The investigation revealed the following: Allegation: Staff are not following resident’s diabetic needs The allegation alleges that med techs are giving residents their insulin. During the facility visit, LPA observed residents going to the Medication Room to see the trained LVN, to have their blood sugar level checked, and to receive their insulin injections. During the visit, LPA observed insulin secured in a locked refrigerator, in the medication room. During record review, LPA reviewed the training and in-service logs for the LVN and medication technicians and observed they have received training regarding medication administration. LPA reviewed the Plan of Operation that indicates a licensed skilled professional can assist with self-administration of injections. LPA received and reviewed Resident R2-R 11’s Medication Administration Record (MAR) and observed glucose testing and insulin injections signed off by the LVN. During interviews with Staff S1-S8, were asked who checks residents’ sugar and provides insulin injections, eight (8) out of eight (8) stated the LVN is who tests residents’ sugar and gives insulin injections. During interviews with Residents R1-R11, were asked who provides them with their insulin shots and tests their sugar, eight (8) out of eleven (11) stated the nurse gives them their shots and tests their sugar. One resident stated they do their own sugar testing, and the nurse is there to document the numbers, and they do their own injections with the nurse watching. Two residents stated they do not require glucose testing or insulin injections. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff are not providing adequate food service The allegation alleges that residents are unable to get a second serving of food during mealtimes due to the kitchen running out of food. During the facility inspection, LPA observed lunch being prepared and served. LPA observed staff preparing residents plates using scoopers measuring half (1/2) a cup for mixed vegetables, fruit, and stuffing. Soup was measured using an 8 fluid ounce ladle. Residents were provided with one to two pieces of chicken with gravy. LPA observed a resident who wanted an alternative meal, and they were provided with either a turkey or ham sandwich, fruit, vegetables, soup, and stuffing. LPA observed multiple residents served a second serving of lunch. After all residents were provided with their meals, LPA observed an ample supply of prepared food still in the kitchen. Additionally, LPA inspected the food supply in the kitchen and observed a two (2) day supply of perishable foods and a seven (7) day supply of nonperishable foods. During record review, LPA received and reviewed invoices from Sysco listing food deliveries on the following dates 12/03/2025, 11/28/2025, 11/25/2025, 11/21/2025, 11/18/2025, 11/14/2025, 11/11/2025, 11/07/2025, 11/05/2025, and 11/04/2025. The food delivered consisted of dairy, meats, poultry, canned goods, frozen goods, dry goods, and condiments. Additionally, LPA received and reviewed the Sanitation and Food Safety Checklist for Assisted Living dated 09/25/2025 and 11/07/2025. On both forms, indicates the facility has a “one week of nonperishable food and 2 days perishable are available.” During interviews with Staff S1-S8, were asked if residents are able to have a second serving during mealtimes, eight (8) out of eight (8) stated residents are able to have a second serving of food during mealtimes. During interviews with Residents R1-R11, were asked if they are provided with enough food throughout the day, eleven (11) out of eleven (11) stated yes, they are provided with enough food throughout the day. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff are eating the food for the residents The allegation alleges that staff are eating all the food resulting in there not being enough food for residents. During the facility inspection, LPA observed lunch being prepared and served. LPA observed staff preparing residents plates using scoopers measuring half (1/2) a cup for mixed vegetables, fruit, and stuffing. Soup was measured using an 8 fluid ounce ladle. Residents were provided with one to two pieces of chicken with gravy. LPA observed a resident who wanted an alternative meal, and they were provided with either a turkey or ham sandwich, fruit, vegetables, soup, and stuffing. LPA observed multiple residents served a second serving of lunch. After all residents were provided with their meals, LPA observed an ample supply of food prepared in the kitchen. LPA did not observe any staff eating the food that was served from the kitchen. During review of an Admission Agreement, LPA observed a resident’s guest may purchase a meal and eat with the resident they are visiting. During interviews with Staff S1-S8, were asked if staff eat the food served to the residents, six (6) out of eight (8) stated they have eaten or seen staff eating the food served to the residents. Additionally, four (4) out of eight (8) stated meals are available for purchase and some staff eat the food for quality testing. During interviews with Residents R1-R11, were asked if there has been a time they wanted a second serving and it was not available due to the kitchen running out of food, eleven (11) out of eleven (11) stated no, the kitchen has not run out of food. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Catherine Dacara, and a copy of this report was provided. Medication Management Program verification, med tech Certification of Completion in Basic Medication Training, and med tech Basic Medication Shadow Training Logs. The following additional documents were requested and are to be emailed to LPA Unusual Incident Reports (URI), Physician’s Orders, Needs and Service Plan, and Medication Administration Records (MAR). The investigation revealed the following: Staff are mishandling the residents medications The allegation alleges residents are not getting their medication because the medication is missing. During the facility inspection, LPA conducted a medication review for eight (8) residents. LPA observed three (3) out of eight (8) residents had medications that were unable to be located in the medication cart and medication room. Additionally, LPA observed two (2) out of eight (8) resident’s medications were not consistent with documented records. During interviews with Staff S1-S8, were asked if there have been any medication errors or missing medications in the past, five (5) out of eight (8) staff stated yes, there was recently a medication error that was documented and reported. During interviews with Residents R1-R11, were asked if there have been any medication errors or missing medications in the past, four (4) out of eleven (11) stated yes, they have had missing medications that the staff did not know what happened to them. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Assistant Administrator, Catherine Dacara, and a copy of this report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jan 15, 2026 · control 11-AS-20251013125552

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jan 25, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of centrally stored medications. This requirement was not met as evidence during record review, observation, and interviews, during medication audit staff were unable to locate 3 of R4’s PRN medications, 4 of R6’s medications, and 1 of R9’s medications.the state’s words, verbatim · CDSS document, Jan 15, 2026

Plan of correction: The Licensee agrees to retrain staff on properly storing centrally stored medications and ensuring they are secured and will work with TSP to implement new procedures they feel is needed. Training Logs will be emailed to LPA by POC.

Allegation investigated: Staff do not assist resident with ambulating. Staff handled resident in a rough manner. Staff do not assist resident with arranging transportation.

On 01/07/2026 at 8:23am, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit at this facility to deliver the complaint investigation findings for the allegations above. During today’s visit, LPA met with Catherine Dacara (Assistant Administrator) and explained the purpose of the visit. The investigation consisted of the following: On 12/29/2025 at 8:50am, Licensing Program Analysts (LPA) Zina Brown, requested documentation & conducted interviews with, Staff (S1-S10) & Residents (R1-R10), between the hours of 9:41am - 4:00 pm. At 12:45pm, LPA obtained the following documentation: Resident Roster (dated 12/19/2025), Employee Schedule Week of 12/21/2025 - 12/27/2025, LIC 601: Identification & Emergency Information, LIC 602: Physician Report for Residential Care Facilities for the Elderly (RCFE) (dated 06/18/2025), LIC 625 Appraisal/Needs & Service Plan (dated 09/23/2025) & list of non-ambulatory residents (received on 12/29/2025). On 01/07/2026, LPA conducted an interview with Administrator (A1) between the hours of 9:38am - 10:01am. Investigation findings continues on LIC 9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not assist resident with ambulating It was alleged that facility staff failed to assist a resident for days at a time and that prior to 12/21/2025 the resident had not been out of bed since 12/16/2025. It was also alleged that staff told resident they cannot get the resident out of bed. On 01/07/2026 between the hours of 9:38am -10:01am, LPA interviewed the Administrator in regard to the allegation. A1 denied the allegation and stated caregivers routinely check on residents in the morning and offer assistance getting out of bed. A1 stated that residents are assisted based on their willingness and ability to transfer safely. Additional caregivers assist when a two- or three-person transfer is required, and the nurse is contacted if a resident is in pain. A1 acknowledged awareness of a R10 remaining in bed prior to 12/21/2025 but denied that any caregiver refused to assist a resident without reason. On 12/29/2025 between the hours of 9:43am - 4:00pm, the LPA interviewed 10 staff regarding the allegation. 9 of 10 staff denied the allegation and stated resident who need assistance with ambulation will help upon request and or following the directives of the residents care plan. 1 of 10 staff did not confirm nor deny the allegation and stated due to R10 have a neck injury it was advised resident be on bed rest for 3-4 days. On 12/29/2025, between the hours of 11:24am - 2:26pm, the LPA interviewed 10 residents regarding the allegation. 1 of 10 residents confirmed the allegation and stated they are suppose to get help from staff when they want to get out of bed but that doesn't happen ; staff would take too long to assist them so they would get themselves out of bed. 9 of 10 residents denied the allegation. 3 of 9 residents stated staff will come by in the morning to assist with transferring, while 6 of 9 residents independently get themselves out of bed. On 01/07/2026 between the hours of 8:40am - 8:45am, LPA conducted a records review and observed the following: the LIC 625 Appraisal/Needs & Service Plan (dated 09/23/2025) stated for R10 one caregiver reported that two of caregivers are not able to transfer R10 due to an unintentional fall as a result of the resident's weight. Caregivers noted R10 needs at least 3 caregivers to assist him with his ADLs and transfer. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Investigation findings continues on LIC 9099-C Allegation; Staff handled resident in a rough manner It was alleged that staff attempted to transfer a resident from their bed to their wheelchair by pulling their arms to raise themselves from the bed which the resident reported that a male caregiver pulled the resident up too quickly by their arms and hurt the residents neck. On 01/07/2026 between the hours of 9:38am -10:01am, LPA interviewed the Administrator in regard to the allegation. A1 denied the allegation and stated that staff are trained to use appropriate transfer techniques based on resident ability. A1 stated that staff are instructed to contact the nurse if a resident appears uncomfortable or in pain and to complete a report if a resident reports injury. A1 stated they were not aware of any caregiver handling a resident roughly during a transfer. On 12/29/2025 between the hours of 9:43am - 4:00pm, the LPA interviewed 10 staff regarding the allegation. 10 of 10 staff denied the allegation and expressed not handling the resident in a rough manner. On 12/29/2025, between the hours of 11:24am - 2:26pm, the LPA interviewed 10 residents regarding the allegation. 10 of 10 residents denied the allegation and stated never experiencing being handle in a rough manner by staff. On 01/07/2026 , between the hours of 9:20am - 9:25am, LPA conducted a records review and observed the following: LPA did not observe any incidents reports nor resident notes in regards to this allegation. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Investigation findings continues on LIC 9099-C Allegation : Staff do not assist resident with arranging transportation It was alleged that staff do not assist a resident with scheduling their ACCESS transportation services, resulting in the resident being unable to attend church services. On 01/07/2026 between the hours of 9:38am -10:01am, LPA interviewed the Administrator in regard to the allegation. A1 denied the allegation and stated that the facility assists residents with scheduling ACCESS transportation upon request. A1 stated that some residents schedule their own transportation. A1 reported that transportation issues involving R10 occurred due to scheduling errors and missed phone calls, not staff inaction. A1 stated that if ACCESS cancels transportation, staff notify the resident and offer to reschedule. On 12/29/2025 between the hours of 9:43am -4:00pm, the LPA interviewed 10 staff regarding the allegation. 8 of 10 staff denied the allegation and stated resident or the resident's family will arrange their own transportation but the front desk will assist with arranging transportation for the residents upon request. 2 of 10 staff were unaware of the allegation. 2 of the 2 staff stated not having any knowledge of residents transportation being delayed and or canceled. On 12/29/2025, between the hours of 11:24am - 2:26pm, the LPA interviewed 10 residents regarding the allegation. 8 of 10 residents denied the allegation and states making arrangements for transportation themselves. 2 of 10 residents did not confirm nor deny the allegation. 1 of 2 residents stated not knowing how to setting up rides or transportation but would like to someone who would help them get more information on how to do so in regards to this matter. While the other 1 of 2 resident stated this allegation does not apply at all due to them never trying to go somewhere. On 01/07/2026 , between the hours of 9:20am - 9:25am, LPA conducted a records review and observed the following: LPA did not observe any reports and or notes in regards to this allegation. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies were cited for the allegations above. An exit interview was conducted with Catherine Dacara (Assistant Administrator) & a copy of this report is provided.the state’s words, verbatim · CDSS document, Jan 7, 2026 · control 11-AS-20251223093452

Type of visit: Case Management - Deficiencies

On 01/07/2025, The Department conducted an unannounced visit to deliver findings for the alleged allegations for complaint Control Number 11-AS-20251223093452. LPA met with Catherine Dacara (Assistant Administrator) as the purpose of the visit was explained. On 01/07/2025 between the hours of 8:30am - 8:45am, LPA conducted a records review and observed the following: the department did not receive a LIC 625: Serious/Unusual Incident Report in regard to Resident 10 (R10) having an unwitnessed fall and being sent out to the hospital on 12/09/2025. The facility failed to report the incident as required to the department. Deficiency cited under California Code of Regulation Title 22 Division 6 Chapter 8 are being cited on the attached LIC 809-D. Exit interview conducted with Catherine Dacara (Assistant Administrator), appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 7, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Jan 21, 2026

Reporting Requirements(a)(1)Each licensee shall submit serious incident reports to. . . the Department may require, including the following: (1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence of any of the events This requirement was not met as evidenced by: based observation, LPA observed that the facility did submit a LIC 624 to the department within 7 day of incident occurring.the state’s words, verbatim · CDSS document, Jan 7, 2026

Plan of correction: The facility shall will submit a serious incident reports (by 01/08/2026) for the incident that occur on 12/09/2025 with the resident (R10) who had an unwitnessed fall & went to the hospital. Also the facility will conduct an in-service training on reporting requirement for all staff. The completion of training must be fax to 424-544-1016 or zina.brown@dss.ca.gov to department by POC due date.

Allegation investigated: Staff do not insure an appropriate skilled professional is administering insulin to residents.

*This report supersedes the investigation report dated 12/12/2025. A subsequent visit was conducted on 12/19/2025 to update the LIC9099-D. Although this report supersedes the previous report, the complaint investigation findings remain the same.* On 12/19/2025, the department was greeted by the Executive Director, Jennifer Rivas and the purpose of the visit was explained. On 12/12/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted a subsequent complaint investigation visit regarding the allegation listed above. LPA met with the Executive Director, Jennifer Rivas, and the purpose of the visit was explained. The LPA was allowed entry to the facility. Substantiated The investigation consisted of the following: On 07/24/2025, facility records were gathered. On 08/22/2025, a tour of the facility was conducted, interviews were conducted, and facility records were gathered. A tour of the facility consisted of the medication room and kitchen. Interviews consisted of Witness 1 (W1), Resident 1 (R1) to Resident (6), and Staff 1 (S1) to Staff (7). On 08/25/2025, Staff 8 (S8) was interviewed. On 12/11/2025, interviews were conducted, records were gathered and reviewed. Interviews consisted of Witness 2 (W2), Resident 7 (R7) to Resident 11 (R11), and Staff 9 (S9). On 12/12/2025, a tour of the Medication Room was conducted, interviews were conducted, records were gathered and reviewed. Interviews consisted of R5, R7, R10, Resident 12 (R12) to Resident 14 (R14), Staff 10 (S10), and Witness 3 (W3). R1’s to R15’s records were reviewed which consisted of Medication Administration Records (MARs), Physicians Reports, and Residents that Receives Daily Insulin/Boold Sugar Checks. Facility records reviewed consisted of Personnel Reports, Resident Rosters, Schedule Reports, Staff Training's. Other pertinent records were also reviewed during this investigation. Investigation revealed the following: Allegation: “Staff do not ensure an appropriate skilled professional is administering insulin to residents.” Interviews conducted revealed the following: On 08/22/2025, W1 indicated that there was no Licensed Vocational Nurse (LVN) in the morning shifts, and a Medical Technician (MedTech) was providing insulin and providing blood sugar checks to residents. On 08/22/2025, S1 indicated that they are the only LVN in the facility and they work Monday to Friday from 7 AM to 4 PM. Moreover, S1 indicated that recently they started to work weekend shifts. Furthermore, S1 indicated that they “usually make it” to provide residents with their injections and blood sugar checks. S1 was asked what happens when they do not make it and S1 did not answer the question. On 08/22/2025, S2 indicated that S1 does not come in during the weekends and residents do not receive their injections nor blood sugar checks on the weekends. On 08/22/2025, S3 indicated that S1 sometimes comes in during the weekends and sometimes agency LVNs (the facility contracts agency staff when they are short staffed) come in during the weekends but sometimes no LVNs come during the weekends; S3 is not sure what happens when no LVNs come in. On 08/22/2025, S7 indicated that before there were no LVNs in the facility during the weekends and a MedTech had to come in the facility and provide injections and blood sugar checks to residents. On 08/25/2025, S8 indicated that they have witnessed MedTech’s provide injections and blood sugar checks to residents. Furthermore, S8 explains that the facility has requested for them to provide injections and blood sugar checks to residents because the LVN was not in the facility, S8 declined and indicated, that day, residents did not receive their injections nor blood sugar checks. On 12/11/2025, S9 indicated that they have heard of a MedTech providing injections and blood sugar checks to residents. On 12/12/2025, S10 indicated that on 12/10/2025 an agency LVN did not provide injections nor blood sugar checks to residents. On 12/12/2025, W3 confirmed that an agency LVN did not provide injections nor blood sugar check to residents. W3 explained that on 12/11/2025 residents informed them that they were upset that they did not receive their insulin injections nor blood sugar checks. Interviews conducted with R1 to R14 revealed the following: 6 out of 14 residents agreed with the allegation; indicating that there have been days when a MedTech provided them with blood sugar checks and when they did not receive their insulin injection, injection, nor blood sugar check. 6 out of 14 residents are not sure if there have been days when they have missed an injection or blood sugar check. 2 out of 14 residents are certain that a nurse provides them with their medication as required by their physician. Records reviewed revealed the following: Personnel Report dated 7/7/2025, indicated that S1’s job title is “LVN”, and their schedule is Monday to Friday from 7:00 AM to 4:00 PM, as well as S1 is the only LVN in the facility. S1 holds a State of California Board of Vocational Nursing and Psychiatric Technicians License for Vocational Nurse. Personnel Report dated 12/09/2025, showed that there is no LVN in the report. Residents Physician’s Reports revealed the following: Physician’s Reports for R1, R4, R9, R7, R10, R13, R14, and R15 indicated that residents cannot manage their own medication including providing themselves with injections and performing their own glucose testing (blood sugar checks). Physician’s Report for R5 indicated that resident can provide their own injections with assistance, but they are not able to perform their own glucose testing. Physician’s Report for R11 indicated that resident can provide their own injections but requires their insulin dosage to be drawn before self-injections, and they are not able to perform their own glucose testing. Residents MARs revealed the following: According to R1’s MAR they did not receive their “AM” blood sugar check and insulin injection on 06/02/2025 and 06/19/2025; R1 did not receive their “PM” blood sugar checks and “PM” insulin injections on 05/10/2025, 05/11/2025, 05/17/2025, 05/18/2025, 05/25/2025, 06/07/2025, 06/15/2025, and 07/20/2025. According to R4’s MAR they did not receive their “AM” blood sugar check from 05/03/2025 to 05/31/2025; R4 did not receive their “PM” blood sugar check and insulin injection on 05/10/2025, 05/11/2025, 05/25/2025, 6/7/2025, 06/15/2025, 06/31/2025, and 7/20/2025; R4 did not receive their Ozempic injection on 07/10/2025 and 07/17/2025. According to R5’s MAR they did not receive their “PM” blood sugar checks and “PM” insulin injections on 05/10/2025, 05/11/2025, 05/18/2025, 05/25/2025, 06/07/2025, 06/09/2025, 06/15/2025, and 12/10/2025; R5 did not receive their “PM” insulin injection on 07/20/2025. According to R7’s MAR they did not receive their “AM” blood sugar check and insulin injection on 06/19/2025 and 12/10/2025; R7 did not receive their “PM” blood sugar checks and “PM” insulin injections on 05/10/2025, 05/11/2025, 05/18/2025, 06/07/2025, 06/15/2025, 07/20/2025, and 12/10/2025. According to R8’s MAR they did not receive their “AM” blood sugar check and insulin injection on 06/19/2025. According to R10’s MAR they did not receive their “AM” blood sugar check and insulin injection on 05/27/2025, 06/19/2025, 07/11/2025, and 12/10/2025. According to R12’s MAR they did not receive their 4:00 PM blood sugar check on 12/04/2025 and 12/06/2025; R12 did not receive their 8:00 AM blood sugar check on 12/10/2025. According to R14’s MAR they did not receive their 8:00 AM insulin injection on 12/10/2025. Schedule Reports revealed the following: From 06/29/2025 to 7/26/2025 and 08/10/2025 to 08/30/2025, S1 is scheduled from 7:00 AM to 4:00 PM and “Open As Needed” on Saturdays and Sundays. From 08/03/2025 to 08/09/2025, S1 was scheduled off. S1’s Time Card Reports from 05/01/2025 to 07/31/2025 revealed the following: S1 did not work on 05/10/2025, 06/07/2025, 06/09/2025, and 07/11/2025. S1 did not work in the afternoon and evening of 05/11/2025, 05/18/2025, 06/10/2015, and 07/25/2025. S1 did not work early in the early morning, afternoon and evening time on 05/25/2025. S1 did not work early in the morning and evening of 06/15/2025. S1 did not work from 8:00 AM to 11:59 PM on 06/05/2025. S1 did not work in the morning and afternoon of 07/05/2025. Observations revealed the following: Pictures taken in the medication room show that injection needles were improperly discarded. Injection needles were in white trash bags. On 8/22/2025, LPA Leandro toured the medication room and confirmed that said pictures were taken in the facility's medication room. On 12/12/2025, the medication room’s refrigerator was at 55 degrees Fahrenheit. The refrigerator had insulin medication and other medications that had to be refrigerated at 36 to 46 degrees Fahrenheit. The facilities freezer had a large block of ice on the bottom and a soda inside it next to ice packs. The refrigerator/freezer have a sign that states “Please Do Not Store Food.” Substantiated: Based on interviews, observations, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Jennifer Rivas.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 11-AS-20250722112818

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87628(a) · Plan of correction due date: Dec 26, 2025

Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the section cited above by not ensuring a skilled professional was administering insulin through injections to residents in care which poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: The Executive Director has agreed to ensure that a skilled professional will administer insulin through injections to residents who are unable to perform their own injections. The Executive Director will create a plan to ensure that a skilled professional will be in the facility during the times that residents require their insulin injections. The plan will be emailed to Socorro.Leandro@dss.ca.gov

Type of visit: Case Management - Deficiencies

On 12/19/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding Complaint Control Number 11-AS-20250722112818. The department observed deficiencies during the course of the investigation and delivered deficiencies to the Executive Director, Jennifer Rivas. The following deficiencies were observed: · Pictures taken in the medication room show that injection needles were improperly discarded. Injection needles were in white trash bags. On 8/22/2025, LPA Leandro toured the medication room and confirmed that said pictures were taken in the facility's medication room. Interviews with staff and witnesses confirmed that the facility has improperly discarded injection needles. · On 08/22/2025 and 12/12/2025 one glucometer was observed in the medication room; according to staff and witnesses (on both days) one glucometer is used for all residents who require glucose testing. On 12/12/2025, LPA requested to view extra glucometers but medication room staff was unable to show LPA extra glucometers; staff did not know if the facility had extra glucometers. · Interviews with staff and witnesses on 08/22/2025 and 12/12/2025 in the medication room confirmed that the facility uses one glucometer for all the residents who require glucose testing. · On 12/12/2025, the medication room’s refrigerator was at 55 degrees Fahrenheit. The refrigerator had insulin medication and other medications that had to be refrigerated at 36 to 46 degrees Fahrenheit. The facilities freezer had a large block of ice on the bottom and a soda inside it next to ice packs. The refrigerator/freezer has a sign that states “Please Do Not Store Food.” · Interviews conducted with staff, residents, and witnesses indicated that a Medical Technician (MedTech) has provided injections and blood sugar checks (glucose testing) to residents. · Interviews and records reviewed confirmed that residents have not been receiving their medical injections nor glucose testing as prescribed. · Records reviewed and interviews with residents, staff, and witnesses confirmed that residents who require assistance with glucose testing and injections did receive assistance with hand-over-hand and did not receive their medication/medical care as prescribed. Deficiencies are being cited based on observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Jennifer Rivas .the state’s words, verbatim · CDSS document, Dec 19, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87628(b)(1-3) · Plan of correction due date: Jan 15, 2026

Diabetes (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (1) Assisting residents with self-administered medication as specified in Section 87465, Incidental Medical and Dental Care Services. (2) Ensuring that sufficient amounts of medicines, testing equipment, syringes, needles and other supplies are maintained and stored in the facility as specified in Section 87465(c). (3) Ensuring that syringes and needles are disposed of as specified in Section 87303(f)(2). This requirement is not met as evidenced by: Based on observation, interviews and records reviewed the licensee did not comply with the section cited above in not assisting residents with self-administering medications such as insulin injections and glucose testing with a glucometer, the facility did not ensure that sufficient amounts of testing equipment such as glucometers were in the facility, and the facility has improperly disposed of needles, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: The Executive Director has agreed to read Diabetes 87628 (b)(1-3) and create a plan to stay in compliance. The Executive Director has agreed to train Medical Technicians (MedTechs) on “hand-over-hand.” The plan and trainings will be emailed to Socorro.Leandro@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(1)(A) · Plan of correction due date: Jan 15, 2026

Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (A) The preservation of medicines requires refrigeration, if the resident has no private refrigerator. This requirement is not met as evidenced by: Based on observation and record review the licensee did not comply with the section cited above in not preserving medication as required because the medication that required refrigeration was in a refrigerator that was too hot, the refrigerator was at 55 degrees Fahrenheit and insulin medication and other medications needed to be refrigerated at 36 to 46 degrees Fahrenheit, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: On 12/12/2025, staff placed a new refrigerator in the medication room The Executive Director has agreed to create a plan to preserve medication that requires refrigeration, follows medication guidelines and at correct temperature. The Executive Director has agreed to train staff on said plan. The plan and trainings will be emailed to Socorro.Leandro@dss.ca.gov

Allegation investigated: Staff are not adequately trained.

On 12/17/2025 at 08:45am, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit at this facility to deliver the complaint findings for the allegations above. During today’s visit, LPA met with Jennifer Rivas (Executive Director) and the purpose of the visit was explained. The investigation consisted of the following: On 11/13/2025, LPA conducted interviews with Administrator (A1), Staff (S1-S10) & Residents (R1 - R10) between the hours of 8:29am - 2:30pm. LPA also requested and received the following documents: Staff Roster (dated 11/07/2025), Resident Roster (dated 11/01/2025), Resident #1's personnel record such as LIC 503 Pre-Placement Appraisal (dated 09/28/2022), LIC 602: Physician Report (dated 07/27/2023), Admission Agreement (dated 08/01/2024) & Dietary Preference (dated 10/25/2022), Fall Menu Week 3 (October & November 2025), staff training for 2025 & Medication Administration Record for R1 - R10 (for October - November 2025) . Substantiated Allegation: Staff are not adequately trained. It was alleged that there are many staff members who are not trained. On 11/13/2025, between the hours of 11:12am - 11:22am, LPA interviewed A1, who denied the allegation and stated that in-service training for staff is conducted once a month, and this month's training will address fall risk. Between 9:15am - 1:21pm, LPA interviewed 9 staff members: 9 of 9 staff denied the allegation and stated they receive in-service training on a regular basis. Between 8:20am - 2:00 pm, LPA interviewed 10 residents: 8 of 10 residents denied the allegation and stated the staff know what they are doing when helping residents and have not noticed a difference between newer staff and those who currently work or formerly worked at the facility. 2 of 10 residents did not confirm nor deny the allegation; R6 stated "no comment," while R8 stated doesn't think much about it because they don't know which staff are new and that does not involve himself. On 12/16/2025, between 8:35am - 11:15am, LPA conducted a records review and observed the following: For 2025, the facility conducted twenty-nine (29) in-service training's between January 28, 2025, - September 29, 2025. Each training included a sign-in sheet acknowledging staff participation and understanding of the material presented. Topics covered during these trainings included new employee orientation; sexual harassment; workplace violence; injury and illness prevention; bloodborne pathogens; missing resident response procedures; dementia and memory care practices; activities of daily living and personal care; medication administration; infection control; residents' rights and mandated reporting; fall and elopement safety; housekeeping and food safety practices; activity programming; customer service; and applicable facility policies and procedures. A total of 46 employees work for the facility, with 18 out of 46 staff members being caregivers. Of the 18 caregivers out of the 46 staff have not completed all the required training per Title 22 regulations and health & safety code. Based on LPA's observations and interviews that were conducted and the records that were reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6, Chapter 8, as cited on the attached LIC 9099D. Exit interview conducted with Catherine Dacara (Administrator) and a copy of this report with appeal right was provided. Allegation: Staff do not ensure resident diapering needs are met It was alleged that residents are not getting their diapers changed in a timely manner. On 11/13/2025 between the hours of 11:12am - 11:22am, LPA interviewed A1 denied the allegation and stated staff conduct rounds to ensure resident who need diaper changes are assigned promptly. On 11/13/2025, between 9:15am - 1:21 pm, LPA interviewed 9 staff: 7 of 9 staff denied the allegation and stated upon the call light going off, caregiver are radio over the walkie-talkies to assist the residents and also resident are changed every 2-3 hours or upon the residents’ request. 2 of 9 staff did not confirm nor deny the allegation but stated at time sometimes when the facility is short staff it does affect how quickly the resident receive diapering care needs. On 11/13/2025, between 8:29am- 2:00pm, LPA interviewed 10 residents: 2 of 10 residents denied the allegation and stated that they are in fact incontinent but expressed the staff check and change them, once in the morning and once in the night or 3 times in the afternoon and 2 times in the middle of the night. 7 of 10 residents did not confirm nor deny and state that they are not wearing diapers because they are not incontinent 1 of 10 residents had no knowledge of the allegation and stated no comment at the time of the interview. On 12/16/2025, between 1:30pm -2:30pm, LPA conducted a records review and observed the following: The facility has 35 incontinent residents. According to incontinence logs for September through November 2025, 33 residents received incontinence care, including bowel movements, toileting, supervised toileting for safety, showers, wet or dry briefs, or care was refused. Care was documented at various times throughout the day and night, ranging from overnight (NOC) to hourly intervals between 1:00 aam and 11:00 pm Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Allegation: Staff do not ensure that resident's with special dietary needs are adequately fed It was alleged that residents who require a special diet are not accommodated. On 11/13/2025 between the hours of 11:12am - 11:22am, LPA interviewed A1 denied the allegation and stated that residents with special diets or food allergies are identified on a list created by the front desk, which is posted in the kitchen. A1 also stated that if a resident cannot eat what is being served, an alternative menu is offered. However, if the resident does not want anything from the alternative menu, the facility will ask the resident what they prefer and will try to accommodate their request as much as possible. Between 9:15am - 1:21 pm, LPA interviewed 10 staff: 10 of 10 staff denied the allegation and stated the facility has documentation such a binder on file and the whiteboard located in the kitchen which list the residents special diets and food allergies. Staff also states the facility has other options such as sandwich, chicken, yogurt , Jello, rice pudding and fruit as alternative food. Between 8:29am - 2:00pm, LPA interviewed 10 residents: 1 of 10 residents confirmed the allegation and stated the facility does not handle their dietary preferences at all with no healthy alternative options provided as a result of purchasing their own food for the last two years. 8 of 10 residents denied the allegation and stated not asking for something specific and did not experience being served food they couldn't eat. 1 of 10 resident did not confirm nor deny the allegation and stated being allergic but the facility doesn't give them avocados. However one time the resident was served veal and can't eat veal. On 11/13/2025 at 12:11pm, LPA conducted a tour of the kitchen and dining room and observed the following: A white board which states 12 of the residents are diabetic, 2 of the residents are allergic (for R6 jelly, lemonade, no red drinks) and no shellfish for another resident. For R1 no dairy products, no bell peppers, no red meat (only turkey). For 2 residents of one being R7 food must be puree. Also for one of the residents no meat. On 11/26/2026 between the hours of 11:16am - 11:25am, LPA conducted a record review a observed the following: Resident 1 (R1) LIC 602A Physicians Report for Residential Care Facilities for the Elderly (RCFE) - (dated 07/27/2023 page 3 of 6 states under the physical health status e. special diet is checked no. Also, the GPLB Resident Summary Sheet (spreadsheet), stated that the facility requested Resident 1 (R1) Physician Report on 08/19/2025. Resident 1 (R1) provided a Rx from Vannarith So, MD Internal Medicine (dated 12/21/2023) states patient (R1) is lactose intolerance, intolerance to bell pepper and allergic to bleach. Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Catherine Dacara (Administrator) and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 17, 2025 · control 11-AS-20251104162513

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Jan 19, 2026

Personnel Requirements - General: All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Based on observation and interviews, the facility failed to ensure all caregivers complete the required 2025 training per Title 22 regulations.the state’s words, verbatim · CDSS document, Dec 17, 2025

Plan of correction: The facility will ensure all caregivers will complete all annual training needed to be in compliance with Title 22 regulations. The facility will submit proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016, Attn: Zina Brown, or via email at zina.brown@dss.ca.gov by the POC due date.

Allegation investigated: Staff do not insure an appropriate skilled professional is administering insulin to residents.

On 12/12/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted a subsequent complaint investigation visit regarding the allegation listed above. LPA met with the Executive Director, Jennifer Rivas and the purpose of the visit was explained. The LPA was allowed entry to the facility. The investigation consisted of the following: On 07/24/2025, facility records were gathered. On 08/22/2025, a tour of the facility was conducted, interviews were conducted, and facility records were gathered. A tour of the facility consisted of the medication room and kitchen. Interviews consisted of Witness 1 (W1), Resident 1 (R1) to Resident (6), and Staff 1 (S1) to Staff (7). On 08/25/2025, Staff 8 (S8) was interviewed. On 12/11/2025, interviews were conducted, records were gathered and reviewed. Interviews consisted of Witness 2 (W2), Resident 7 (R7) to Resident 11 (R11), and Staff 9 (S9). On 12/12/2025, a tour of the Medication Room was conducted, interviews were conducted, records were gathered and reviewed. Interviews consisted of R5, R7, R10, Resident 12 (R12) to Resident 14 (R14), Staff 10 (S10), and Witness 3 (W3). R1’s to R15’s records were reviewed which consisted of Medication Administration Records (MARs), Physicians Reports, and Residents that Receives Daily Insulin/Boold Sugar Checks. Facility records reviewed consisted of Personnel Reports, Resident Rosters, Schedule Reports, Staff Trainings. Other pertinent records were also reviewed during this investigation. Substantiated Investigation revealed the following: Allegation: “Staff do not insure an appropriate skilled professional is administering insulin to residents.” Interviews conducted revealed the following: On 08/22/2025, W1 indicated that there was no Licensed Vocational Nurse (LVN) in the morning shifts, and a Medical Technician (MedTech) was providing insulin and providing blood sugar checks to residents. On 08/22/2025, S1 indicated that they are the only LVN in the facility and they work Monday to Friday from 7 AM to 4 PM. Moreover, S1 indicated that recently they started to work weekend shifts. Furthermore, S1 indicated that they “usually make it” to provide residents with their injections and blood sugar checks. S1 was asked what happens when they do not make it and S1 did not answer the question. On 08/22/2025, S2 indicated that S1 does not come in during the weekends and residents do not receive their injections nor blood sugar checks on the weekends. On 08/22/2025, S3 indicated that S1 sometimes comes in during the weekends and sometimes agency LVNs (the facility contracts agency staff when they are short staffed) come in during the weekends but sometimes no LVNs come during the weekends; S3 is not sure what happens when no LVNs come in. On 08/22/2025, S7 indicated that before there were no LVNs in the facility during the weekends and a MedTech had to come in the facility and provide injections and blood sugar checks to residents. On 08/25/2025, S8 indicated that they have witnessed MedTech’s provide injections and blood sugar checks to residents. Furthermore, S8 explains that the facility has requested for them to provide injections and blood sugar checks to residents because the LVN was not in the facility, S8 declined and indicated, that day, residents did not receive their injections nor blood sugar checks. On 12/11/2025, S9 indicated that they have heard of a MedTech providing injections and blood sugar checks to residents. On 12/12/2025, S10 indicated that on 12/10/2025 an agency LVN did not provide injections nor blood sugar checks to residents. On 12/12/2025, W3 confirmed that an agency LVN did not provide injections nor blood sugar check to residents. W3 explained that on 12/11/2025 residents informed them that they were upset that they did not receive their insulin injections nor blood sugar checks. Interviews conducted with R1 to R14 revealed the following: 6 out of 14 residents agreed with the allegation; indicating that there have been days when a MedTech provided them with blood sugar checks and when they did not receive their insulin injection, injection, nor blood sugar check. 6 out of 8 residents are not sure if there have been days when they have missed an injection or blood sugar check. 2 out of 14 residents are certain that a nurse provides them with their medication as required by their physician. Records reviewed revealed the following: Personnel Report dated 7/7/2025, indicated that S1’s job title is “LVN” and their schedule is Monday to Friday from 7:00 AM to 4:00 PM, as well as S1 is the only LVN in the facility. S1 holds a State of California Board of Vocational Nursing and Psychiatric Technicians License for Vocational Nurse. Personnel Report dated 12/09/2025, showed that there is no LVN on the report. Residents Physician’s Reports revealed the following: Physician’s Reports for R1, R4, R9, R7, R10, R13, R14, and R15 indicated that residents cannot manage their own medication including providing themselves with injections and performing their own glucose testing (blood sugar checks). Physician’s Report for R5 indicated that resident can provide their own injections with assistance, but they are not able to perform their own glucose testing. Physician’s Report for R11 indicated that resident can provide their own injections but requires their insulin dosage to be drawn before self-injections, and they are not able to perform their own glucose testing. Residents MARs revealed the following: According to R1’s MAR they did not receive their “AM” blood sugar check and insulin injection on 06/02/2025 and 06/19/2025; R1 did not receive their “PM” blood sugar checks and “PM” insulin injections on 05/10/2025, 05/11/2025, 05/17/2025, 05/18/2025, 05/25/2025, 06/07/2025, 06/15/2025, and 07/20/2025. According to R4’s MAR they did not receive their “AM” blood sugar check from 05/03/2025 to 05/31/2025; R4 did not receive their “PM” blood sugar check and insulin injection on 05/10/2025, 05/11/2025, 05/25/2025, 6/7/2025, 06/15/2025, 06/31/2025, and 7/20/2025; R4 did not receive their Ozempic injection on 07/10/2025 and 07/17/2025. According to R5’s MAR they did not receive their “PM” blood sugar checks and “PM” insulin injections on 05/10/2025, 05/11/2025, 05/18/2025, 05/25/2025, 06/07/2025, 06/09/2025, 06/15/2025, and 12/10/2025; R5 did not receive their “PM” insulin injection on 07/20/2025. According to R7’s MAR they did not receive their “AM” blood sugar check and insulin injection on 06/19/2025 and 12/10/2025; R7 did not receive their “PM” blood sugar checks and “PM” insulin injections on 05/10/2025, 05/11/2025, 05/18/2025, 06/07/2025, 06/15/2025, 07/20/2025, and 12/10/2025. According to R8’s MAR they did not receive their “AM” blood sugar check and insulin injection on 06/19/2025. According to R10’s MAR they did not receive their “AM” blood sugar check and insulin injection on 05/27/2025, 06/19/2025, 07/11/2025, and 12/10/2025. According to R12’s MAR they did not receive their 4:00 PM blood sugar check on 12/04/2025 and 12/06/2025; R12 did not receive their 8:00 AM blood sugar check on 12/10/2025. According to R14’s MAR they did not receive their 8:00 AM insulin injection on 12/10/2025. Schedule Reports revealed the following: From 06/29/2025 to 7/26/2025 and 08/10/2025 to 08/30/2025, S1 is scheduled from 7:00 AM to 4:00 PM and “Open As Needed” on Saturdays and Sundays. From 08/03/2025 to 08/09/2025, S1 was scheduled off. S1’s Time Card Reports from 05/01/2025 to 07/31/2025 revealed the following: S1 did not work on 05/10/2025, 06/07/2025, 06/09/2025, and 07/11/2025. S1 did not work in the afternoon and evening of 05/11/2025, 05/18/2025, 06/10/2015, and 07/25/2025. S1 did not work early in the early morning, afternoon and evening time on 05/25/2025. S1 did not work early in the morning and evening of 06/15/2025. S1 did not work from 8:00 AM to 11:59 PM on 06/05/2025. S1 did not work in the morning and afternoon of 07/05/2025. Observations revealed the following: Pictures taken in the medication room show that injection needles were improperly discarded. Injection needles were in white trash bags. On 8/22/2025, LPA Leandro toured the medication room and confirmed that said pictures were taken in the facility's medication room. On 12/12/2025, the medication room’s refrigerator was at 55 degrees Fahrenheit. The refrigerator had insulin medication and certain medicines had to be refrigerated at 36 to 46 degrees Fahrenheit. The facilities freezer had a large block of ice on the bottom and a soda inside it next to ice packs. The refrigerator/freezer have a sign that states “Please Do Not Store Food.” Substantiated: Based on interviews, observations, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Jennifer Rivas.the state’s words, verbatim · CDSS document, Dec 12, 2025 · control 11-AS-20250722112818

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a-j) · Plan of correction due date: Jan 3, 2026

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. (3) When residents require prosthetic devices, vision and hearing aids, the staff shall be familiar with the use of these devices, and shall assist such persons with their utilization as needed. (4) The licensee shall assist residents with self-administered medications as needed. (5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician. (B) Medications during an illness determined by a physician to be temporary and minor. (C) Assistance required because of tremor, failing eyesight and similar conditions. (D) Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. (7) There shall be adequate privacy for first aid treatment of minor injuries and for examination by a physician if required. (8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. (B) Sterile first aid dressings. (C) Bandages or roller bandages. (D) Scissors. (E) Tweezers. (F) Thermometers. (9) The licensee shall ensure that infection control practices are maintained in the facility as specified in Section 87470, Infection Control Requirements. (b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation. (2) Once ordered by the physician the medication is given according to the physician's directions. (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met:(1) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (1) The specific symptoms which indicate the need for the use of the medication. (2) The exact dosage. (3) The minimum number of hours between doses. (4) The maximum number of doses allowed in each 24-hour period. (f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff. (2) The name, address and telephone number of each emergency agency to be called in the event of an emergency, including but not limited to the fire department, crisis center or paramedical unit or medical resource, shall be posted in a location visible to both staff and residents. (3) The name and telephone number of an ambulance service shall be readily available. (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (A) The preservation of medicines requires refrigeration, if the resident has no private refrigerator. (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. (3) Each container shall carry all of the information specified in (6)(A) through (E) below plus expiration date and number of refills. (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy (F) Instructions, if any, regarding control and custody of the medication. (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: (1) Name of the resident. (2) The prescription number and the name of the pharmacy. (3) The drug name, strength and quantity destroyed. (4) The date of destruction. (j) In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring that each resident receives needed first aid and needed emergency medical services and for assisting residents as needed with self-administration of medications. The names of the staff employees so responsible and the designated procedures shall be documented and made known to all residents and staff. This requirement is not met as evidenced by: Based on interviews, observation, and records reviewed, the licensee did not comply with the section cited above, the facility did not ensure that residents received their required medical care, in not having a skilled professionals provide injections and blood sugar checks for residents in care, thus, residents missed said medical care and medication, furthermore, insulin medication/medication that had to be kept refrigerated was in refrigerator that was too hot; moreover, needles were improperly discarded, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 12, 2025

Plan of correction: The Executive Director has agreed to read California Code of Regulations (CCR) Incidental Medical and Dental Care and create a plan to follow said regulations. The Executive Director has agreed to create a plan to ensure that a skilled professional will provide medical care and medication as required by their residents. The Executive Director will include in their plan training to their MedTechs: on hand over hand, disposing of needles, infection control, what happens if they get pricked by a needle, daily documentation of medication room refrigerators, MAR documentation, and what to do when residents miss their medication and blood sugar check. Email proof of correction to Socorro.Leandro@dss.ca.gov

Allegation investigated: Staff do not ensure residents are cleaned properly.

On 12/11/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted a subsequent complaint investigation visit regarding the allegation listed above. LPA met with the Executive Director, Jennifer Rivas and the purpose of the visit was explained. The LPA was allowed entry to the facility. The investigation consisted of the following: On 07/24/2025, facility records were gathered. On 08/22/2025, a tour of the facility was conducted, interviews were conducted, and facility records were gathered. A tour of the facility consisted of the medication room and kitchen. Interviews consisted of Witness 1 (W1), Resident 1 (R1) to Resident (6), and Staff 1 (S1) to Staff (7). On 08/25/2025, Staff 8 (S8) was interviewed. On 12/11/2025, interviews were conducted, records were gathered and reviewed. Interviews consisted of Witness 2 (W2), Resident 7 (R7) to Resident 11 (R11), and Staff 9 (S9). Unsubstantiated Investigation revealed the following: Allegation: “Staff do not ensure food is stored properly”, it is being alleged that the facility food is not of good quality and not stored properly. On 08/22/2025, a kitchen tour was conducted, and the following was observed: at 12:04 PM LPA Leandro took a picture of mashed potatoes on a paper plate without a cover (e.g. plastic wrap) inside the refrigerator; at 12:04 PM LPA Leandro took a picture of a cotton cleaning towel inside the refrigerator; at 12:05 PM LPA Leandro took a picture of strawberries with mold on them inside the refrigerator, the mold was fuzzy with green and white; at 12:06 PM LPA Leandro took a pictures of sweet potatoes with mold on them inside the refrigerator, the mold was fuzzy with green and white; at 12:06 PM LPA took a pictures of tomatoes with mold on them inside the refrigerator, the mold was black and fuzzy; (facility staff discarded said produce). Substantiated: Based on observations the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Executive Director, Jennifer Rivas. Investigation revealed the following: Allegation: “Staff do not ensure residents are cleaned properly”, it is being alleged that staff refuse to provide residents with showers. Interviews conducted with R1 to R11 revealed the following: 10 out of 11 residents denied the allegation and 1 out of 11 residents agreed with the allegation. Interviews conducted with S1 to S9 revealed the following: 9 out of 9 staff denied the allegation. Interviews conducted with W1 to W2 revealed the following: 1 out of 2 witnesses denied the allegation and 1 out of 2 witnesses did not know if said allegation did or did not occur. Records reviewed of Shower Schedules from 05/01/2025 to 07/25/2025 indicates that staff: “assist” residents with showers, “stand by” when residents showers, and “remind” residents to shower. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left with the Executive Director, Jennifer Rivas.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 11-AS-20250722112818

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8)(9)(28) · Plan of correction due date: Dec 23, 2025

General Food Service Requirements (b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above in not having all food of good quality, not having all food in storage, and not protecting food from contamination, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: The Executive Director has agreed to read California Code of Regulations (CCR) General Food Service Requirements and create a plan to follow said regulations. The Executive Director has agreed to include in the plan: daily observation of food and discard food if it is not of good quality,... properly store food, and protect all food from contamination. The Executive Director has agreed to retrain kitchen staff. Email proof of correction to Socorro.Leandro@dss.ca.gov

Allegation investigated: Staff mismanaged resident medication

On 11/19/2025, at 8:45am, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit at this facility to deliver the complaint finding for the allegation above. During today’s visit, LPA met with Jennifer Rivas (Executive Director) and the purpose of the visit was explained. The investigation consisted of the following: On 11/13/2025, LPA conducted interviews with Administrator (A1), Staff (S1-S10) & Residents (R1 - R10) between the hours of 8:29am - 2:30pm. LPA also requested and received the following documents: Staff Roster (dated 11/07/2025), Resident Roster (dated 11/01/2025), Resident #1's personnel record such as LIC 503 Pre-Placement Appraisal (dated 09/28/2022), LIC 602: Physician Report (dated 07/27/2023), Admission Agreement (dated 08/01/2024) & Dietary Preference (dated 10/25/2022), Fall Menu Week 3 (October & November 2025) and Medication Administration Record for R1 - R10 (for October - November 2025). Report continues on LIC 9099-C Substantiated The investigation revealed the following: Allegation: Staff mismanaged resident medication It was alleged that for the last 3 months a resident medications have been passed out late. On 11/13/2025 between the hours of 11:12am - 11:22am, LPA interviewed A1 who denied the allegation and stated the facility uses a medication cart for medtech to administer the medication to the residents. A1 also stated the facility just suspended two (2) medtech for lack of performance and Technical Support Program (TSP) provided by the Department of Social Service Community Care Licensing came to the facility about two weeks ago to assist with medication training. On 11/13/2025, between 9:15am - 1:21 pm, LPA interviewed 9 staff: 2 of 9 staff confirmed the allegation and stated due to short staff and or stopping to help assist another resident there have been challenges with timely medication administration 2 of 9 staff denied the allegation and stated not rushing to administrator medication quickly to avoid making a mistake while another staff stated it's no there hasn't been any challenges with timely medication administration 5 of 9 staff were unaware and or have no knowledge of the allegation due to their assigned job roles such a receptionist, caregiver, and activities director. On 11/13/2025, between 8:29am- 2:00pm, LPA interviewed 10 residents: 4 of 10 residents confirmed and stated by R1 that medication were for 3 months while other residents such as R3, R7 and R9 stated their medication being given late or missed once before. 3 of 10 residents denied and stated never experienced receiving their medication being given late nor missed. 3 of 10 residents did not confirm nor deny the allegation due to R6 stating no comment while R8 stated not remembering and R10 have not having any knowledge of their medication being give late or missed. On 11/19/2025, between the hours of 9am - 11am, LPA conducted medication review for 10 residents (R1 - R10) and observed the following: Medication Administration Record (MAR) for November 2025 indicated the medtechs administered medication by initial & timestamp. However medication is still observed to be in the bubble for Resident 1 (R1) 8pm Pregabalin 150mg on 11/1, 11/04, 11/1/11 and 11/18 Resident 1 (R1) 6:30am Pantoprazole SD DR 40 on 11/01 Resident 5 (R5) 8pm Rosuvastatin Calcium 10 MG on 11/09 Resident 5 (R5) 6:30am Pantoprazole SD DR 40 MG on 11/01 Resident 9 (R9) 8pm Atorvastatin 40 MG on 11/13, 11/14 and 11/15 Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights. The investigation revealed the following: Allegation: Facility does not have a certified Administrator It was alleged that the facility does not have a certified Administrator since Michael Mendoza. On 11/13/2025 between the hours of 11:12am - 11:22am, LPA interviewed A1 who stated Melissa Flores is currently acting as the facility Administrator and is not sure how long she's been in the position. A1 stated she has a Administrator certification. On 11/13/2025, between 9:15am - 1:21 pm, LPA interviewed 9 staff: 9 of 9 staff denied the allegation and stated Jennifer Rivas has been acting as the facility Administrator for a couple months. On 11/13/2025, between 8:29am- 2:00pm, LPA interviewed 10 residents: 1 of 10 resident denied the allegation and stated Jennifer Rivas is the current Administrator of the facility 9 of 10 are unaware of the allegation. On 11/17/2025, between the hours of 2:20pm - 2:30pm, LPA conducted a records review and observed the following: The previous Administrator for the facility was Michael Mendoza. Upon the departure of Michael Mendoza, the facility had Melissa Flores acting as the Administrator who held a Administrator Certification effective 08/11/2023 - 08/11/2025. On 11/7/2025 LPA received an email from Jennifer Rivas who provided her Proof of Completion for Certification Program for 740 - Residential Care Facility for the Elderly effective as of 02/23/2024 - 02/23/2026. Unfounded: This agency has investigated the complaint alleging (for the allegation above). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. Exit interview conducted with Jennifer Rivas (Administrator) and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 11-AS-20251104162513

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 17, 2025

Incidental Medical & Dental Care (a) A plan for incidental medical care shall be developed by each facility. The plan shall encourage routine medical care & assist in obtaining care, by compliance with..: (4) the licensee shall assist residents with self-administered medication as needed This requirement was not met as evidenced by interviews, observations, and record review showing medications for R1, R5, and R9 were not administered as prescribed. However, LPA observed medications not given but signed out, posing a health and safety risk to residents.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: The Administrator will have a licensed Pharmacist provide additional medication training for all the medtech and the LVN will conduct daily audits for Medication Administration for the next 30 days. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

Allegation investigated: Staff refused to change resident's soiled diaper

On 11/19/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced complaint investigation visit regarding the allegation listed above. LPA met with the Executive Director Jennifer Rivas, and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 11/19/2025, records were gathered, and interviews were conducted. Staff 1 (S1) and Resident 1 (R1) were interviewed. Facility records were reviewed which consisted of Personnel Report dated 11/07/2025, Resident Roster dated 11/18/2025, Staff Schedule from 11/09/2025 to 11/15/2025, R1’s Medical Assessment dated 06/18/2025, R1’s Resident Appraisal dated 07/04/2025. Unsubstantiated The investigation revealed the following: Allegation: “Staff refused to change resident's soiled diaper”, it is being alleged that facility staff refused to change R1’s soiled diaper. Interview conducted with R1 revealed the following: R1 denied the allegation. Additionally, R1 explained that in the morning of 11/10/2025, facility staff came to their room changed them and got them ready for their medical appointment. Furthermore, R1 left the facility and outside the facility premises had a bowel movement, once R1 arrived at their medical appointment R1 had a soiled diaper. R1 indicates that facility staff do assist with incontinent care needs and have never refused to change their soiled diaper. Interview conducted with S1 revealed the following: S1 indicated that facility staff did not transport R1 to their medical appointment. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of this report was left with the Executive Director Jennifer Rivas.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 11-AS-20251114164934

Allegation investigated: Staff does not prevent resident from smoking inside the facility.

On 10/24/2025 Licensing Program Analyst (LPA) Troy Watson made an unannounced complaint visit to the facility listed above. LPA Watson was greeted by the Office Manager Shenick Jackson and explained the purpose of this visit is to investigate the allegation mentioned above. The investigation consisted of the following: On 10/24/2025 LPA Watson requested, received and reviewed the following documents: Resident Roster, Staff Roster, Unusual Incident Report, Psychiatric Emergency Team Assessment, and Placement for Evaluation and Treatment. CONTINUED ON LIC9099-C Unsubstantiated On 10/24/2025 LPA Watson conducted interviews with Resident #2 - Residents #11 (R2-R11). An attempt to interview Resident#1 (R1) was made but the resident was no longer at the facility because is currently in College Medical Center in the City of Long Beach on a 51/50 hold. LPA Watson also conducted interviews with Staff#1 – Staff #5 (S1-S5). LPA Watson toured the facility with the Assistant Administrator Catherine Dacara and found the facility clean and in good repair. The investigation revealed the following: Allegation: Staff do not prevent residents from smoking inside the facility. On 10/24/2025 LPA Watson interviewed Staff #1-Staff #5 (S1-S5). Of those interviewed, 5 out of 5 staff denied the above allegation. On 10/24/2025 LPA Watson interviewed Residents #2 – Residents #11 (R2-R11). An attempt to interview Resident#1 (R1) was made but R1 was no longer at the facility at the time of the interviews. Of those interviewed 10 out of 11 denied the above allegation. LPA Watson completed interviews with 10 residents at the facility and every resident interviewed was asked the question, does staff allow residents to smoke in the facility, and all residents interviewed answered no. LPA Watson interviewed 5 staff members at the facility listed above and all staff members were asked, do you allow residents to smoke inside the facility, and all staff interviewed answered no. CONTINUE ON LIC9099-C Based on record reviews, staff and client interviews and observations there is insufficient evidence to support the allegation: “Staff do not prevent residents from smoking inside the facility.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with the Administrator Assistant, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 24, 2025 · control 11-AS-20251017130143

Allegation investigated: Licensee did not follow proper eviction procedures for resident.

On 10/08/2025, Licensing Program Analyst (LPA), Socorro Leandro conducted an unannounced subsequent complaint investigation visit regarding the allegation listed above. LPA met with the Assistant Administrator, Jennifer Rivas and the purpose of the visit was explained. LPA was granted entry to the facility. Investigation consisted of the following: On 09/22/2025, Resident 1 (R1's) records were gathered. On 10/06/2025, R1 and Staff (1) were interviewed and R1’s records were gathered. On 10/07/2025, R1’s records were reviewed which consisted of New Resident Alert; Admission Agreement dated 04/04/2025; Identification and Emergency Information; Thirty Day Notice to Quit dated 05/07/2025; L.A. Superior Court, Long Beach, Eviction Restoration Notice dated 10/06/2025; and emails between the Department and the Facility were reviewed. Substantiated Allegation: “Licensee did not follow proper eviction procedures for resident”, it is being alleged that the facility did not follow proper eviction procedures for R1. Interviews conducted revealed the following: According to S1 the facility did follow proper eviction procedures. According to R1 the facility did not follow proper eviction procedures, furthermore, R1 indicated that they do not read or understand the English language, additionally, R1 indicated that they received their Eviction Notice in English and not in their native language. R1’s records reviewed revealed the following: the New Resident Alert states R1 “only speaks Spanish.” The Thirty Day Notice to Quit dated 05/07/2025 indicates that R1 did not follow general policies of the facility [referring to CCR87224(a)(3)] but did not describe how R1 did not follow said general policies of the facility, furthermore, the document indicates that R1 is not an appropriate fit for the facility [referring to CCR87224(a)(4)] but does conducted/provide a reappraisal of R1 as stated in regulation CCR87224(a)(4) and explain how R1 is not an appropriate fit for the facility. Emails, faxes, and mail reviewed from the facility to the department did not demonstrate that the facility provided a written report of an eviction within 5 days to R1. Substantiated: Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted, plans of corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Assistant Administrator, Jennifer Rivas.the state’s words, verbatim · CDSS document, Oct 8, 2025 · control 11-AS-20250919141527

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a-f) · Plan of correction due date: Oct 9, 2025

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required.(1) Nonpayment of the rate for basic services within ten days of the due date ...(3) Failure of the resident to comply with general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement. (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident...(f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by: Based on interviews and records review the licensee did not comply with the section cited above in not describing how R1 did not follow the general policies of the facility nor explain how R1 is not an appropriate fit for the facility. Furthermore, the facility did not provide a written report to the department within 5 days of providing an eviction to R1.the state’s words, verbatim · CDSS document, Oct 8, 2025

Plan of correction: The Assistant Administrator has agreed to edit R1's Thirty Day Notice to Quit to be in compliance with CCR Eviction Procedures and re-submit it to the department. Once the department reviews the Thirty Day Notice to Quit and indicates that it is within compliance of CCR Eviction Procedures, the facility will be able to provide R1 with the updated Thirty Day Notice to Quit. The facility will also, notify the department in writing within 5 days of serving R1 of an eviction. Email LPA Leandro, LPA Brown, and LPM Hammond.

Type of visit: Case Management - Deficiencies

On 10/08/2025, Licensing Program Analyst (LPA), Socorro Leandro conducted a case management to deliver a deficiency relating to complaint control number: 11-AS-20250919141527. LPA met Assistant Administrator, Jennifer Rivas and explained the purpose of the visit. LPA was allowed entrance to the facility. On 10/06/2025, Staff 1 (S1) indicated that the Sherrif’s had be in the facility 3 times all ready and that Resident 1 (R1) had received a court order for them to leave the facility. Records reviewed revealed the following: R1 received a L.A. Superior Court, Long Beach, Eviction Restoration Notice dated 10/06/2025 and the department was not notified. A deficiency is being cited based on interviews conducted and records reviewed in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding Reporting Requirements. An exit interview was conducted, plans of corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Assistant Administrator, Jennifer Rivas.the state’s words, verbatim · CDSS document, Oct 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 31, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on interviews and records review the licensee did not comply with the section cited above in not submitting Unusual Incident Reports to the facility regarding having Sherriffs coming out to the facility and providing R1 with a L.A. Superior Court, Long Beach, Eviction Restoration Notice dated 10/06/2025.the state’s words, verbatim · CDSS document, Oct 8, 2025

Plan of correction: The Assistant Administrator has agreed to: fax Unusual Incident Reports regarding R1 to the department; re-read CCR Reporting Requirements and understand the regulation; re-train staff on how to submit Unusual Incident Reports. Email proof of correction to Socorro.Leandro@dss.ca.gov

Type of visit: Case Management - Health Checks

On October 6, 2025, Licensing Program Analyst (LPA) Ernand Dabuet conducted a Case Management visit to review health and safety concerns related to complaint #11-AS-20250919141527. Assistant Administrator Catherine Dacara greated the LPA and explained that the visit aimed to gather information regarding the eviction of Resident #1 (R1). The regional office had received information indicating that the Los Angeles Superior Court in Long Beach served an Eviction Restoration Notice to Resident #1. During the visit, the LPA interviewed Assistant Administrator Catherine Dacara, Staff Member #1 (S1), and Resident #1 (R1) about the eviction. The following documents were requested: - ID and Emergency Information (dated: 04/04/2025) - Admission Agreement (dated: 04/04/2025) - Physician Report for Community Care Facilities LIC 602A (dated: 04/08/2025) - Preplacement Appraisal Information LIC 603 (dated 04/04/25) - Appraisal/Needs and Services Plan LIC 625 (dated: 07/09/2025) - Thirty day Notice to Quit (dated: 05/07/2025) - Los Angeles Superior Court, Long Beach Eviction Restoration Notice (dated: 10/06/2025) An exit interview conducted with Catherine Dacara, and a hard copy was provided.the state’s words, verbatim · CDSS document, Oct 6, 2025

Allegation investigated: Staff did not safeguard resident’s personal belongings. Staff did not protect resident from financial abuse.

On 07/23/2025, Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial visit to gather information regarding the above allegations. LPA met with Assistant Administrator Cathrine Dacara and the purpose of the visit was explained. On 07/31/25, LPA Regina Cloyd conducted a subsequent visit, met with Office Manager Shenick Jackson, and explained the purpose of the visit. LPA spoke with Assistant Administrator Catherine Dacara over the phone. On 08/22/25, LPA met with Assistant Administrator Dacara. On 09/04/25, LPA met with Executive Director Christopher Redmond. Investigation consisted of the following: On 07/23/2025, LPA Villegas obtained Resident Roster, Staff Roster, and theft policy. On 07/31/25, LPA Cloyd obtained Resident Roster (as of 07/23/2025), Staff Roster (as of 07/25/2025), Personal Property Inventory for three residents, and a summary of Trust Accounts (as of 07/21/2025). LPA interviewed seven residents (R2 – R8) and five staff members (S2 – S6). On 08/22/2025, LPA retrieved in R1’s inventory Sheet (08/14/25), Inventory Pick Up Notice (04/14/25). Continue to LIC9099-C. Unsubstantiated Identification and Emergency Information (08/15/24), Physician’s Report (05/16/24), Bank Statement (06/19/24 – 07/22/24), Internal Incident Report (11/12/24), interviewed two staff members and one resident, and observed room 261. On 08/25/25, LPA received R1’s bank statements (12/20/24 – 05/20/25, 06/16/25 – 07/11/25). On 09/04/25, LPA interviewed the Maintenance Director and Executive Director. The investigation revealed the following: Regarding the allegation, “Staff did not safeguard resident’s personal belongings,” it is being alleged that the staff did not safekeep resident’s personal belongings, such as television and purse, during hospitalization. Record review of R1’s personal property inventory (08/15/24) revealed R1 had clothes, five pairs of shoes, two purses, one mirror, and a 32” Sony television (Model #W830K) upon admission. The form does not indicate that it was revisited upon discharge due to missing signatures. Record review of notice (04/14/25) revealed Witness #1 picked up four boxes of personal property for R1. Interview with Maintenance Director indicated that R1’s television was broken because R1 requested maintenance to look at it. LPA observed the broken television (Model #W830K) and there was no visual. Maintenance Director indicated that he doesn’t see the personal property inventory sheet but packs up the resident’s belongings. The Maintenance Director indicated that the clerical staff will complete the inventory sheet. The Executive Director indicated that the inventory sheet is completed unless a resident moves out prior. Three out of five resident interviews (R2, R4 - R5, R7 - R8) indicated that their personal items are safeguarded. Regarding the allegation, “Staff did not safeguard resident’s personal belongings,” based on observations, record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Continue to LIC9099-C. Regarding the allegation, “Staff did not protect resident from financial abuse,” it is being alleged that R1 left purse with the cards on R1’s bed during hospitalization. On 07/14/2025, R1’s bank informed R1 that there were multiple fraudulent charges made to R1’s debit card totaling $8,240.33. Record review of bank statement revealed R1's balance was $8,583.23 as of 07/22/24. Internal incident report (11/12/24) revealed R1 might go to a nursing home for short-term. Interview with Witness #2 indicated that R1 was admitted into the nursing home on 11/13/24 and was discharged on 03/04/25. Record review of bank statement revealed R1's balance was $1,054.17 as of 12/20/24. Theft and Loss Prevention Program revealed if a resident has to temporarily leave the community for various reasons such as medical care in a hospital, skilled nursing facility, or vacationing, the resident will have a double lock placed on their door to their unit so that no individuals can enter their room. However, R1 had a roommate. Interview with the Executive Director indicated that the facility will place valuables in a locked cabinet at the resident’s request. Six out of six staff interviews (S2 – S6) indicated that the residents have a key to their bedroom door. Four staff indicated (S2, S4 - S6) residents keep their debit cards. Five out of five staff interviews (S2 – S6) indicated that the facility investigates when items are reported lost or stolen. Three out of five resident interviews (R2, R4 - R5, R7 - R8) indicated that their personal items are safeguarded. Regarding the allegation, “Staff did not protect resident from financial abuse,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator Catherine Dacara.the state’s words, verbatim · CDSS document, Sep 4, 2025 · control 11-AS-20250715135007

Allegation investigated: Staff are mismanaging residents medication.

On 08/21/2025 Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent visit to deliver findings regarding the above allegations. LPA met with the Assistant Administrator Catherine Dacara and the purpose of the visit was explained. Investigation consisted of the following: On 07/25/2025, around 8:00AM LPA Anguiano toured the facility, interviewed (9) staff members (S1–S9), interviewed (11) residents (R1-R11) and conducted record reviews of facility, staff and resident’s records. On 08/06/2025 LPA interviewed (3) staff members (S1-S3), and acquired staff (S6) training records. Investigation revealed the following: Regarding the allegation “Staff are mismanaging residents’ medication” it is being alleged that medications are not being given to residents per doctors’ orders. Interviews conducted revealed the following: 9 out of the 11 residents did not agree with the allegation, and 2 out of the 11 residents agreed with the allegation. Substantiated 9 out of the 9 staff members did not agree with the allegation. Although S1 stated that the facility has a system in place to ensure that medications are given to residents in care, S1-S5 were not able to explain why the medications for S1-S3 were unaccounted for. LPA observations revealed the following: On 07/25/2025, R1-R3 residents bubble pack medications were popped on incorrect days with no document to explain the reasons. R1 and R2’s medication for 07/26/2025 and R3’s medication for 07/31/2025 were unaccounted for without documentation or explanation. Records review revealed the following: The July 2025 medication administration records (MAR) for R1-R2 did not indicate that R1 and R2’s medication for 07/26/2025 and R3’s medication for 07/31/2025 were given. Based on interviews, observation and records reviews the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6), is being cited, please see attached LIC-9099D. A Civil penalty is being assessed for repeat violation please see LIC421RP. An exit interview was conducted, plans of corrections were developed and appeals rights were provided to Catherine Dacara. Interviews conducted revealed the following: 10 out of the 11 residents did not agree with the allegation, and 1 out of the 11 residents agreed with the allegation. 9 out of the 9 staff members did not agree with the allegation, S1 said that all staff that give medication need to attend a course, pass a test, and shadow other Medtech’s before allowed to give medications to residents. LPA observations revealed the following: On 07/25/2025 and 08/06/2025 LPA observed Medtech’s S1-S4 administering medication to residents. Records review revealed the following: S1-S6 all had certificate of completion of Basic Medication Training Course in staff records. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation "Unqualified staff operating the facility" may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Investigation revealed the following: Regarding the allegation "Staff did not treat residents with dignity and respect" it is being alleged that staff are yelling and using profanity when talking to residents. Interviews conducted revealed the following: 10 out of the 11 residents did not agree with the allegation, and 1 out of the 11 residents agreed with the allegation. 9 out of the 9 staff members did not agree with the allegation, S1 said that all residents are treated like family and are respected. LPA observations revealed the following: On 07/25/2025 and 08/06/2025 LPA observed staff treating residents respectfully. Based on interviews conducted and LPA observations, although the allegation "Staff did not treat residents with dignity and respect " may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and appeals rights were provided to Catherine Dacara.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 11-AS-20250721120311

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87465(h)(6)(A-F) · Plan of correction due date: Aug 21, 2025

Incidental Medical and Dental Care. The following...shall apply to medications...stored: The licensee shall be responsible for assuring that a record of...medications for each resident is maintained...medication. This requirement was not met as evidence by: Based on observation and record review, the licensee did not comply with the section cited above,On 07/25/2025, 3 out of 3 resident medications were missing and unaccounted for this poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: The licensee agreed to create a plan to have all staff giving medications recount all the residents’ routine & PRN medications by the end of their shift. All staff assisting residents with medication to be re-trained by a licensed professional pharmacist. Proof of correction to be submitted to the department via email Jose.anguiano@dss.ca.gov by POC due date.

Type of visit: Office

On August 18, 2025, at 11:15 AM, an office meeting was held to discuss Glen Park at Long Beach Operations. Present at the meeting were Janae Hammond, Licensing Program Manager (LPM); Zina Brown, Licensing Program Analyst (LPA); Marina Pink, Chief Operations Officer; and Melissa Flores, Administrator. During the meeting, the LPM discussed the following: Administrator Oversight: Clarifying the roles and responsibility of the Administrator pursuant to Title 22 Regulations 87507 Administrator Qualifications & Duties. Designated Substitute for Administrator Medication Administration: Repeat citations for medication errors. Personnel Requirements: Communication with Licensing during visits. Record Keeping: Production of records during investigations and inspections. The department offered the Technical Support Program (TSP) and the facility agreed to participate. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2025

Allegation investigated: Facility staff failed to prevent resident from getting an infection.

On August 17, 2025, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Roniesha Bryant, Med Tech, greeted the LPA. Executive Director Christopher Redmond and Assistant Administrator Catherine Dacara are notified by telephone. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above. The investigation included interviews, a collection of records, and a tour of the facility. Interviews conducted with Resident #1 to Resident #10 (R1-R10) and Staff #1 and Staff #4 (S1-S4). The Department reviewed several documents, including the Personnel Report LIC 500 (dated 07/31/25), the Resident Roster (dated 08/06/25), and Resident #1 (R1)'s Physcians Report LIC 624A (dated 02/24/25), Resident Appraisal LIC603A (dated 01/01/23), Physicans Medication Orders (dated 08/07/25), Medical Clinic Record (dated 08/04/25) and DHCS ISP (dated 05/23/25), as well as other pertinent records associated with this complaint. (Evaluation Report contiues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility staff failed to prevent resident from getting an infection. The complaint details that the facility staff failed to prevent Resident #1 (R1) from contracting an infection. It is reported that (R1) developed the infection due to inadequate sanitation within the facility and the presence of dirty or unsanitized tableware. Reports have indicated that management staff were informed, but no action has been taken. No further details have been provided on this matter. On August 07, 2025, between 10:00 AM and 04:30 PM the Department interviewed residents identified as Resident #1 through Resident #10 (R1-R10). Eight (8) out of the ten (10) resident members could not support this claim. (R3-R10) reported that they have never experienced an infection while receiving care at this facility. While (R1-R2) both verified being diagnosed with a viral infection. (R3-R10) have expressed general satisfaction with the tableware's condition. They appreciate its cleanliness and indicate that if any issues arise, they would be willing to return it to the staff for replacement. (R2) acknowledged having contracted the viral infection outside of the facility through contact with a close associate who does not reside at Glen Park at Long Beach. (R2) understands and has not interacted closely with the facility's residents. During a routine medical visit, (R1) was diagnosed with a viral infection. (R1) believes this infection was contracted at the facility, likely due to the use of unclean or poorly sanitized tableware. Furthermore, (R1) stated that management has not been informed about this issue. It is assumed that the condition has been recognized as having appropriate antibiotic treatment available for (R1). (R1) indicates that, considering (R1's) health condition, the likelihood of contracting the viral infection through an intimate encounter is considerably improbable. On August 07, 2025, and August 08, 2025, between 09:00 AM and 4:15 PM, the Department interviewed staff members identified as Staff #1 through Staff #4 (S1-S4). Four (4) out of the four (4) staff members are not able to corroborate this claim. (S1-S3) reported that they were not informed about Resident #1's (R1) existing infection. According to (S1-S2), the medical discharge paperwork for (R1) was provided, and upon review, it did not mention any infection diagnosis. The primary physician for (R1) did not communicate any concerns or symptoms related to an infection to the facility staff. (Evaluation Report continues LIC 9099-C) (S1, S2 and S4) they verified that (R1 and R2) have no association with one another and are acquaintances only. (R1 and R2) do not share a room or share a table during meals. In addition, (R1) eats alone during meals as preference and does not use facility tableware supplies. (R1) preference utilizing plastic flatware. Additionally, (S4) was only informed that a specific new medication had been prescribed for (R1) to treat a viral infection, which was to be administered over a 14-day treatment period. (S3) communicated that, to (S3's) knowledge, there have been no reported claims from residents concerning dirty or unsanitized tableware, nor have there been any instances of infections attributed to inadequate cleanliness of tableware supplies. A review of Resident #1's (R1's) Medical Clinic Record (dated 08/04/25) revealed no indication of a viral infection or any mention of medicine to treat the infection. Physician Report LIC 602A (dated 02/24/25) and Resident Appraisal (dated 11/01/23) revealed that (R1) can self-care, can attain personal grooming and hygiene items, can leave the facility unattended, and has a history of skin condition and atopy, which makes (R1) more susceptible to infections. Further review of the Department of Health Care Services Individual Service Plan (dated 05/23/25) revealed (R1) is at risk for skin breakdown and infection. Prescription Medication Orders (dated 08/07/25) revealed that (R1) is prescribed prescription and PNR medications of a total of (30). Eight (8) out of the thirty (30) have side effects that weaken the immune system and are more susceptible to infection (ref: National Institute of Health), and a weakened immune system can be a trigger for viral infections. According to (ref: National Institute of Health) A viral infection can impact how long bacteria survive on utensils, but it's unlikely. Bacteria need specific conditions, like warmth and moisture, to live. Therefore, sharing utensils, cups, and straws poses a low risk for spreading an infection since the environment is not suitable for bacteria to survive long enough to infect someone else. It is unlikely due to its low survivability outside of the body. The Department inspected the facility on August 07, 2025, and observed the facility in clean and sanitary condition including the dining and kitchen area. The Department observed Staff #3 (S3) washing, rinsing and soaking tableware in hot water with soap and bleach. Then the tableware items are stored in high temperature hood commercial dishwasher for a continuous cleaning and sanitation. (Evaluation Report continues LIC 9099-C) Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted with Roniesha Bryant, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Aug 17, 2025 · control 11-AS-20250806102852

Allegation investigated: Facility staff not providing adequate food service

This report supersedes report dated 07/10/2025 On 08/06/2025 at 8:45 AM, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit at this facility to deliver the complaint findings. During today's visit, LPA met with Christopher Redmond (In-Training Executive Director), and explained the purpose of the visit. An initial complaint visit was completed on 05/12/2025. During the initial visit the department conducted interviews with Assistant Administrator (A1), Staff #1 - Staff #9 (S1 - S9), and Resident #1 - #11 (R1 – R11). LPA requested copies of the staff roster (dated 04/17/2025), resident roster (dated 05/08/2025), LIC 601: Identification and Emergency Form (for R1), LIC 602: Physician Report (for R1), Admission Agreement (for R1), LIC 603: Preplacement Appraisal Information (for R1), LIC 625: Appraisal Needs and Service Plan (for R1), Reappraisal (for R1), Medication Administration Record for R1 (March 2025 – May 2025), and LIC 624: Unusual Incident/Injury Report for R1 (March 2025). Substantiated The investigation revealed the following: Allegation 1: Facility staff not providing adequate food service It was alleged that for the past months facility staff were not providing vegan meals. The resident often received only a slice of bread and some canned vegetable. On 05/12/2025 at 10:30 AM, LPA interviewed Assistant Administrator (A1), who denied the allegation, stating that "If a resident has a special diet, we follow the doctor's orders. It is posted in the kitchen and on the table. If they’re still hungry, snacks and an alternative menu are available.” On 05/12/2025, between 10:30 AM – 1:55 PM, and on 07/10/2025 between the hours, 9:55am - 9:57am, LPA interviewed 9 staff regarding the allegation: 9 of 9 staff denied the allegation. 1 out of 9 staff stated Resident 1 (R1) is the only is the only vegan resident and upon all resident admission, they request for dietary restrictions. Also Staff 9 stated that the vegan resident is offered salad, tuna, sugar-free jello, sugar-free pudding, cottage yogurt. And further stated if the resident would like more food or alternative option available are chicken, vegetables, and green salad. Between 9:48 AM – 2:37 PM, LPA interviewed 11 residents: 1 of 11 residents confirmed the allegation, 4 of 11 residents denied the allegation and 7 of 11 residents were aware of the allegation. On 06/24/2025, LPA conducted a records review and observed the following: For Resident's 1 (R1) LIC 603 Replacement Appraisal Information, under the Social Factor section it states vegetarian and under the service needed, its check yes for special diet/observation of food intake is vegetarian, rice upsets stomach. For Resident's 1 (R1) LIC 625 Appraisal/Needs & Service Plan on page 1 of 4 it states under the background information section "Now she's on vegan diet, no rice. Rice upsets her stomach. On 07/10/2025, LPA conducted a tour of the kitchen and dining room and observed the following: Resident 1's dietary instructions and name tags are not post on the table of the dining room nor in the kitchen. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided with appeal rights. The investigation revealed the following: Allegation 2: Facility staff are unable to communicate effectively with the residents It was alleged that the resident attempted to communicate with the kitchen staff, but they do not understand her because they only speak Spanish. On 05/12/2025 at 10:30 AM, LPA interviewed Assistant Administrator (A1), who denied the allegation, stating “Most residents here speak two to three languages. We have bilingual staff, and I also use Google Translate if needed. If there’s a barrier, we call the family or public guardian to assist.” Between 10:30 AM – 1:40 PM, LPA interviewed 9 staff regarding the allegation: 9 of 9 staff denied the allegation and stated that staff will collaboration with bilingual coworkers to overcome language barriers and or use of translation tools such google translator to communicate with the residents as needed. Between 9:48 AM – 2:37 PM, LPA interviewed 11 residents: 2 of 11 residents confirmed the allegation of which one of the residents expressed that staff ignored them, didn’t understand them, or failed to assist them when communication challenges arose. 8 of 11 residents denied the allegation stated that staff were helpful and compassionate, and communication was not an issue and 2 of 11 residents did not confirm or deny. Based on information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. No deficiencies were cited for the allegations above. An exit interview was conducted, and a copy of this report was provided to Christopher Redmond (In-Training Executive Director).the state’s words, verbatim · CDSS document, Aug 6, 2025 · control 11-AS-20250506162009

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Aug 13, 2025

Basic Services. . .However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal . . . Based on conducted interviews and records review the licensee failed provide the dietary needs as specified in Replacement Appraisal and Appraisal/Needs & Service Plan for Resident (R1).This poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 6, 2025

Plan of correction: The licensee will honor the dietary needs of all the residents as specified in Pre-Admission, Replacement Appraisal and Appraisal Needs & Service Plan. The licensee will ensure the dietary need for all residents are posted in the kitchen and on all the tables of the dining room. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

Type of visit: Case Management - Other

On 08/06/2025 at 8:40am Licensing Program Analyst (LPA) Antonine Richard conducted a Case Management visit to the facility above. For the purpose of following up on a confirmation of staff removal notification. LPA met with Christopher Redmond (In-Training Executive Training) and explained the reason for the visit. A notification letter was generated to notify the licensee of Staff #1(S1) confirmation of removal. LPA spoke with Staff #2 (S2) who explained that S1 no longer works at the facility. Upon verification on 08/06/2025 at 8:48 from for the facilities Human Resources (HR) department, S1 was employee with the facility from 06/14/2021 - 11/12/2024. At 9:15am, during this visit, LPA obtained a copy of the LIC 500 Personnel Report from the receptionist, which confirm that Staff #1 is not working at the facility. The Department received information an individual Staff #1 should not be on site, and this has been verified during today’s visit. No citations issued during today's visit. An exit interview was conducted, and a copy of this report was provided to Christopher Redmond (In-Executive Director).the state’s words, verbatim · CDSS document, Aug 6, 2025

Type of visit: Case Management - Deficiencies

On July 28, 2025, between 9:07 AM and 09:53 AM, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit and met with Christopher Redmond, Executive Director, and explained the purpose of the visit. On July 24, 2025, the Department conducted its annual inspection and issued Title 22 Regulation Incidental Medical and Dental Care 87465(h)(6) (A-F). As a result of the deficiency cited on July 24, 2025, civil penalties are assessed on July 28, 2025, under the California Code of Regulations, Title 22, Division 6, Chapter 8. Please refer to the attached document LIC 9099-D for more information. An exit interview was conducted with Christopher Redmond, Executive Director , and a copy of this report was provided, including information about the appeal rights.the state’s words, verbatim · CDSS document, Jul 28, 2025

Type of visit: Required - 1 Year

On 07/24/2025 at 8:40am Licensing Program Analyst (LPA) Zina Brown and Lizeth Villegas and conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Catherine Dacara (Assistant Administrator) and explained the purpose of today’s visit. The facility is licensed to serve four (4) ambulatory, 174 non-ambulatory, and 30 bedridden resident age 60 and above. The facility is approved to accept or retain 30 residents on hospice and may accept or retain reside who have dementia. Currently, the facility has 92 residents. The facility has a current administrator certificate (#7019164740 Exp. 8/12/25) for Melissa Flores. The facility has liability insurance with Bridgeway Insurance Company with each occurrence at $1,000,000 and general aggregate at $3,000,000 (policy #8H-A7-MM-0002272 valid 12/05/2024 - 12/05/2025) The facilities annual fees are current. The two-story commercial building consists of one hundred (100) resident bedrooms, multiple resident bathrooms,(3) common bathrooms, (4) shaded patios, (1) smoking area, dining room, commercial kitchen, staff room, office area, media room, garden area, a laundry, and multiple storage rooms. The facility has a memory care unit with delay egress doors. LPA's Brown and Villegas conducted a records review of (10) resident records, (10) staff records, and the facility disaster plan. Facility disaster plan is observed to be current and in compliance with Title 22 regulations at the time of visit. LPA Brown conducted a review of (9) Resident Medication Administration Records did observe discrepancies at the time of visit. Report continues on LIC 809-C Between the hours of 9:25am - 10:05am, LPA Villegas and staff toured the physical plant. Ten (10) bedrooms were inspected, (3) of the (7) bedrooms inspected were in the memory care unit. All bedrooms were observed to have pull cords located next to the residents bed and in the bathroom. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for residents’ personal belongings is available. In the memory care unit, the resident have auditory alarms located on outside patio doors. The water temperature was tested in (10) resident bathrooms. All rooms had the required furniture. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. LPA observed the facility to have a first aid kits, manual, and emergency supplies. A comfortable temperature was maintained in the facility. LPA observed the facility to be sanitary, well maintained, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed and are accessible to residents. The commercial kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. LPA observed the kitchen area to be clean and free from pests. The facilities fire extinguishers were checked and found to be fully charged and accessible; and last serviced on 09/20/2023. All exit doors in the facility have alarm systems. The facility has hardwired and battery-operated smoke and carbon monoxide detectors and are in working condition. A working landline telephone remains available. The last fire drill was conducted 07/13/2025. There were no bodies of water or obstructions on the premises. LPA observed the following not in compliance: On 07/24/2025, LPA observed no personnel record on file for Staff #9 and medication discrepancies. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did observe deficiencies, and citations were issued at this time. Exit interview was held and a copy of the Facility Evaluation Report with Appeal Rights were provided to Catherine Dacara (Assistant Administrator)the state’s words, verbatim · CDSS document, Jul 24, 2025

Allegation investigated: Staff are not providing resident with daily meals. Staff are not addressing resident bathing needs. Staff are restricting resident from participation in activities. Staff are financially abusing resident. Staff do not respond to residents call button in a timely manner.

On 07/23/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit to this facility to further investigate the above-mentioned allegations and deliver findings. The department met with Christopher Redmond-Executive Director Intern and explained the purpose of the visit. LPA was granted access to the facility. The investigation consisted of the following: On 04/17/25, the department requested and collected copies of the following documents: Identification and Emergency Information, Physician's Report, Admission Agreement, Personal Rights, and Appraisal/Need & Service Plan for residents #1 - #3 (R1 - R3). Additionally, the department requested the staff roster, client roster, the facilities meal schedule for the months of March and April 2025, the activity schedule for the months of March and April 2025, and the staff schedule dated: March 1, 2025 - April 19, 2025. CONTINUED ON LIC9099-C Unsubstantiated On 05/22/25, the department requested the following documents: staff roster, resident roster, and the shower schedule. The department conducted interviews with staff #1 - #7 (S1 – S7), residents #3 - #4 (R3 – R4), and attempted to interview residents #1 - #2 (R1 – R2). On 07/16/25, the department conducted interviews with staff #8 (S8), (R2), residents #5 - #10 (R5-R10), and attempted to interview R1. On 07/23/25, the department received the following documents: Medication Administration Records (MAR) for R1, R3, and R4, for the months of March, April, and May 2025, and the facility’s activities calendar for the month of June. Additionally, the department conducted a tour of the kitchen and dining room. The investigation revealed the following: Allegation: Staff are not providing residents with daily meals. It is being alleged that the facility is not providing a resident with their daily meals. It is also being alleged that the facility is not providing the resident with their dietary needs. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed, 8 out of 8 staff denied the allegation. 8 out of 8 staff stated that residents receive three meals a day, including snacks in between. 8 out of 8 staff said that the facility does accommodate residents with special dietary needs. S1 stated that all residents receive three meals daily, including snacks, and that meals are determined based on their dietary needs. S1 said that if a resident has a special diet, the facility follows the doctor's orders, and it’s posted in the kitchen. If the residents are still hungry, snacks and alternative menu options are always available. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 7 out of 9 residents said that staff are providing them with their daily meals. 7 out of 9 residents stated that they had no complaints about the food being served at this facility. 7 out of 9 residents said this facility is meeting their dietary needs. The Department reviewed the Menu for the months of March, April and May 2025, and observed that the residents are getting a variety of nutritious foods for breakfast, lunch, and dinner. The menu was a healthy diet that emphasizes a wide variety of foods from all food groups, including fruits, vegetables, grains, lean protein sources (like fish, beans, eggs, lean meats) and dairy and dairy alternatives. On 07/23/25, the department conducted a tour of the kitchen and dining room and observed residents’ special dietary instructions posted on a board in the kitchen. Additionally, the department observed that residents were served lunch soup, vegetables, a turkey club sandwich, salad and chips. The department observed some residents immediately ate the food while others spent leisure time socializing along with their meals. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff are not addressing resident bathing needs. It is being alleged that staff are not assisting a resident with bathing. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed 8 out of 8 staff denied the allegation. 8 out of 8 staff stated that staff assist residents with bathing 2-3 times a week. S1 said the caregivers are well organized, and they directly help the residents with their bathing needs. S1 said the facility has what they call “zones”, and each caregiver has their own zone. That caregiver gets to know the residents within that zone and offers to assist the residents with showers every morning. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 3 out of 9 residents said staff assist them with their bathing needs, while 6 out of 9 residents said they do not require any assistance with bathing. 7 out of 9 residents said they are satisfied with the services provided to them. The department reviewed the facility’s shower schedules for the months of March 2025 and May 2025. The department observed that residents are divided by zones 1-3, and each resident is scheduled to shower 2-3 times a week. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. CONTINUED ON LIC9099-C Allegation: Staff are restricting residents from participating in activities. It is being alleged that a resident is being restricted from engaging in activities. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed 8 out of 8 staff denied the allegation. 8 out of 8 staff said that residents are encouraged daily to participate in activities. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 9 out of 9 residents said staff do not restrict them from participating in any activities. 7 out of 9 residents said they are satisfied with the services provided to them. The Department reviewed the facility's activities calendar, which featured daily events, social activities, arts and crafts, yoga, table games, bingo, karaoke and spa days planned for residents in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff are financially abusing residents. It is being alleged that staff are withdrawing money from a resident’s account without their consent. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed 8 out of 8 staff denied the allegation. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 9 out of 9 residents said staff have not financially abused them. 9 out of 9 residents said they do not know if staff are financially abusing a resident. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. CONTINUED ON LIC9099-C Allegation: Staff do not respond to residents’ call button in a timely manner. It is being alleged that staff are not responding to a residents call button. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed, 8 out of 8 staff denied the allegation. 8 out of 8 staff said that staff usually take 5 minutes to respond when a resident activates their call light. S1 stated that when a resident activates their call light or button, that call will go directly to the reception desk. The staff at the reception desk have radios, and they will radio a caregiver for assistance. S1 said they also have a paging system if needed. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 9 out of 9 residents denied the allegation. 5 out of 9 residents said staff take about 5 minutes to respond when a resident activates their call light. 7 out of 9 residents said they are satisfied with the services provided to them. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of the report was provided to Christopher Redmond, Executive Director Intern. The department conducted interviews with staff #1 - #7 (S1 – S7), residents #3 - #4 (R3 – R4), and attempted to interview residents #1 - #2 (R1 – R2). On 07/16/25, the department conducted interviews with staff #8 (S8), (R2), residents #5 - #10 (R5-R10), and attempted to interview R1. On 07/23/25, the department received the following documents: Medication Administration Records (MAR) for R1, R3, and R4, for the months of March, April, and May 2025, and the facility’s activities calendar for the month of June. Additionally, the department conducted a tour of the kitchen and dining room. The investigation revealed the following: Allegation: Staff are not dispensing medication as prescribed. It is being alleged that the facility is not administering a resident’s medication as prescribed. On 05/22/25, between 10:15 AM and 12:45 PM, the department interviewed S1-S7, and on 07/16/25, between 03:15 PM and 3:25 PM, the department interviewed S8. Of those interviewed 8 out of 8 staff denied the allegation. 8 out of 8 staff stated that staff administer the resident’s medication on time and as prescribed by their physician. On 05/22/25, between 1:30 PM and 3:00 PM, the department interviewed R3-R4. On 07/16/25, the department interviewed R2, and R5-R10. The department was unable to interview R1 on both dates. Of those interviewed, 7 out of 9 residents said that staff administer their medication on time and as prescribed by their physician, and 2 out of 9 residents said staff do not administer their medication on time and as prescribed. On 07/23/25, the department reviewed MAR’s for R1, R3, and R4 for the months of March, April, and May 2025. The records revealed discrepancies, and various medications were missed on various dates for R1, R3, and R4, for the months of March, April, and May 2025. Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited. Please see the attached LIC 9099-D. An exit interview was conducted, and a copy of the report was provided to Christopher Redmond, Executive Director Intern.the state’s words, verbatim · CDSS document, Jul 23, 2025 · control 11-AS-20250407163921

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(4) · Plan of correction due date: Aug 6, 2025

87464(f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met as evidenced by: Based on records reviewed and interviews, On 07/23/25, MAR's for R1, R3, and R4 for March-May 2025 revealed discrepancies, and various medications were missed on various dates for R1, R3, and R4, for the months of March, April, and May 2025which poses/posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 23, 2025

Plan of correction: Licensee will provide training for all med techs to attend regarding policies and procedures for medications. Proof of training will be sent to LPA before POC due date.

Allegation investigated: Facility staff not providing adequate food service.

On 07/10/2025 at 8:25 AM, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent visit at this facility to deliver the complaint findings. During today's visit, LPA met with Christopher Redmond (In-Training Executive Director), and explained the purpose of the visit. The investigation consisted of the following: An initial complaint visit was completed on 05/12/2025. During the initial visit the department conducted interviews with Assistant Administrator (A1), Staff #1 - Staff #9 (S1 - S9), and Resident #1 - #11 (R1 – R11). LPA requested copies of the staff roster (dated 04/17/2025), resident roster (dated 05/08/2025), LIC 601: Identification and Emergency Form (for R1), LIC 602: Physician Report (for R1), Admission Agreement (for R1), LIC 603: Preplacement Appraisal Information (for R1), LIC 625: Appraisal Needs and Service Plan (for R1), Reappraisal (for R1), Medication Administration Record for R1 (March 2025 – May 2025), and LIC 624: Unusual Incident/Injury Report for R1 (March 2025). Substantiated The investigation revealed the following: Allegation 2: Facility staff are unable to communicate effectively with the residents It was alleged that the resident attempted to communicate with the kitchen staff, but they do not understand her because they only speak Spanish. On 05/12/2025 at 10:30 AM, LPA interviewed Assistant Administrator (A1), who denied the allegation, stating “Most residents here speak two to three languages. We have bilingual staff, and I also use Google Translate if needed. If there’s a barrier, we call the family or public guardian to assist.” Between 10:30 AM – 1:40 PM, LPA interviewed 9 staff regarding the allegation: 9 of 9 staff denied the allegation and stated that staff will collaboration with bilingual coworkers to overcome language barriers and or use of translation tools such google translator to communicate with the residents as needed. Between 9:48 AM – 2:37 PM, LPA interviewed 11 residents: 2 of 11 residents confirmed the allegation of which one of the residents expressed that staff ignored them, didn’t understand them, or failed to assist them when communication challenges arose. 8 of 11 residents denied the allegation stated that staff were helpful and compassionate, and communication was not an issue and 2 of 11 residents did not confirm or deny. Based on information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. The investigation revealed the following: Allegation 1: Facility staff not providing adequate food service It was alleged that for the past months facility staff were not providing vegan meals. The resident often received only a slice of bread and some canned vegetable. On 05/12/2025 at 10:30 AM, LPA interviewed Assistant Administrator (A1), who denied the allegation, stating that "If a resident has a special diet, we follow the doctor's orders. It is posted in the kitchen and on the table. If they’re still hungry, snacks and an alternative menu are available.” On 05/12/2025, between 10:30 AM – 1:55 PM, and on 07/10/2025 between the hours, 9:55am - 9:57am, LPA interviewed 10 staff regarding the allegation: 10 of 10 staff denied the allegation. 1 out of 10 staff stated Resident 1 (R1) is the only is the only vegan resident and upon all resident admission, they request for dietary restrictions. Also Staff 10 stated that the vegan resident is offered salad, tuna, sugar-free jello, sugar-free pudding, cottage yogurt. And further stated if the resident would like more food or alternative option available are chicken, vegetables, and green salad. Between 9:48 AM – 2:37 PM, LPA interviewed 11 residents: 1 of 11 residents confirmed the allegation, 4 of 11 residents denied the allegation and 7 of 11 residents were aware of the allegation. On 06/24/2025, LPA conducted a records review and observed the following: For Resident's 1 (R1) LIC 603 Replacement Appraisal Information, under the Social Factor section it states vegetarian and under the service needed, its check yes for special diet/observation of food intake is vegetarian, rice upsets stomach. For Resident's 1 (R1) LIC 625 Appraisal/Needs & Service Plan on page 1 of 4 it states under the background information section "Now she's on vegan diet, no rice. Rice upsets her stomach. On 07/10/2025, LPA conducted a tour of the kitchen and dining room and observed the following: Resident 1's dietary instructions and name tags are not post on the table of the dining room nor in the kitchen. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED under California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 11-AS-20250506162009

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Jul 17, 2025

Basic Services. . .However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal . . . Based on conducted interviews and records review the licensee failed provide the dietary needs as specified in Replacement Appraisal and Appraisal/Needs & Service Plan for Resident (R1). This poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2025

Plan of correction: The licensee will honor the dietary needs of all the residents as specified in Pre-Admission, Replacement Appraisal and Appraisal Needs & Service Plan. The licensee will ensure the dietary need for all residents are posted in the kitchen and on all the tables of the dining room. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

Allegation investigated: Staff is stealing residents personal property.

This report serves to clarify the Investigation findings and is created to supersede the LIC9099 and LIC9099-C reports created on 04/10/2025. Although this report supersedes the previous report, the complaint investigation findings remain the same. 05/29/2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint regarding the above-mentioned allegation. LPA met with the Administrator, Catherine Dacara, and explained the purpose of today's visit. The investigation consisted of the following: On February 5, 2025, LPA and staff toured the facility, visiting rooms #225 and #228. LPA Richard reviewed and requested, staff and residents' roster. Individual Services Plan (ISP), Physician's Report for Residential Care for the Elderly (RCFE). Admission Agreement, Theft/Loss Policy, Resident Safeguard of Valuables/Property. LPA Richard interviewed six (6) residents (R2-R7), four (4) staff (S1-S4), and other documents. Report continued LIC9099-C Unsubstantiated Allegation: Staff are stealing residents' personal belongings. The complaint alleges that staff at Glen Park in Long Beach have stolen residents' jewelry and paintings and have stolen other residents' belongings. On February 5, 2025, between 11:00 AM and 12:00 PM, LPA Richard conducted interviews with four staff members #1-4 (S1-S4). All four staff members denied the allegation. They explained that each resident has a key, and if a resident is not in their room, the staff are not permitted to enter, except to clean the resident's room. Additionally, they emphasized that the facility ensures the protection of all residents' belongings, and no residents have ever complained to them about missing jewelry or other items from their rooms. On February 5, 2025, between 12:00 PM and 2:00 PM, LPA Richard interviewed seven residents #1-7 (R1-R7). 6 out of 7 residents denied that any staff member had ever stolen their personal belongings. They indicated that each resident has a key to their room and can lock it when they are not present. Additionally, they mentioned that staff typically knocked before entering their rooms. On April 9, 2025, the Licensing Program Analyst (LPA) interviewed Witness 1 (W1). W1 reported that Resident #1 (R1) mentioned to them that some items were missing from R1's room three years ago, during the tenure of a different Executive Director. However, W1 could not specify what items were missing, who among the staff might have taken them, or the exact date of the incident. Reports continued LIC9099-C W1 also indicated that a resident was responsible for the theft and returned the items to R1 when confronted. On February 5, 2025, LPA Richard reviewed various documents related to R1, including the Safeguard of Valuables/Property form dated April 25, 2017. This document indicated that all items listed as missing were found in R1's room. LPA also reviewed the Theft/Loss Policy, which states that any lost or stolen property valued at $25 or more must be documented on an Unusual Incident Form within 72 hours of discovery. Any property valued at $100 or more must be reported to the Police. LPA did not find any Theft/Loss documents filed in the facility by R1. Based on the information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, May 29, 2025 · control 11-AS-20250203140724

Allegation investigated: Staff do not ensure that resident has transportation to receive substance abuse and mental health treatment.

On 05/29/2025, at 9:20am, Licensing Program Analyst (LPA) Zina Brown conducted a subsequent complaint visit at this facility to deliver the complaint findings. During today’s visit, LPA met with Catherine Dacara (Assistant Administrator) and explained the purpose of the visit. The investigation consisted of the following: An initial complaint visit was completed by the department on 05/12/2025 during the visit conducted interviews with Administrator (A1), Staff (S1-S8) and Residents (R1-R11) from 9:51am – 2:30pm. The department received the following documents: Resident Roster (dated 05/28/2025), Staff Roster (dated 04/17/2025), LIC 601 Identification and Emergency Information (for R1) - dated 03/12/2025, LIC 602: Physician Report for RCFE (for R1) - dated 03/04/2025, LIC 603A: Resident Appraisal (for R1) - dated 03/13/2025, LIC 624: Unusual Incident/Injury Report - dated 04/25/2025, Admission Agreement – (dated 03/12/2025) and Medication/Treatment Administration Record March 2025 - May 2025. Unsubstantiated The investigation revealed the following: Allegation - Staff do not ensure that resident has transportation to receive substance and mental health treatment It is alleged that the facility had 911 respond due to individual needing a ride to a weekly appointment to get methadone. Glen Park does not have the ability to provide this individual with methadone and/or a ride to appropriate facility for such. On 05/29/2025 at 9am, LPA conducted a review of R1's file. In the Admission Agreement, on page 13 of 27 of the facility admission agreement is stated under Transportation Services: Transportation for our Activity related programs is free. We will assist residents with signing up for transportation services with community transportation resources if applicable such as Dial-a-Ride and/or ACCESS. The community will transport residents within a 7-mile radius of community for all matters. The residents will need to inform the front front desk of transportation needs, and the receptionist will decide with the driver. In R1's file it is documented resident can not determine his need for prescription and or nonprescription PRN medication and cannot clearly communicate his symptoms indicating a need for nonprescription PRN medication (licensee must contact physician before each dose). R1 receives methadone shots weekly. Coastal Recovery arranges transportation for R1. However if Coastal Recovery does not show up to provide R1 transportation, the facility assist R1 with public transportation via city bus and or uber/lyft to ensure resident did not his sessions. On 05/12/2025, the department interviewed Administrator (A1), Staff (S1–S8), and Residents (R1–R11) from 9:51 a.m. to 2:30 p.m. about the allegation. Four (4) of nine (9) staff denied the allegation. The remaining five (5) out of nine (9) staff did not confirm or deny the allegation. The department interviewed residents (R1–R6) about the allegation, and two (2) of eleven (11) confirmed the allegation. Six (6) of 11 residents denied the allegation. Three (3) of eleven (11) resident didn’t confirm nor deny the allegation. Most residents interviewed stated that they are provided transportation assistance to attend their appointments and have not experienced issues with accessing their treatment providers. Based on records review, interviews and observation LPA did not find sufficient evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. No deficiencies were cited for this allegation. An exit interview was conducted, and a copy of this report was provided to Catherine Dacara (Assistant Administrator)the state’s words, verbatim · CDSS document, May 29, 2025 · control 11-AS-20250506180252

Allegation investigated: Staff illegally evicted resident in care.

On 05/12/25, Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit regarding the allegation above. LPA Villegas met with the Assistant Administrator Cathrine Dacara as the purpose of te visit was explained. Investigation Consisted of the following: On 04/24/25, LPA Richard conducted the following interviews: Administrator (A1), Executive Director (S1), Licensed Vocational Nurse (S2), Office Manager (S3), and Resident’s #2-5 (R2-R5). LPA Richards obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R1) Identification and Emergency Information, Physicians Report, Medication Mar (MAR), Needs of Service Plan, Resident Appraisal (dated 04/02/25) and Patient Pogress notes (dated 03/26/25 to 04/02/25). On 5/12/25 at 11am LPA Villegas conducted second interview with A1 and from 11:30am- 1pm LPA Villegas conducted interviews with R6-R9. On 05/12/25 LPA conducted a file review for R1. The investigation revealed the following: Substantiated Allegation: Staff illegally evicted resident in care. It is being alleged that Glen Park at Long Beach would not readmitted resident after resident was discharged from the hospital. On 04/24/25 and 05/12/25 interviews were conducted with R2-R9 regarding the allegation above, 8 of 8 residents interviewed denied the allegation above. Resident #1 (R1) was not interviewed as R1 is no longer receiving care at Glen Park at Long Beach. On 4/24/25 LPA Richard conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above and reported that resident was not evicted as it was determined upon reassessment that resident needed a hire level of care. On 04/24/25 and 05/12/25 interviews were conducted with A1 regarding the allegation above, A1 denied the allegation above and reported that upon reassessment of R1, it was determined that the facility could not meet R1's needs as R1 requires a higher level of care. On 05/12/25 LPA Villegas conducted a file review for R1, per admission agreement, R1 was admitted to Glen Park at Long Beach on 03/26/24, on Physicians Report dated: 3/11/2024, and Needs of Service Plan dated:10/26/2024 it is indicated that R1 has Schizophrenia. On unusual incident report dated 03/28/25 it is reported that R1 was placed on a 5150 on 3/25/25, on resident appraisal dated 04/02/25 it is indicated that R1 needs mental health attention. LPA Villegas did not observe any record confirming that an incident report was sent to CCLD communicating that R1 was hospitalized 03/25/25. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 12, 2025 · control 11-AS-20250418141748

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(4) · Plan of correction due date: May 26, 2025

The licensee may evict a resident for one or more of the reasons... (30) days written notice to the resident is required except...If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant... and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. Based on interviews and record review the licensee did not comply with the section cited above as there was no indication that there was significant change in R1, R1 did not have a need that was not previously identified. which poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 12, 2025

Plan of correction: The licensee and executive director will review title 22 eviction regulations and submit a statement acknowleding the review and acknowledge the understanding of title 22 regulations. Licensee and executive director to submit a written plan detailing how facility will get into complaince of title 22 regulations. Plan to be submitted to LPA by POC due date.

Type of visit: Case Management - Other

On 05/12/25, Licensing Program Analyst (LPA) Villegas conducted an unannounced case management visit to issue citation observed during complaint investigation # 11-AS-20250418141748. LPA met with Assistant Administrator Cathrine Dacara as the purpose of the visit was explained. LPA noted during complaint investigation on 05/12/25 the facility failed to report to CCLD that R1 was placed on a 5150 hold on 3/25/25. During file review, facility could not provide proof/a fax confirmation that the incident report was sent to CCLD within seven days of the occurrence. Citation on 809D. Exit interview conducted, appeal rights explained, and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 12, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: May 12, 2025

Each licensee shall furnish to the licensing agency such reports as the Department may require...A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Based on interviews conducted and records review licensee failed to report that R1 was placed on a 5150 hold which poses a health and safety risk to residents in carethe state’s words, verbatim · CDSS document, May 12, 2025

Plan of correction: Director to submit a plan to ensure facility is in compliance with 87211 (a)(1) and submit plan outlining the steps that will be taken to ensure compliance of section cited. Plan to be submitted to LPA by POC due date

Allegation investigated: Staff is stealing residents personal property.

On 04/10/2025, Lincensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint visit regarding the above allegation. The department met with the Administrator Catherine Dacara, and explained the reason for the visit. The investigation consisted of the following: On 02/05/2025, (LPA) and staff toured the facility inside and visit room #225 and room #228. LPA Richard reviewed and requested, staff and resident's roster. Individual Services Plan (ISP), Physician's Report for Residential Care for the Elderly (RCFE). Admission Agreement, Theft/Loss Policy, resident Safeguard of Valuables/Property. LPA Richard interviewed six (6) residents (R2-R7), and four (4) staff (S1-S4), and other documents. Unsubstantiated Allegation: Staff is stealing residents' personal belongings. It is being alleged that staff at Glen Park in Long Beach have stolen resident jewelry and paintings and have stolen other resident belongings. On 02/05/2025, between 11:00 AM, and 12:00 PM, LPA Richard interviewed four (4) staff (S1- S4). 4 out of 4 staff denied the allegation against them. They stated that all the residents have their key, and if a resident is not in the room, the staff is not allowed to enter except to clean resident rooms. They also stated that the facility makes sure all the residents' belongings are protected, and no resident ever complained to them about missing jewelry or other items inside their rooms. On 02/05/2025, between 12:00 PM and 2:00 PM, LPA Richard interviewed seven (7) residents (R1- R7). 6 out of 7 denied that staff ever stole their personal belongings. They also stated that each resident has a key to their room, and they can lock their room if they are not there. They also stated that the staff usually knocked before entering inside their room. LPA interviewed seven (7) residents (R1- R7). 1 out of 7 residents was unable to provide any details of the items stolen, the dates when it occurred, or the names and descriptions of the individuals involved about the allegation that staff is stealing residents’ personal belongings. Continued LIC9099-C On 04/09/25, LPA interviewed Witness (W1), who stated that R1 did inform W1 that some items were missing from R1 room and that happened 3 years ago under a different Executive Director, but W1 could not describe the items, names of the staff who stole the items, and date when it happened. W1 also stated that it was a resident who stole the item and returned it to R1 when confronted. On 02/05/2025, LPA Richard reviewed various documents related to (R1), including Safeguard of Valuables/Property (dated 04/25/17), the record indicating that there were several items listed but no mention of one the items reporting missing. On 02/05/25, LPA reviewed the Theft/Loss Policy, which indicated that lost or stolen property with a value of $ 25 or more shall be documented on an Unusual Incident Form (LIC624) within 72 hours of discovery. Stolen property with a value of $ 100 or more shall be reported to the Police. LPA did not observe any documents about R1 missing items in records. Based on the information gathered, interviews, and record reviews, there is not enough evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted with the Administrator, Catherine Dacara. A copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 11-AS-20250203140724

Allegation investigated: Staff do not properly maintain the residents report. Staff mishandled the residents personal funds. Staff do not have proper documentation regarding the residents. Staff did not properly report incidents involving residents. Staff did not prevent the residents from engaging in an altercation. Staff allow a resident to be soiled for extended period of time. Staff did not address the residents change in medical condition. Staff did not seek timely medical attention for a resident.

On 04/10/25, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint investigations visit. LPA met with the Administrator Catherine Dacara, and the purpose of the visit was explained. The investigation consisted of the following: On 12/20/24, LPAs Antonine Richard and Deborah Lee toured the facility, reviewed and obtained the following documents. On 12/20/24, LPAs obtained the resident roster (dated 12/13/24), staff roster (dated 12/13/24), and Medication Administration Record (MAR) for insulin injection (dated 11/01/24 to 11/30/24), Appraisal/Needs and Services Plan, Trust Account (3857) balance Sheet (dated 11/12/24), Record of client ‘s/Resident’s Safeguarded cash resources (dated 11/12/24), Petty Cash Receipt (dated 12/12/24), Unusual Incident/Injury Report (dated 10/09/24 to 11/06/24), Identification and Emergency Information 4), Physician’s Report (RCFE) (dated 05/22/24) Admission Agreement, Changing schedule. On 12/20/24, at 9:30 am to 12:00 pm, LPAs interviews with residents #1-7 (R1-R7), at 12:15 pm to 1:30 pm, LPAs interviews with staff #1-4 (S1-S4), at 1:30 pm to 2:30 pm LPAs interviews with Executive Director (ED) Licensed Vocational Nurse.(LVN). Unsubstantiated Allegation #1: The Staff does not properly maintain the residents' rooms. It is being alleged that rooms in the memory care unit are in badly need of repair. The department interviewed the facility Administrator (A1), who denied the allegation, stating that cleaning is done daily and that there is a cleaning schedule for Housekeeping to follow. On 12/20/24, between 09:30 am-02:00 pm, LPAs interviewed 8 residents (R1- R8). 8 out of 8 interviewed stated that the rooms are cleaned regularly. LPAs interviewed two (2) staff (S1, S4), and 2 out of 2 staff stated that rooms are cleaned daily unless the residents request not to have housekeeping clean the room that day. On 12/20/24, LPA obtained a copy of the daily cleaning schedule with outlined cleaning duties for the assigned staff (dated 12/ 2024, 04/2025) that indicates each resident's rooms are cleaned daily. Based on the interview and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore, the allegation is unsubstantiated. Allegation #2: Staff mishandled the president’s personal funds. It is being alleged that staff did not keep P & I documentation's and signatures of the residents showing transfer for cash. On 12/20/24, between 9:30 am to 12:00 pm, LPAs interviewed eight (8) residents (R1- R8). 8 out of 8 denied having any issue with their P & I fund. They also stated that they do not have any issue with the facility handling their funds, and they have had no discrepancies with their P & I fund. On 12/20/24, between 1:00 pm to 2:00 pm, LPAs interviewed the Administrator (A1), who denied the allegation and stated that not all the residents’ funds are being handled by the facility as some of the residents handle their funds. On 12/20/24, LPAs reviewed and collected several residents' Records of Client’s/Resident’s Safeguarded Cash Resources (dated 11/12/24-12/12/24) and Petty Cash (dated 11/12/24 -12/12/24); there are no records of residents reporting any missing money on 2024. Based on the interview and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore, the allegation is unsubstantiated. Allegation #3: Staff do not have proper documentation regarding the residents. It being alleged that the facility doesn’t have proper documentation for the resident. On 12/20/24, between 09:30 am to 12:00 pm, (LPAs) Richard and Lee requested, obtained and review eight (8) residents (R1 - R8) services records which included the following: Admission Agreement LIC 604, Appraisal/Needs and Services Plan LIC 625, Physician's Report LIC 602A, Identification and Emergency Information LIC 601. LPAs found written records, including Unusual Incident/Injury Reports LIC 624 for each client. Based on the information gathered, reviewed, and obtained, there is no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to support the alleged violation. As a result, the allegation is Unsubstantiated. Allegation #4: The Staff did not properly report incidents involving residents. It being alleged that the facility did not report altercations between residents. On 12/20/24, between 1:00 pm to 2:00 pm, LPA interviewed the Administrator (A1) who stated that the facility always reports any incidents that happened at the facility regardless is residents on residents or staff between residents. A1 also stated that all staff are required to complete incidents report when they occur and they are reviewed, then sent out. The LPAs' records reviewed of all the Incident reports (dated 10/09/24 to 11/06/2024) indicated that the facility reports all the incidents to the proper agency or the responsible party of all the residents. Based on the interview, the record reviewed the LPAs found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to support the alleged violation. As a result, the allegation is Unsubstantiated. Allegation #5: Staff did not prevent the residents from engaging in an altercation. It is being alleged that the staff did not prevent the resident from engaging in an altercation. On, 12/20/24, between 9:30 am to 12:00 pm, LPAs interviewed the eight (8) residents (R1- R8). 8 out of 8 stated that when the residents were fighting each other, the staff always tried to separate them by stepping between the residents. They also stated that the facility usually calls 911 if they don’t stop. On 12/20/24, between 1:00 pm to 2:00 pm, LPAs interviewed the Administrator, who denied the allegation and stated the facility would call 911 every time if the staff failed to separate them or get control of the situation. Based on the interview, the record reviewed the LPAs found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to support the alleged violation. As a result, the allegation is Unsubstantiated. Allegation #6: The Staff allows residents to be soiled for an extended period of time. It is being alleged that the residents are often left soiled for hours. On 12/20/24, LPAs interviewed eight (8) residents (R1- R8). 8 out of 8 stated that they get changed every two hours. 1 out of 8 stated that the longest they waited to be changed was around 30 minutes or so after they pushed the button. The staff do their best. On 12/20/24, between 1:00 PM to 2:00 PM, LPAs interviewed the Administrator (A1), who stated that the facility has a changing schedule, which is typically every 2 hours and/or earlier as needed. LPAs interviewed staff (S4) who stated that the facility has a schedule to change the resident every two hours. But if the residents push the call button, the next available staff member will go and help the residents. On 12/20/24, records reviewed of the changing schedule (dated 12/01/24 -12/20/24) indicated the staff does change the residents every two hours and sooner if the residents are in need. Based on the interview, the record reviewed the LPAs found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to support the alleged violation. As a result, the allegation is Unsubstantiated. Allegation # #7 Staff did not address the resident's change in medical condition. It is being alleged that staff did not have the right level of care plan for the resident, resulting in the resident going to the hospital multiple times. On 12/20/24, between 9:30 am to 12:00 pm, LPAs interviewed eight (8) residents (R1- R8). 8 out of 8 denied the allegation. LPAs interviewed 1 out of 8 residents who stated multiple visits to the hospital and stated it is to make sure the heart and body ache are not life threatening. Not because the facility does not have a care plan, the facility provided a great care plan during admission. LPAs interviewed two (2) staff members (S2- S3). 2 out of 2 denied the allegation and stated that MedTech pass meds, and are responsible for giving the medications. The Licensed Vocational Nurse (LVN) also monitors the condition of the resident if the resident's care plan needs to be reassessed. On 12/20/24, records reviewed of needs of services plan (dated 10/29/24) indicated that the facility is addressing the residents' change in condition every year. Based on the interview, the record reviewed the LPAs found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to support the alleged violation. As a result, the allegation is Unsubstantiated. Allegation #8 Staff did not seek timely medical attention It is being alleged that staff did not give the resident medication of insulin in time. On 12/20/24, between 9:30 am to 12:00 pm, LPAs interviewed seven (7) residents (R1- R7). 7 out of 7 denied the allegation and stated that the facility staff provides services on time, and they are happy with the staff's response time. The facility is a big place, so it depends on the shift; some are busier than others, so it may take them time to get to you after you push the button. The staff do their best. LPA records review of Medication (dated 11/01/24 to 11/30/24) indicated that all clients received the correct medications on time. On 12/20/24, at 1:00 pm, LPAs interviewed two (2) staff members. All denied the allegation and stated that when a resident needs medical attention, we do provide the resident the help they need, especially if the resident is on insulin injections. The only time insulin is not given is when the instructions call for the insulin to be held if a reading is too low, and when that happens, it is documented on the MAR. Also, if the resident is in a hospital or refuses and that too is documented on the MAR. Based on the interview and records reviewed, there is insufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore, the allegation is unsubstantiated. No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator Catherine Dacarathe state’s words, verbatim · CDSS document, Apr 10, 2025 · control 11-AS-20241215212802

Allegation investigated: Staff did not provide clients medical records in a timely manner.

On 02/27/25 at 9am Licensing program analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Quality Assurance Director Rafeal Silvas the purpose of the visit was explained. The investigation consisted of the following: On 02/27/25 LPA Villegas obtained a copy of the following documents: staff roster, resident rosters, list of residents obtaining services from PACE/Welbe health,and identification and emergency information form for residents #1-13 (R1-R13). On 02/27/25 between 9:10am- 10:30am LPA conducted interviews with residents #1-7 (R1-R7), and between 10:30am- 10: 50am LPA Villegas conducted interviews with staff #1-2 (S1-S2). The investigation revealed the following: Allegation: Staff did not provide clients medical records in a timely manner. It is being alleged that copies of Medication Administration Records are not being provided in a timely manner when requested. There were no residents identified in nitial report. Unsubstantiated On 02/27/25 between 9:10am- 10:30am LPA conducted interviews with residents #1-7 (R1-R7) regarding the allegation above, 7 of 7 residents interviewed denied the allegation above. On 02/27/25 between 10:30am- 10:50 am am LPA Villegas conducted interviews with staff #1-2 (S1-S2), 2 of 2 staff denied the allegation above and reported copies of medication administration records are provided when requested, copies of records can take 2-5 days to generate. On 02/27/25 LPA did not observed any evidence that any request was made by a resident or responsible party. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Quality Assurance Director Rafeal Silvas, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 11-AS-20250219143528

Allegation investigated: Resident did not receive medication as prescribed.

On 02/27/2024 at 10:45 am, Licensing Program Analyst (LPA) Zina Brown and Licensing Program Manager (LPM) Janae Hammond conducted a subsequent visit in order to deliver investigation findings. LPA/LPM met with Rafael Silva, Quality Assurance Director.and explained the purpose of the visit . The investigation consisted of the following: On 12/16/2024 LPA ZinaBrown interviewed the Administrator (A1), Staff #2 - Staff #6 (S2 - S6) and Resident # 1 - Resident #9 (R1 – R9). LPA requested resident/staff Roster, resident files for Resident #1 - Resident #9 (R1 - R9) such as LIC 601 / Pre-Placement Appraisal/ Functional Capability Assessment/Medication List/ Admission Agreement/ Physician Report, proof of Staff Training (med-tech/caregiver) – Initial Training and ongoing training, timecards for staff (October 2024 – December 2024), list of incontinence residents. On 1/21/25 at 2:48pm LPA interviewed Staff #1. On 1/21/24 at 8:47am LPA interviewed Resident #10. On 1/24/25 at 9:05am LPA/LPM interviewed Staff #7. Substantiated The investigation revealed the following: Allegation: Resident did not receive medication as prescribed. It was alleged there are multiple medication errors including some residents are not receiving their medications. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied being aware of any residents not receiving their medications. On 12/16/2024 between 11:45am - 1:00 pm and 1/21/25 2:48pm and 1/24/25 at 9:05 am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 3 of 7 staff interviewed denied the allegation; 3 of 7 staff interviewed were unable to answer the questions since they do not administer medications and 1 out of 7 staff confirmed the allegation. On 12/16/2024 between 10:00am - 11:30am and 1/22/2025 8:47am - 9:38am and 1/21/25 8:47am, LPA/LPM interviewed Residents #1-10. 6 of 10 residents denied the allegation; 3 of 10 residents confirmed the allegation and 1 of 10 residents stated they sometimes don’t receive medications. LPA/LPM reviewed 9 residents Medication Administration Records (MAR) and medications, 9 out of 9 reviewed had medication errors. 8 of 9 medications were not in the medication was not in the bubbled pack and the MAR was not signed;1 of 9 residents MAR is not signed from 12/1/24-12/16/24 for routine medications; 3 of 9 residents medication was still in the bubble pack (not given) and the MAR was not signed. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D. Exit interview conducted, appeal rights explained, and a copy of this report was provided to Rafael Silva, Quality Assurance Director. The investigation revealed the following: Allegation: Unqualified staff is administering insulin injections to residents. It is alleged appropriate skilled professionals are not administering insulin injections to diabetic resident on the weekend when the LVN is not working. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 stated LVN administers insulin Monday-Friday and med tech administer insulin hand over hand to residents. On 12/16/2024 between 11:45am -1:00 pm and 1/21/25 2:48pm and 1/24/25 at 9:05am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 2 of 7 staff interviewed stated the LVN administers insulin and med techs prepare the medication and the resident self administers; 2 of 7 state the LVN administers insulin and comes in to assist as needed on the weekend; 2 of 7 state they have witnesses the LVN and med techs administer insulin and 1 of 7 state the LVN administers insulin and they have never witnessed med techs administer insulin. On 12/16/2024 between 10:00am-11:30am and 1/21/2025 8:47am - 9:38am, LPA/LPM interviewed Residents #1-10. 9 of 10 residents stated the LVN administers insulin and 1 of 10 stated the LVN and med techs administer insulin. Allegation: Facility staff are stealing residents medication. It is alleged staff are stealing residents Narcotic medications. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied being aware of staff stealing medications. On 12/16/2024 between 11:45am - 1:00 pm, 1/21/25 2:48pm and 1/24/25 at 9:05am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 7 of 7 staff interviewed denied the allegation. On 12/16/2024 between 10:00am - 11:30am and 1/21/2025 8:47am-9:38am, LPA/LPM interviewed Residents #1-10. 10 of 10 residents denied the allegation. Report continues on LIC 9099-C page. Allegation: Illegal Eviction It was alleged R8 was issued, and eviction notice and was put outside the facility on the streets. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied R8 was issued an eviction notice but stated the facility intends to issue one. On 12/16/2024 between 11:45am-1:00 pm,1/21/25 2:48pm and 1/24/25 at 9:05am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 4 of 7 staff interviewed denied the allegation; 2 of 7 staff are aware of residents being evicted in the past. 1 out of 7 staff stated R8 was talked to about his behavior but was not issued an eviction notice. On 12/16/2024 between 10:00am-11:30am and 1/21/2025 8:47am - 9:38am, LPA/LPM interviewed Residents #1-10. 9 of 10 residents denied the allegation; 1 out of 10 residents confirmed receiving a verbal eviction. LPA/LPM conducted a file review and did not observe and eviction notices on file for R8. Allegation: Facility charging residents for services without consent. It is alleged facility does weekly COVID testing and residents insurance is being billed without consent from the residents or responsible parties. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied the allegation and stated the facility pays for COVID testing. On 12/16/2024 between 11:45am-1:00 pm, 1/22/25 2:48pm and 1/24/25 at 9:05am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 7 of 7 staff interviewed denied the allegation. On 12/16/2024 between 10:00am-11:30am and 1/21/2025 8:47am-9:38am, LPA/LPM interviewed Residents #1-10. 8 of 10 residents denied the allegation; 2 out of 10 residents confirmed the allegation. LPA/LPM conducted a review of records and did not observe any evidence that residents are being charged for COVID testing. Based on the records reviewed, interviews conducted and Observations the allegation are Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Rafael Silva, Quality Assurance Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 11-AS-20241210135158

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(6) · Plan of correction due date: Feb 28, 2025

87465 Incidental Medical and Dental Care Each facility shall develop a planned routine of medical and dental care and assisting in obtaining such care.When requested by the physician or Department, the facility shall maintain a record of centrally stored medication dosages. Based on observation, interview, and record review, the licensee did not comply with the cited section. During medication reviews, LPA observed MAR documentation showing resident didnt receive their medication which posing a potential health, safety, or personal rights risk.the state’s words, verbatim · CDSS document, Feb 27, 2025

Plan of correction: The Executive Director will conduct in-service training and implement a plan to check medications regularly to prevent discrepancies. Proof will be submitted via email at zina.brown@dss.ca.gov by the POC due date.

Allegation investigated: Licensee does not ensure facility is adequately staffed to meet resident's needs. Staff are not properly trained. Staff did not properly assess residents prior to admission.

On 02/27/2024 at 9:45 am, Licensing Program Analyst (LPA) Zina Brown and Licensing Program Manager (LPM) Janae Hammond conducted a subsequent visit in order to deliver investigation findings. LPA/LPM met with Rafeal Silva, Quality Assurance Director and explained the purpose of the visit . The investigation consisted of the following: On 12/16/2024 LPA Brown interviewed the Administrator (A1), Staff #2 - Staff #6 (S2 - S6) and Resident # 1 - Resident #9 (R1 – R9). LPA requested resident/staff Roster, resident files for Resident #1 - Resident #9 (R1 - R9) such as LIC 601 / Pre-Placement Appraisal/ Functional Capability Assessment/Medication List/ Admission Agreement/ Physician Report, proof of Staff Training (med-tech/caregiver) – Initial Training and ongoing training, timecards for staff (October 2024 – December 2024), list of incontinence residents. On 1/21/25 at 2:48pm LPA interviewed Staff #1. On 1/21/24 at 8:47am LPA interviewed Resident #10. On 1/24/25 at 9:05am LPA/LPM interviewed Staff #7. Unsubstantiated The investigation revealed the following: Allegation: Licensee does not ensure facility is adequately staffed to meet resident's needs. It was alleged that the facility is not meeting the resident’s needs adequately due to the facility not being adequately staffed. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 states the facility has about 34 staff and is adequately staff even with the agency that the facility uses. On 12/16/2024 between 11:45am - 1:00 pm, 1/21/25 2:48pm and 1/24/25 at 9:05 am, LPA/LPM interviewed Staff #1-7 regarding the allegation; 3 out of 7 staff confirmed the allegation facility is not adequately staffed, 4 out of 7 staff denied the allegation and feel the facility is adequately staffed. On 12/16/2024 between 10:00am - 11:30am and 1/21/2025 8:47am-9:38am, LPA/LPM interviewed Residents #1-10. 4 out of 10 residents confirmed the allegation; 6 out of 10 residents denied the allegation. LPA reviewed and observed on the Personnel Report LIC 500 and Timesheets Personnel Report that the following 10 Care Partners, 3 Med Techs (who work as Care Partners as well), 1 LVN, 1 Executive Director, 1 Office Manager, 1 Intake Coordinator, 2 Front Desk Staff, 2 Activity Director, 6 Housekeepers, 1 Maintenance Staff (who also serves as a medtech as well). The facility also utilizes a Home Care Organization, Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. Allegation: Staff are not properly trained It was alleged that the facility has not properly trained their staff. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied the allegation as she states the training process consist of the use of care and compliance for 40 hours of annual training, video training (20 hours), onboard training (30 days) and continued training as needed (8 hours on site). On 12/16/2024 between 11:45am - 1:00 pm, 1/21/25 2:48pm and 1/24/25 at 9:05 am, LPA/LPM interviewed Staff #1-7 regarding the allegation, 6 out of 7 staff interviewed denied the allegation; 1 out of 7 staff did not answer the question. On 12/16/2024 between 10:00am-11:30am and 1/21/2025 8:47am-9:38am, LPA/LPM interviewed Residents #1-10. 4 out of 10 residents interviewed confirmed the allegation; 6 out of 10 residents denied the allegation. On 12/19/2024, LPA received documented staff training conducted in 2024 and observed the following training completed for 9 out 9 staff: new employee 20 hour video training, OSHA Bloodborne Pathogen Training 30 Mins, Basic Medication Training, Medication Technician (8 Hours), Annual Training (2 Hours) 4 Quarter Dementia Topics: Dementia Care: Aggressive Behaviors, Therapeutic Interventions, California Medication Regulations, Workplace Violence and Home Care Organization. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has not been met, therefore the above allegation is found to be unsubstantiated. Allegation: Staff did not properly assess residents prior to admission. It was alleged that the facility does not conduct a pre placement assessment of residents prior to them being admitted to the facility. On 12/16/2024 at 9:45am, LPA/LPM interviewed the Administrator Melissa Flores regarding the allegation. A1 denied the allegation of residents not being assessed prior to admission. On 12/16/2024 between 11:45am -1:00 pm, 1/21/25 2:48pm and 1/24/25 a, LPA/LPM interviewed staff regarding the allegation; 5 out of 6 staff interviewed denied the allegation; 1 out of 6 staff interviewed were unable to answer the question. On 12/16/2024 between 10:00am -11:30am and 1/21/2025 8:47am-9:38am LPA/LPM interviewed residents #1-10 regarding the allegation 8 out of 10 residents interview denied the allegation; 1 out of 10 residents confirmed the allegation; 1 out of 10 residents was unable to answer the question. LPA conducted a file review of 10 resident records. 10 of 10 records reviewed contained proper admission documents. Based on the records reviewed, interviews conducted and Observations the allegations are Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Rafeal Silva, Quality Assurance Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 27, 2025 · control 11-AS-20241211135609

Allegation investigated: Staff did not meet resident's showering needs. Staff did not seek resident timely medical attention. Staff did not ensure security of resident's personal belongings. Staff gave an explanation of circumstances at the time of resident's death, different from what a doctor reported.

This report is an amendment of the complaint investigation dates 01/21/2024. The purpose of this amendment is to provide additional information to the complaint investigation. The findings remain Unsubstantiated. On 01/11/2024 Community Care Licensing Division (CCLD) conducted an unannounced visit to the facility Glen Park at Long Beach on 11/16/2023 and was greeted by Administrator Michael Mendoza (A1). CCLD staff explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. Investigation consisted of the following: CCLD staff interviewed Administrator Michael Mendoza A1, 10 out of 97 residents (R1-R97), 3 out of 3 staff (S1-S3). On 11/16/2023 CCLD staff obtained and reviewed copies of the following records: Shower log notes (date 11/13/2023), Incident reports (date 10/30/2023, 10/31/2023, 11/02/2023), St Mary’s Hospital summary of email (date 11/14/2023), Personal Property Inventory (date 09/28/2023), Physician Report (dated 08/23/2023) for R11. Unsubstantiated The investigation revealed the following: Regarding Allegation #1: Staff did not meet resident’s showering needs. It is being alleged that staff did not provide showers to residents. Record reviews indicate the following: R11’s Physician Report date 8/29/2023 indicates that R11 is able bathe self. The facilities shower logs for November 2023 indicates that R11 was reminded every Tuesdays and Fridays to take a shower. Interviews indicate the following: A1 indicates that all residents can take a shower at any time. 7 out of 7 staff indicate that R11 could take a shower with no assistance from staff, and that the facility keeps a shower log for those residents that refuse or forget to take a shower weekly. 10 out of 11 residents indicate that they can take a shower when they want, and staff have never told resident not to take a shower. Regarding Allegation #2: Staff did not seek resident timely medical attention. This complaint alleged that staff did not seek timely medical attention after being notified that R11 was sick on 10/30/2023. Record reviews indicate: The facility ’s Incident report dated 10/30/3023 indicates that R11 was not feeling good, and staff assessed R11’s condition and their blood pressure was noted as regular. Staff requested cough medication and called R11’s doctor but there was no answer. The Incident report dated 10/31/2023 indicates that R11 had a cough, chest pain, and was asked R11 wanted to be taken to the hospital but R11 refused to be taken to the hospital, staff was to follow up with R11 and R11 family. Incident report date11/02/2023 indicates that R11 was found by staff unresponsive, CPR was done, 911 was called and R11 was transported to the hospital. Interviews indicate the following: A1 indicated that on 11/2/2023, S2 called A1 to R11’s room and A1 performed CPR on R11, staff moved R11 from the bed to the floor where A1 continued CPR on R11, and that 911 was called and A1 was able to find a pulse when the fire department arrived. A1 indicates that R11 was transported to St. Mary Hospital. S2 indicates that on 11/02/2023 S2 found R11 unresponsive in R11 bed. S2 indicates S2 started CPR on R11 and called 911. S2 indicates that S2 called A1 who arrived, continued CPR and A1 found a pulse. S2 indicates that R11 was transported to the hospital for evaluation. CCLD staff conducted an interview with R1-R10. 10 out of 10 residents indicate that when residents need medical attention staff provides timely medical services. Regarding Allegation #3: Staff did not ensure security of resident’s personal belongings. This complaint alleged that staff did not secure R11’s purse. Record reviews indicate the following: R11’s personal property inventory log (dated 09/28/2023) indicated that there were 12 items noted for R11 personal belongings. This record indicates that R11 was admitted to the facility without a purse. There was no documented poof of stolen or lost property from R11 room. Interviews indicate the following: A1 indicates that on 11/14/2023 R11’s personal belongings were collected and stored for safety. A1 indicates that R11 purse was moved to the office, never was missing or stolen and that the resident purse was given back to resident family. A1 indicates that a property log is taken of exactly what the staff collects for the resident’s room and. CCLD staff conducted an interview with S7-S8. 7 out of 7 staff indicate that when R11 passed away staff collected the personal belongings of the resident, and a property log is kept for the facility records and that R11’s purse was never stolen or missing and was moved to the office for safety. 10 out of 10 residents indicate that none of their personal belongings have gone missing or been stolen while living at the facility and that staff make sure the facility is secure and safe. Regarding Allegation #4: Staff explained circumstances at the time of resident’s death, different from what a doctor reported. This complaint alleged that the facility provided wrong information to a resident’s family regarding the resident’s medical emergency that happened on 11/02/2023, it is also being alleged that the resident passed away collapsing in the backyard at the facility. Record reviews indicate the following: Incident report dated 11/02/2023 indicates that R11 was observed non-responsive in their bedroom, was given CPR, 911 was called and was transported to Saint Mary’s Hospital. R11’s death certificate indicates that R11 passed away from Acute Myocardial Infarction, coronary artery disease at the hospital. Interviews indicate the following: A1 indicates that that A1 called the R11 family on 11/02/2023 and advised R11 family member that R11 had a heart attack and was transported to the hospital. S2 indicates that R11 was found unresponsive, and CPR was performed. S2 indicates that the front office contacted R11s’ family and advised of R11 medical status.10 out of 10 residents indicate that staff inform their families of any medical status or updates. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “staff did not meet residents showering needs”, “staff did not seek resident timely medical attention”, “staff did not ensure security of residents personal belongings”, “staff gave an explanation of circumstance at the time of residents death different from what a doctor reported” is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Melissa Flores A1.the state’s words, verbatim · CDSS document, Feb 6, 2025 · control 11-AS-20231113122915

Type of visit: Case Management - Other

On 02/06/25 LPA Gonzalez conducted a case management visit regarding complaint control number 11-AS-20241115103623 at the facility listed above to deliver an amended report. LPA met with Quality Assurance Director, Rafael Silva, and explained the purpose of this visit. The original LIC9099-D dated 01/06/2025, is being amended. This revised LIC9099-D dated 01/06/2025, will supersede the original document. A copy of this report was discussed and a hard copy with the appeals was provided to the Quality Assurance Director, Rafael Silva.the state’s words, verbatim · CDSS document, Feb 6, 2025

Allegation investigated: Staff are not ensuring resident's medication is being administered as prescribed. Facility staff mismanaged residents’ medication. Facility staff are financially abusing residents.

The investigation consisted of the following: On 10/11/2024, Community Care Licensing Division (CCLD) Staff conducted a complaint investigation at the above facility to address the following allegations. CCLD Staff conducted staff and resident interviews and reviewed staff and facility records. On 11/08/2024, CCLD Staff reviewed medication and interviewed residents. On 01/23/2025, CCLD Staff reviewed partial medication records. On 01/30/2025, CCLD Staff conducted a subsequent complaint visit and met with Administrator Melissa Flores. CCLD Staff explained the purpose of today’s visit and reviewed partial medication records. Allegation: Regarding the allegation "Staff are not ensuring resident's medication is being administered as prescribed," it is being alleged that the Executive Director (S1) has made errors while passing out medication three months ago (around July 2024 or August 2024). Continue to LIC9099-C. Unsubstantiated The Administrator was unable to provide medication records with S1’s credentials. Four out of four staff interviews indicated that the Executive Directors will assist with medication administration if assistance is needed. Five out of eight resident interviews indicated that the Executive Director has not assisted them with medication. Three out of eight resident interviews indicated that the Executive Director has assisted them with medication but has not made errors. Regarding the allegation “Staff are not ensuring resident's medication is being administered as prescribed," based on interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Allegation: Regarding the allegation "Facility staff mismanaged residents’ medication," it is being alleged that Staff #9 and #10 took oxycodone and xanex from residents six months ago (in April 2024 or May 2024). Resident #1’s (R1) hydrocodone was filled 05/23/24 and the medication administration record shows distribution in May 2024. Interview with R1 indicated that R1 did not take this medication and hasn’t ran out. Resident #2’s (R2) hydrocodone was filled 03/21/24 and the medication administration revealed daily distribution in April 2024 and May 2024. Interview with R2 indicated that R2 ran out because staff did not refill the medication until R2 ran out. Resident #3’s (R3) hydrocodone was filled 01/11/24 and the facility does not have controlled medication count records. On 11/08/24, LPA observed 81 out of 90 tablets on hand for R3. Interview with R3 indicated that R3 has not ran out of medication. Resident #6’s hydrocodone was filled 05/20/24 and the facility does not have controlled medication count records. Interview with R6 indicated that medication is well stocked but the facility does not refill it on time. Resident #7’s (R7) hydrocodone was filled 05/06/24 and the controlled medication count revealed medication administration from 09/09/24 – 01/07/25. R7 indicated that medication runs out because it is not refilled in time. Interview with the Administrator indicated that the facility does not have controlled medication count from 05/06/24 – 09/08/24. Resident #8’s (R8) oxycodone was filled 05/14/2024 and the controlled medication count revealed medication administration from 05/28/24 – 12/07/24. Interview with the Administrator indicated that the facility does not have controlled medication count from 05/14/24 – 05/27/24. R8 indicated that R8 ran out in the past because the doctor only prescribed two week’s worth. Continue to LIC9099-C. Resident #10’s (R10) alprazolam/xanex was filled on 02/05/24 and the controlled medication count revealed medication administration from 05/29/24 – 10/07/24. Interview with the Administrator indicated that the facility does not have controlled medication count from 02/05/24 – 05/28/24. Interview with Staff #1 (S1) indicated S9 and S10 has not been in the facility since 2019 – 2020. MedTech Staff #3, #4, and #8 indicated medication has not came up short and they not met nor witnessed S9 and S10 administer medication. Regarding the allegation “Facility staff mismanaged residents’ medication," based on record review, observation, and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Regarding the allegation "Facility staff are financially abusing residents," it is being alleged that Staff #9 (S9) and Staff #10 (S10) have been stealing money from the residents’ P &I funds. Interview with the Executive Director (S1) indicated S9 has not been in the building since COVID 2020 and S10 since August 2019. S1 indicated that money is given every Thursday after lunch and if a large lump sum is needed then a check is requested. S1 indicated that the Office Manager conducts this process. Record review revealed seven out of nine residents had a balance on their P & I ledger. Six out of the seven residents indicated they did not have issues with P&I funds. One resident had a $0.00 balance, one resident had a negative balance, and both indicated they did not have issues with their P & I funds. Two out of two staff interviews indicated they have not received resident complaints concerning P & I funds. Regarding the allegation “Facility staff are financially abusing residents," based on record review, observation, and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Administrator Melissa Flores.the state’s words, verbatim · CDSS document, Jan 30, 2025 · control 11-AS-20241003141025

Type of visit: Case Management - Deficiencies

On 01/23/25 8:21 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced complaint investigation for control number 11-AS-20241003141025 at the facility listed above and met with Administrator Melissa Flores. LPA was following up on requested documents from 12/24/24 (email), 11/27/24 (email), 11/15/24 (visit), and 11/08/24 (visit). On 01/23/25 around 2:15 PM, partial documents were provided. On 11/15/24, a technical violation was issued for CCR 87506 (a) Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Deficiencies are being cited today under California Code of Regulations Title 22. See LIC809-D. A copy of this report was discussed and a hard copy with the appeals was provided to the Administrator Melissa Flores.the state’s words, verbatim · CDSS document, Jan 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jan 28, 2025

87506 (a) Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidence by: On 01/23/25 around 2:15 PM, LPA received partial records controlled medication count records for Residents #1 - 5 which poses a potential personal rights risk to residents in care. LPA did not receive medication administration records issued by the former Executive Director (S1).the state’s words, verbatim · CDSS document, Jan 23, 2025

Plan of correction: The Licensee will provided controlled medication count records from April 2024 - November 2024 for Residents #1 - 5. The Licensee will also provide July 2024 - Oct 1, 2024 Medication Administration Records issued by former Executive Director (S1) by the POC due date.

Allegation investigated: Staff unable to meet residents care needs.

Community Care Licensing Division (CCLD) conducted an unannounced visit to Glen Park at Long Beach Facility on 01/15/2025 and was greeted by Administrator Melissa Flores (S1). CCLD staff explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation. The investigation consisted of the following: CCLD staff interviewed Administrator (S1), staff (S1-S4), residents (R1-R11). CCLD staff requested and reviewed copies of the following: Physician Report (dated 10/11/2024), incident report (dated 1/1/2025), Needs and Service plan (dated 10/30/2024), Medication Administration Record (MAR) (date 11/1 to 12/31/2024). CCLD staff toured the facility with S1. The investigation revealed the following: Unsubstantiated Regarding Allegation #1: Staff unable to meet residents care needs. It is being alleged that staff was not able to give R1 medications due to staffing issues. CCLD staff toured the facility with S1. CCLD staff noted staff giving medications to residents. CCLD staff noticed staff cleaning and taking care of resident’s needs. CCLD staff reviewed incident report (date 1/1/2025) R1 passed away from health issues. physician report (date 10/11/2024), needs and service plan (date 10/30/2024) for R1. R1 has health issues. 4 out of 4 staff indicate that R1 needs were being met and 4 out of 4 staff indicate that staff was able to meet residents care needs. R1 passed away on 1/1/2025 and could not be interviewed. 2 out of 10 residents indicate that there are staffing issues and staff do not meet residents care needs. 8 out of 10 residents indicate that staff does meet residents care needs. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has not been met; therefore, the allegation of “staff unable to meet residents care needs”, is found to be UNSUBSTANTIATED. No deficiencies cited during today's visit. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Melissa Flores S1.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 11-AS-20250106145437

Allegation investigated: Staff are not ensuring residents have clean linens Staff are not assisting residents with changing clothes Staff are not assisting residents with showers Staff are not assisting residents with medications timely Staff do not assist resident with follow-up medical appointments

On 1/15/2025, the Department of Social Services (DSS) - Community Care Licensing Division (CCLD) staff conducted an unannounced complaint visit at this facility. CCLD staff was greeted by Quality Assurance Director, Melissa Flores. The investigation consisted of the following: The department interviewed 5 staff, 11 residents, and attempted to interview 2 residents; toured the laundry room, medication room, and 7 resident rooms; reviewed staff roster, resident roster, shower schedule, and Medication Administration Records (MARs). Unsubstantiated The investigation revealed the following: Regarding the allegation “staff are not ensuring residents have clean linens”, it is being alleged that residents’ linens are soiled. Interviews conducted revealed the following: 11 out of 11 residents denied the allegation and 5 out of 5 staff denied the allegation. Observations revealed the following: the department toured 7 resident rooms and did not observe soiled linens. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “Staff are not assisting residents with changing clothes”, it is being alleged that staff are not assisting residents in changing clothes (e.g. soiled clothing). Interviews conducted revealed the following: 11 out of 11 residents denied the allegation and 5 out of 5 staff denied the allegation. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “Staff are not assisting residents with showers”, it is being alleged that staff are not assisting residents with showers. Interviews conducted revealed the following: 11 out of 11 residents denied the allegation and 5 out of 5 staff denied the allegation. Records reviewed revealed the following: the facility has a Shower Schedule which describes residents who require assistance, reminders, stand by, independent, etc. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “Staff are not assisting residents with medications timely”, it is being alleged that staff are not providing residents with their medication in a timely manner. Interviews conducted revealed the following: 10 out of 11 residents denied the allegation and 5 out of 5 staff denied the allegation. Records reviewed revealed the following: 5 out of 5 Medication Administration Records (MARs) indicate that medications were provided to residents during the prescribed time frame. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Regarding the allegation “Staff do not assist resident with follow-up medical appointments”, it is being alleged that staff refuse to assist residents with follow-up medical appointments. Interviews conducted revealed the following: 10 out of 11 residents denied the allegation and 5 out of 5 staff denied the allegation. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. No citations were issued. An exit interview was conducted, and a copy of this report was left with the Quality Assurance Director.the state’s words, verbatim · CDSS document, Jan 15, 2025 · control 11-AS-20250113085224

Allegation investigated: Staff is not allowing resident to return to facility for re-entry.

On 1/14/2025 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Melissa Flores/ Quality Assurance Director and later with Rafael Silva-Quality Assurance. LPA Iniguez explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (S#1-S#2) and Resident’s interviews (R#1-R#4). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#4) Identification and Emergency Information, (R#1-R#4) Admissions agreements, (R#1-R#4) Physicians Report or LIC 602A, (R#1-R#4) Client/Resident Personal Property and Valuables or LIC 621, Facility’s Hospitalization Log for January 2025. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Staff is not allowing resident to return to facility for re-entry. The details of the complaint alleged that facility staff is not allowing a resident to return from hospital. During the records review, LPA Iniguez observed the facility’s hospital board and noted that (R#1) is currently at (Hospital #1) (A#1) stated that (R#1) is currently at College Medical Hospital, the facility has not refused to take them back. In addition, (A#1) stated that when it comes to (R#1), we have not refused to take them back, we just need to re-assess them before returning to us. During interviews with residents (R#1-R#5), (4) out of (5) stated that while they were at the hospital, the facility never told them that they could not come back to the facility. During interviews with facility staff (S#1-S#2), (2) out (2) stated that they have not told (R#1) that they cannot come back; they need to make sure (R#1) is assessed prior to hospital discharge. Evaluation Report continues LIC 9099-C During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Rafael Silva/ Quality Assurance Directorthe state’s words, verbatim · CDSS document, Jan 14, 2025 · control 11-AS-20250110152757

Type of visit: Case Management - Deficiencies

On 01/13/25, the department conducted an unannounced visit to this facility. The department met with Quality Assurance Director, Melissa Flores, and the purpose of the visit was explained. This visit was conducted to amend the citation issued on 01/06/25 and to issue a civil penalty in association with complaint investigation # 11-AS-20241115103623. Civil penalties are being assessed, see LIC421IM. An exit interview was conducted and a copy of this report, amended deficiency notice, LIC421IM, and appeal rights were discussed and left with Quality Assurance Director, Melissa Flores.the state’s words, verbatim · CDSS document, Jan 13, 2025

Allegation investigated: Facility staff did not dispense medications to resident as prescribed

*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 1/10/25. On 1/10/25, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Office Manager, Shanick Jackson and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 1/10/25, Licensing Program Analyst (LPA) Felisa Shirley requested and received copies of the following: LIC 500, Resident Roster, copies of resident file, MAR for December 2024 and January 2025 and Med Tech Certifications. The investigation revealed the following: Con'd on 9099-C Substantiated Allegation: Facility staff did not dispense medications to resident as prescribed On 1/10/25, LPA Felisa Shirley conducted a review of resident’s service file including Medication Administration Records (MAR). Records revealed that there three medications with dates with no entries by made by Med Techs and there are three prescribed medications that were not dispensed and still in the bubble pack. LPA Shirley interviewed staff-1 thru staff-7 (S-1 thru S-7). LPA asked, does staff dispense medications to residents as prescribed? Of those interviewed, 7 out of 7 answered yes. LPA interviewed Resident-1 thru Resident-7 (R-1 thru R-7). LPA asked, do you receive your medications as prescribed by your doctor?” Of those interviewed, 6 out of 7 answered yes and 1 answered no. According to the information gathered there is sufficient evidence to support the allegation mentioned above. Based on interview and record review the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies are issued and an exit interview is conducted with Melissa Flores. A copy of this report and appeal rights were provided. Allegation: Facility staff spoke inappropriately to resident It is being reported that R-1 was spoken to inappropriately by management. On 1/10/25, LPA spoke with R-1 and resident stated that they were told that they had to make an appointment to speak to management, that this is not a medical facility and maybe did not belong in this facility. LPA Shirley interviewed staff-1 thru staff-7 (S-1 thru S-7). LPA asked, do you speak inappropriately to residents? Of those interviewed, 7 out of 7 answered no. LPA interviewed Resident-1 thru Resident-7 (R-1 thru R-7). LPA asked, has staff or management spoken to you inappropriately?” Of those interviewed, 6 out of 7 answered no, and 1 answered yes. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Facility staff spoke inappropriately to resident,” therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of the LIC 9099 report was provided to Melissa Flores, Executive Director.the state’s words, verbatim · CDSS document, Jan 10, 2025 · control 11-AS-20250103134517

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 6, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and records review, records revealed that there were three medications with dates with no entries made by Med Techs for R-1 and there were three prescribed medications that were not dispensed and still in the bubble pack. This action poses as an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 10, 2025

Plan of correction: Licensee will submit plan informing the department medication training has been performed with all staff. A written proof of correction must included along with date, time and participants names. Correction must be submitted by due date: 3/6/25 to LPA's email: felisa.shirley@dss.ca.gov or fax attn: to LPA Felisa Shirley to 424-544-1016

Allegation investigated: Staff physically abused resident. Staff was under the influence while caring and supervising resident.

On 01/06/25 the department conducted a subsequent complaint visit at this facility to deliver the complaint findings. The department met with Quality Assurance Director, Melissa Flores, and the purpose of today’s visit was explained. The investigations consisted of the following: On 11/21/24, the department interviewed staff #1-#8 (S1-S8), and residents #1-#9 (R1-R9) and conducted a facility tour. Additionally, the department received and reviewed the following documents: staff roster, resident roster, resident's shower schedule, Unusual Incident/Injury Reports dated 10/03/24, 10/31/24, and discharge paperwork from St. Mary Medical Center-Long Beach printed on 10/03/24 for R4. On 01/06/24 the department received the following documents: Medication Administration Records (MARs) for the months of October 2024 and November 2024. Continued on LIC809-C Substantiated The investigation revealed the following: Allegation: Staff physically abused resident. It was alleged that a resident was physically assaulted while in care. It is also being alleged that a resident was pushed out the facilities front door. On 11/21/24, the department interviewed S1-S8 and R1-R9. Based on interviews conducted, eight (8) out of eight (8) staff interviewed said they do not know or recall of an incident where a resident was pushed out the front door. Five (5) out of eight (8) staff interviewed revealed that a resident was physically assaulted while in care back in October 2024. An interview conducted with S7 revealed that a resident was physically assaulted by a staff member on 10/02/24 and that employee had been terminated. Based on interviews conducted, six (6) out of nine (9) residents interviewed said they did not know of an incident involving a staff member physically assaulting a resident. Records review of an Unusual Incident/Injury Report dated 10/03/24, and discharge paperwork from St. Mary Medical Center-Long Beach revealed that on 10/02/24, a caregiver had physically assaulted a resident, and emergency services were called. St. Mary Medical Center discharge paperwork revealed that R4 was seen on 10/02/24 for a facial injury. The discharge diagnosis was blunt trauma, abrasions of multiple sites, and subconjunctival hemorrhage. Based on observation, interviews conducted, and a review of records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. Allegation: Staff was under the influence while caring and supervising resident. It was alleged that a med-tech was sent home after being under the influence while administering medication. Based on interviews conducted, five (5) out of eight (8) staff interviewed revealed that they knew of a med-tech being under the influence while administering medication. An interview with S7 revealed that a other staff reported to management that a med-tech was under the influence. That staff member then admitted to being under the influence and was sent home and terminated. Based on interviews conducted, five (5) out of nine (9) residents interviewed said they did not know of an incident involving a staff member being under the influence while administering medication. Records review of an Unusual Incident/Injury Report dated 10/31/24 revealed that on 10/29/24, an employee admitted to being under the influence while at work. The employee was removed from the building and terminated. Based on observation, interviews conducted, and a review of records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Quality Assurance Director, Melissa Flores, and a copy of the report and appeal rights was provided. The investigation revealed the following: Allegation: Staff are not properly documenting resident's medications when administered. It is alleged that the MARs are incorrect and are being tampered with. On 11/21/24, the department interviewed S1-S8 and R1-R9. Based on interviews conducted, eight (8) out of eight (8) staff interviewed stated that the MARs are correct. Eight (8) out of eight (8) staff interviewed stated that the MARs have not been tampered with by staff. Based on interviews conducted, seven (7) out of nine (9) residents interviewed said that staff administers their medication daily and on time. Seven (7) out of nine (9) residents interviewed revealed that they don’t know if the MARs are incorrect or if they have been tampered with. On 01/06/25, the department reviewed MARs for the month of October 2024 and November 2024 and observed the MAR’s to be complete and in order. Based on observation, interviews conducted, and a review of records, the department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Staff do not ensure resident's showering needs are being met. It is alleged that residents are not showering. Based on interviews conducted, eight (8) out of eight (8) staff interviewed stated that resident’s follow a shower schedule. Eight (8) out of eight (8) staff interviewed stated that the resident’s shower 2-3 times a week. Based on interviews conducted, seven (7) out of nine (9) residents interviewed said that they do shower. Seven (7) out of (9) residents interviewed revealed that staff ensure their showering/hygiene needs are being met. Seven (7) out of nine (9) residents interviewed revealed they are satisfied with the services being provided by staff at this facility. Continued on LIC809-C A review of records, of the resident's Shower Schedule revealed that the residents are scheduled to at least two (2) showers a week. Based on observation, interviews conducted, and a review of records, the department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Allegation: Staff do not ensure resident's health care needs are being met. It is alleged that staff is not checking resident’s blood pressure before administering medication. It is also being alleged that hospice residents do not get food and that the resident’s don’t get physical therapy. Based on interviews conducted, eight (8) out of eight (8) staff interviewed stated that staff ensures to check resident’s blood pressure if and when needed. Eight (8) out of eight (8) staff interviewed said that residents are provided three (3) meals a day, and snacks in between. Eight (8) out of eight (8) staff interviewed revealed that all residents who require physical therapy get it as scheduled. Eight (8) out of eight (8) staff interviewed stated that they make sure that the residents care needs are being met daily. Based on interviews conducted, five (5) out of nine (9) residents interviewed said that they don’t get their blood pressure checked because they don’t need it. Seven (7) out of nine (9) residents interviewed said that they are provided three (3) meals a day along with snacks. Seven (9) out of (9) residents interviewed revealed that they are satisfied with the services being provided by staff at the facility. Based on observation, interviews conducted, and a review of records, the department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continued on LIC809-C Allegation: Staff do not have a background clearance. It is alleged that employees do not have clearance to work at the facility. Based on interviews conducted, eight (8) out of eight (8) staff interviewed stated that they had background clearance before they started working at this facility. Based on interviews conducted, six (6) out of nine (9) residents interviewed said that they do not know if the employees have background clearance. The department reviewed the facility's staff roster and compared it to the Facility Personnel Report Summary (LIS536) that was printed on 11/19/24 by the department and revealed that all employees listed on the staff roster provided to the department matched the LIS536 and staff listed had an associate status listed as cleared. Based on observation, interviews conducted, and a review of records, the department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Quality Assurance Director, Melissa Flores and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Jan 6, 2025 · control 11-AS-20241115103623

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Jan 7, 2025

87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidence: Based on interviews, records review, Executive Director Gloriella Jara stated that an employee had physically assaulted R4, which posed an immediate health, safety, and personal rights risk to R4.the state’s words, verbatim · CDSS document, Jan 6, 2025

Plan of correction: Licensee will ensure staff review and sign the facility General Personnel Policies, residents Personal Rights, and Violations or infractions of Company Policy, and email a copy to LPA by POC.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(f) · Plan of correction due date: Jan 7, 2025

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. This requirement was not met as evidence: Based on interviews, records review, Executive Director Gloriella Jara stated that an employee had admitted to being under the influence while at work, which posed an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 6, 2025

Plan of correction: Licensee will ensure staff review and sign the facility General Personnel Policies, residents Personal Rights, and Violations or infractions of Company Policy, and email a copy to LPA by POC.

Allegation investigated: Staff are not properly following general food service requirements

On December 27, 2024 Department of Social Service staff conducted an unannounced complaint visit to address the allegation listed above. The department was greeted by receptionist and granted access to the facility. Subsequently,the department was joined by the Executive Director Melissa Flores and the reason for today's visit was explained. The complaint alleges the following: housekeeping staff serving in the dining and helping in the kitchen is "cross contamination," staff serving and working in the kitchen does not have safe serve and/or food handlers certification, main cook and managers does not have food handlers certificate. The investigation consisted of the following: On 12/27/2024, the department toured the facility and observed food serve during meal time. The department reviewed and requested, staff roster resident's roster copies of food handlers certitificates for all kitchen staff and staff training on infectious control practices.The department interviewed 5 staff (S1-S5) and Executive Director. Unsubstantiated On 12/27/24, The department toured and observed food service area during lunchtime (12:30p). The department observed that all staff wore gloves, hairnets and masks while serving the residents. The department also observed a clearly marked hand sanitizing dispenser mounted on the wall. Lastly, the department observed the following postings in the kitchen area: food handler certificates, food temperature guides, infectious disease and emergency/safety information. On 12/27/24, the department obtained and reviewed staff roster (dated 12/27/24), Resident roster (dated 12/23/24), Food Handler certificates for the 4 kitchen staff (good for 3 years of issue date), copy of Housekeeper job description, copy of caregiver/housekeeper training and job skills proficiency checklist. On 12/27/24, the department conducted an interview with Executive Director who stated that all kitchen staff currently have food handler's certification. She informed department that Housekeeping staff assists with serving meals at mealtimes is as part of their job duties which is outlined in the job description. However, the housekeeping staff do not participate in any aspects of preparing the food; therefore a food handler's certificate is not required. Lastly, the Executive Director informed the department that training on infectious disease practices is required for all staff including Housekeeping and is a part of their job skills training and proficiency checklist. On 12/27/24, the department conducted interviews with staff 1-5 (S1-S5), and asked the following questions: Do you have a food handlers certificate? How long is it good for? Do you practice proper hand hygiene and infectious disease control practices while working in the kitchen/dining? Do those who work with you use proper hand hygiene and infectious disease practices. Page 2 of 3 2 of 5 staff stated that they have a food handlers certification and it is good for 3 years. 3 of 5 staff stated that they do not have a food handlers certificate as they only assist with serving meals and not prepare them. 5 out of 5 staff stated that they always use proper hand hygiene, and infection control procedures. 5 out of 5 stated that those they work with use proper infection disease control practices and good hand hygiene. Based on the information provided, observations made, interviews conducted, and analysis of service records, The department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited. Exit interview was conducted. A copy of this report was provided to Melissa Flores, Executive Director. page 3 of 3the state’s words, verbatim · CDSS document, Dec 27, 2024 · control 11-AS-20241224140519

Allegation investigated: Facility staff are not providing resident with appropriate supervision, resulting in falls. Staff are mismanaging resident's medication Staff do not ensure that resident's toileting needs are being met Staff do not ensure that resident's showering needs are being met. Staff do not ensure that facility has sufficient clean linen Facility is serving expired beverages Staff do not ensure that resident receives a sufficient quantity of food. Staff do not ensure that facility is kept clean and sanitary

On 12/16/24, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by the Interim Administrator, Melissa Flores and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 10/22/24, LPA Shirley spoke to facility Executive Director and reviewed facility records. LPA requested copies of staff and resident rosters, laundry schedule, shower schedule, SIR’s involving falls, incontinence log for R1, incontinence order log, and weekly menus. LPA also interviewed staff 1 thru staff 9(S1 thru S9) and client -2 thru client - 9(C2 thru C9), C1 did not want to interview. LPA made copies of resident’s file. The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Facility staff are not providing resident with appropriate supervision, resulting in falls. It was reported that resident fell several times due to staff not coming to assist them upon request. LPA reviewed schedule for October 2024. From 10/1/24 thru 10/22/24 the schedule list time of supervision and whom the resident is being supervised by. LPA also request copies of all fall Special Incident Reports(SIR) and LPA did not receive not one report for R-1 nor did LPA find any copies of SIRS received for R-1 in Community Care Licensing Division (CCLD) faxes received. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, is staff providing appropriate supervision to avoid resident falls? Of those interviewed, 9 out of 9 answered yes. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, are staff providing sufficient supervision?” Of those interviewed, 6 out of 8 answered yes, 2 answered no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Facility staff are not providing resident with appropriate supervision, resulting in falls,” therefore the allegation is unsubstantiated. Allegation: Staff are mismanaging resident's medication It was reported that R-9 did not receive medications on 9/24/24 and 9/25/24. On 10/22/24, LPA requested, received and reviewed copies of R-9’s electronic Medication Administration Record and upon review, LPA observed that all medications were administered per doctor’s instructions. The electronic MAR also has the initials of the tech and the times that the medications were administered. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, if staff were mismanaging the resident’s medications? Of those interviewed, 8 out of 9 answered no, and 1 said they didn’t know. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, does staff mismanaging your medications?” Of those interviewed, 6 out of 8 answered no, 1 answered yes and 1 does not receive medication at this time. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are mismanaging resident’s medication,” therefore the allegation is unsubstantiated. Con'd on 9099-C Allegation: Staff do not ensure that resident's toileting needs are being met It was reported that a R-1 needed assistance with their incontinence needs and staff were not available during the period of time when they are known to be incontinent. LPA interviewed R-9 about the allegation and she stated that she is sometimes assisted with incontinence issues but staff could be better and more consistent with the assistance that they provide to the residents. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, is staff ensuring that resident’s toileting needs being met? Of those interviewed, 9 out of 9 answered yes. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, are your toileting needs being met?” Of those interviewed, 5 out of 8 answered yes, and 3 had answers other than yes and no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure that resident’s toileting needs are being met,” therefore the allegation is unsubstantiated. Allegation: Staff do not ensure that resident's showering needs are being met. It is being reported that staff are not assisting R-1 with their showering needs as there are lack of towels. During interview with S-1, LPA learned that both washing machines were broken and staff were making runs to the laundry mat to wash items for residents in care. LPA reviewed the invoice dated 10/10/24 in which a representative from Glen Park purchased two washers and two dryers. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, is staff ensuring that resident’s showering needs being met? Of those interviewed, 9 out of 9 answered yes. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, are your showering needs being met?” Of those interviewed, 7 out of 8 answered yes, 1 answered no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure that resident’s showering needs are being met,” therefore the allegation is unsubstantiated. Con'd on 9099-C Allegation: Staff do not ensure that facility has sufficient clean linen On 10/22/24, LPA spoke to Executive Director, Michael Mendoza regarding the allegation regarding facility’s inability to provide clean linen for the residents. Mr. Mendoza stated that the facility’s laundry room was down as the washing machines were broken. Mr. Mendoza also stated that he had recently purchased two washing machines. LPA reviewed the invoice dated 10/10/24 in which a representative from Glen Park purchased two washers and two dryers. At the time when washing machines were down, staff were doing laundry runs to the neighborhood laundry mat to provide clean linen to residents in care. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff ensure that facility has sufficient clean linen? Of those interviewed, 9 out of 9 answered yes. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, do you receive clean linen?” Of those interviewed, 8 out of 8 answered yes. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure that facility has sufficient clean linen,” therefore the allegation is unsubstantiated. Allegation: Facility is serving expired beverages On 10/22/24, LPA Shirley toured the facility’s kitchen, LPA inspected all cabinets and refrigerators. During the inspection, LPA observed that there were no expired beverages in the refrigerator. LPA spoke with S-6 and was told that kitchen staff follows the first rule of food storage, first in first out. The milk carton with the earliest use-by date should be stored in front and used first. This system ensures that older stock is used before newer stock, reducing the risk of spoilage and waste. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff serve expired beverages? Of those interviewed, 9 out of 9 answered no. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, does staff serve expired beverages?” Of those interviewed, 6 out of 8 answered no, 1 answered yes and 1 did not know. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Facility is serving expired beverages,” therefore the allegation is unsubstantiated. Con'd on 9099-C Allegation: Staff do not ensure that resident receives a sufficient quantity of food It is being reported that R-9 is not allowed to eat when they return from outings. LPA reviewed the facility’s House Rules, and they state that residents have access to food and drink at any time and may request a snack from a staff person. House Rules also states that residents will be reminded of the options to have food and drink at any time requested. During interviews, S-1 stated that there is Juice during snacks, there are 3 snacks and 3 meals. S-1 and S-6 stated that the kitchen staff makes extra sandwiches. S-4 and S-9 stated that seconds are allowed. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff ensure that residents receive a sufficient amount of food? Of those interviewed, 9 out of 9 answered yes. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, do you receive a sufficient amount of food?” Of those interviewed, 7 out of 8 answered yes, and 1 answered no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure that residents receive a sufficient quantity of food,” therefore the allegation is unsubstantiated. Allegation: Staff do not ensure that facility is kept clean and sanitary On 10/31/24 at 9:47am, LPA Shirley noted that there was a fresh smell upon entering the facility. LPA Shirley arrived to this facility and observed a team of staff cleaning in the lobby. LPA Shirley observed this facility’s housekeeping schedule and learned that the facility is cleaned on a daily basis and cleaning detail is assigned to cleaning staff according to zones. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff make sure that the facility is kept clean and sanitary? Of those interviewed, 9 out of 9 answered yes. LPA interviewed resident-2 thru resident-9 (R-2 thru R-9). R-1 was not available for interview. LPA asked, does staff make sure that the facility is kept clean and sanitary?” Of those interviewed, 7 out of 8 answered yes, and 1 answered no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not ensure that facility is kept clean and sanitary,” therefore the allegation is unsubstantiated. LPA Shirley conducted an exit interview, and a copy of this report was left for Interim Administrator, Melissa Flores.the state’s words, verbatim · CDSS document, Dec 16, 2024 · control 11-AS-20241014154119

Type of visit: Case Management - Deficiencies

On 12/16/24, Licensing Program Analyst (LPA) Felisa Shirley visited this facility to investigate a complaint and upon investigation learned that the medicine cabinet in R-9’s bathroom has rust on the inside and the cabinet is being used by the resident. The LPA met with Interim Administrator, Melissa Flores, and the purpose for the visit was discussed. LPA Shirley interviewed 9 staff members and 8 residents. Deficiencies cited under California Code of Regulations Title 22 Exit Interview Conducted and a copy of this report was signed and left for, Interim Administrator, Melissa Flores.the state’s words, verbatim · CDSS document, Dec 16, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Dec 30, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on interviews and observations, R-9’s bathroom medicine cabinet is rusted in the inside which poses a possible health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: The Interim Administrator, Melissa Flores shall replace medicine cabinet and send proof of correction to LPA Felisa Shirley at felisa.shirley@dss.ca.gov or fax to 424-544-1016 by POC date of 12/30/24.

Type of visit: Case Management - Other

On 11/15/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced case management visit at the facility listed above. LPA met with the Co-Executive Director Gloriella Jara (S1) and explained the purpose of the visit. On 10/11/2024, LPA requested for Medication Administration Records from S1. On 10/24/24, a follow up email was sent to former Executive Director Michael Mendoza requesting the 10/11/24 documents plus additional information. On 10/25/24, S1 sent Medication Administration Records. On 11/08/24, LPA conducted a subsequent complaint visit for control number 11-AS-20241003141025. Staff #2 (S2) and Staff #3 (S3) informed LPA that some medication is recorded on a separate Controlled Medication Count document. LPA requested for April 2024 – November 2024 Controlled Medication Count records for five (#1 - 5) specific residents. S2 and S3 indicated that the documents are removed monthly and placed in storage. However, S2 indicated that S2 would start gathering the documents on hand to be emailed. On 11/12/24, LPA sent a follow up email to S1, S4, and S5 requesting for the documentation. On 11/15/24, LPA conducted a case management visit for control number #11-AS-20240702154711 and LPA followed up on the requested documents. S1 requested for additional time since S5 is no longer with the facility and S4 is away on vacation. S1 indicated that the documents can be provided on 11/18/24. A technical violation is being issued, see LIC9102. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. A copy of this report was discussed and a hard copy of LIC809, LIC9102, and LIC811 was provided to Co-Executive Director Gloriella Jara.the state’s words, verbatim · CDSS document, Nov 15, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Case Management Visit on Thursday, November 14, 2024, upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a risk assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with Co-Executive Director Gloriella Jara and explained the purpose of today's visit is to amend the complaint report received in the Community Care Licensing office on April 19, 2024, Control #11-AS-20240419102426. The original complaint report, dated Thursday, November 7, 2024, has been amended, and corrections were made on the LIC9099, LIC9099-Cs, LIC9099-D, and LIC9099-A. This amended complaint report, dated Thursday, November 14, 2024, supersedes the original complaint report dated Thursday, November 7, 2024. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Nov 14, 2024

Allegation investigated: Facility staff speak inappropriately to residents in care. Facility staff handle residents in a rough manner.

The investigation consisted of the following: On 10/11/2024, Community Care Licensing Division (CCLD) Staff conducted a complaint investigation at the above facility to address the following allegations. CCLD Staff conducted staff and resident interviews and reviewed staff and facility records. On 11/08/2024, CCLD Staff met with Co-Executive Director Jonathan Barrios and explained the purpose of the visit. CCLD Staff reviewed medication and interviewed residents. Regarding the allegation "Facility staff speak inappropriately to residents in care," it is being alleged that Staff #9 and #10 curse at the residents. Eight out of eight resident interviews indicated that S9 and S10 do not speak to residents without dignity or respect, or they have not met them. Two out of two staff interviews indicated they have not received residents’ complaints concerning disrespectful speech from S9 and S10. Continue to LIC9099-C. Unsubstantiated Two staff members were unavailable. Interview with the Executive Director indicated S10 has not been in the building since COVID 2020 and S9 since August 2019. Regarding the allegation “Facility staff speak inappropriately to residents in care," based on interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Regarding the allegation "Facility staff handle residents in a rough manner," it is being alleged that Staff #9 and #10 are rough when checking residents for bed injuries. Three out of three staff interviews indicated they are not sure if S9 and S10 visit the facility and perform body checks. One out of one staff interviews indicated they have not received resident’s complaint concerning S9 and S10 handling of residents. Interview with the Executive Director indicated S10 has not been in the building since COVID 2020 and S9 since August 2019. Six out of six resident interviews indicated S9 nor S10 has been physically rough with them or been involved with body checks. Regarding the allegation “Facility staff handle residents in a rough manner," based on interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. This report was discussed and a hard copy was left with Co-Executive Director Jonathan Barrios.the state’s words, verbatim · CDSS document, Nov 8, 2024 · control 11-AS-20241003141025

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 ensure a comfortable living environment for residents Staff do not prevent residents from entering other resident's rooms Staff do not meet resident’s modified dietary needs

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Thursday, November 07, 2024. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. The department then met with Co-Executive Director Jonathan Barrios and explained that the purpose of the visit was to complete the 10-day complaint investigation initiated on Monday, January 22, 2024. The investigation consisted of the following: During the course of the investigation the department conducted interviews with staff members 1-4 (1-4) and residents 1-9 (R1-9). The department posed questions pertinent to the nature of the complaint. The department requested and reviewed resident 1's records. The department obtained copies of the following documents: The Department obtained copies of the following documents: Staff and residents roster, admission agreement, physician's report, medical assessment, medication administration records (MARs), consent forms, replacement appraisal information, identification and emergency information, appraisal needs and service plan, safeguards for property/valuables, calendar menus, special incident reports. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Training on reporting dependent adult and elder abuse, staff in-service training, and ongoing staff training. Allegation: Staff do not ensure a comfortable living environment for residents The department interviewed staff members 1-4 (S1-S4) and residents 1-9 (R1-R9) they all stated the facility staff provides residents with a comfortable living environment and meets their daily care needs. S1-S4 and R1-R9 stated that residents with dementia do not walk up and down the halls at night screaming or banging on other residents' doors. S1-S4 and R1-R9 denied the allegation. Allegation: Staff do not prevent residents from entering other resident's rooms The department interviewed staff members 1-4 (S1-S4) and residents 1-9 (R1-R9) who stated the facility staff take measures to prevent residents from entering other residents' rooms. S1-S4 and R1-R9 explained that room doors automatically lock when residents leave their rooms and require a key to unlock the door. They also stated that female residents are not seen running down the hallway screaming, "Get out of my room!" S1-S4 and R1-R9 denied the allegation. Allegation: Staff do not meet residents’ modified dietary needs. The department interviewed staff members 1-4 (S1-S4). All staff stated that the cook follows a meal plan and serves nutritious meals three times a day, seven days a week. S1-S4 explained that if a resident is on a modified diet prescribed by a physician as a medical necessity, staff follow the physician’s orders. S1-S4 stated that the resident in question was not on a restricted or modified diet. They also stated that residents can request substitutions if they do not like the meals served. S3 noted that while not all residents may love every meal, the menu offers a variety of food options to accommodate preferences. S3 reiterated that she follows the meal plan and ensures nutritious meals are served daily. The department also interviewed residents R1-R9. R1 stated that the facility served food to which he was allergic and described the food as not good or nutritious. R2-R9 reported that the food was delicious and that they had no issues with the meals provided. S1-S4 and R2-R9 also stated that residents have alternative meal options if they dislike what is served. The department reviewed the facility’s meal plan and determined that the total daily diet meets the quality and quantity necessary to meet residents’ needs. S1-S4 and R2-R9 denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 4 Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099, and LIC9099-Cs was provided to the Co-Executive Director Jonathan Barrios. There were no deficiencies cited. An exit interview was conducted. Continued LIC9099-C page 2 On 11/07/2024, Co-Executive Director Jonathan Barrios and LPA observed the air conditioning unit in room 220 was operational and in good repair. The Department obtained copies of the following documents: The staff and residents roster, admission agreement, physician's report, medical assessment, medication administration records (MARs), consent forms, replacement appraisal information, identification and emergency information, appraisal needs and service plan, safeguards for property/valuables, special incident report, staff in-service training, ongoing staff training, a video, and photos of room 220 air conditioner unit resident bed, and mattress. Allegation: Staff did not safeguard the resident’s personal belongings. Staff members S1–S4 and residents R2–R9 stated that facility staff are safeguarding residents’ personal belongings. S1 and S2 acknowledged that water was dripping from the air conditioning (AC) unit in the resident’s room, located on the right side of the resident’s bed. They stated that the water had soaked the linens and mattress. S1 and S2 also confirmed that the AC unit was repaired, and the resident’s mattress is now dry and undamaged. Resident R1 provided a video and photos as evidence showing water dripping from the AC unit onto the bed, and wetting the linens and mattress. Residents R2–R9 reported that their AC units were in good working condition and did not experience any water leakage. S3 stated that she had no knowledge of the AC unit leaking water. S4 indicated that he was not employed at the facility during the time of the alleged incident and had no knowledge of the matter. During an inspection of R1’s room, the mattress was observed to be dry and in good condition, with no visible need for replacement. Based on the Department's observations, interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. Appeal rights were discussed, and copies of the Complaint Investigation Report LIC9099-A, LIC9099-C, and LIC9099-D were provided to Co-Executive Director Jonathan Barrios. An exit interview was conducted.the state’s words, verbatim · CDSS document, Nov 7, 2024 · control 11-AS-20240118125422

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 7, 2024

Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. There was a water leak on the right side of the resident's bed caused by the air conditioning unit, which dripped water onto the bed, soaking the linens and mattress. The violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: The deficiency was corrected prior to the complaint visit.

Allegation investigated: Staff engaged in an intimate relationship with a resident.

***The original complaint report, dated Thursday, November 7, 2024, has been amended to correct the LIC9099, LIC9099-Cs, and LIC9099-D, This amended complaint report, dated Thursday, November 14, 2024, supersedes the original complaint report dated Thursday, November 7, 2024.*** Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Thursday, November 07, 2024, upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a risk assessment. Based on the assessment, the facility is cleared of COVID-19 infection. The department then met with Co-Executive Director Jonathan Barrios and explained that the purpose of the visit was to complete the 10-day complaint investigation initiated on Monday, April 22, 2024. The investigation consisted of the following: During the course of the investigation Interviews were conducted. The department posed questions pertinent to the nature of the complaint. The department requested and reviewed resident and staff records. See continued LIC9099-C, page 2 Substantiated Continued LIC9099-C page 2 The Department obtained copies of the following documents: The staff and residents roster, admission agreement, physician's report, medical assessment, medication administration records (MARs), consent forms, replacement appraisal information, identification and emergency information, appraisal needs and service plan, safeguards for cash resources, staff training on reporting dependent and adult and elder abuse, staff in-service training, and ongoing staff training. Allegation: Staff engaged in an intimate relationship with a resident. It was alleged that the staff engaged in an intimate relationship with a resident. The department investigated the allegation. Interviews were conducted with staff members 1-4 (S1-S4) and facility residents 1-10 (R1-R10). A resident reported maintaining a dating and sexual relationship with a facility staff member. The staff admitted to having a sexual relationship with the facility resident, and both the resident and staff member reported going to a local motel together. The department corroborated this information with a printout of the reservation from the local motel. There is sufficient evidence to support the allegation that the facility staff was involved in an intimate relationship with the facility resident. The investigation revealed the following: The Department conducted interviews with staff members 1-4 (S1-S4) and residents (R1-R10). S1-S2 stated that on 04/18/2024, a resident came into the office to report a dating relationship with a staff member that had been ongoing for approximately six weeks. The resident ended the relationship due to the age difference and because the staff member was harassing the resident for the $4,000.00 that the staff member claimed to have spent on the relationship. Both the resident and staff member admitted to the Department that they had been in a consensual romantic and intimate relationship for about two to three months. They both stated that no elder abuse occurred and that the relationship was consensual. Staff member S4 stated he was not employed at the facility at the time of the alleged incident and had no knowledge of the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3 Residents R2-R10 stated they had never witnessed or heard of any resident being in a consensual relationship with staff. Staff members S1-S4 stated that the facility has a zero-tolerance policy against inappropriate relationships between staff and residents. S1 also stated that a Special Incident Report had been reported to the appropriate agencies in a timely manner, prior to the complaint allegation. Based on the Department's observations, interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. Appeal rights were discussed, and copies of the Complaint Investigation Report LIC9099, LIC9099-Cs, and LIC9099-D were provided to Co-Executive Director Jonathan Barrios. An exit interview was conducted. Continued LIC9099-C, page 2 The Department obtained copies of the following documents: The staff and residents roster, admission agreement, physician's report, medical assessment, medication administration records (MARs), consent forms, replacement appraisal information, identification and emergency information, appraisal needs and service plan, safeguards for cash resources, staff training on reporting dependent and adult and elder abuse, staff in-service training, and ongoing staff training. Allegation: Staff financially exploited a resident. The Department conducted interviews regarding the allegation that staff financially exploited a resident. Staff members 1 and 4 (S1-S4) stated they conducted an investigation after being notified of the incident by the resident. However, the facility had no evidence of any staff financially exploiting a resident. There were no witnesses or documents indicating that the resident owed any money to the staff member. S1-S4 stated that the facility has a zero-tolerance policy against inappropriate relationships between staff and residents. The resident stated he was in a consensual relationship with one of the staff members. According to the resident, after he ended the relationship, the staff member began harassing the resident, claiming the resident owed the staff $4,000 for money the staff had spent on the resident during the relationship. The resident explained that he is on a fixed income, did not agree to reimburse the staff member, and does not have the money to do so. A resident reported that on 04/18/2024, the staff member again requested the alleged amount. The resident stated he went to the administrator to file a complaint, wanting the harassment to stop and avoid further contact. Neither the resident nor the staff member provided receipts or documentation regarding the amount claimed. The resident no longer resides at the facility, and the staff member is no longer employed there. Residents 1 through 10 (R1-R10) reported satisfaction with the facility, stating that the staff provides a comfortable living environment and meets their daily needs. All residents (R2-R10) stated that they have never experienced financial exploitation by staff. Staff 4 (S4), stated that he was not an employee at the time of the alleged incident and had no knowledge of the allegation. The Department did not have sufficient evidence to determine the veracity of the allegation. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099-A, and LIC9099-C was provided to the Co-Executive Director Jonathan Barrios. There were no deficiencies cited. An exit interview was conductedthe state’s words, verbatim · CDSS document, Nov 7, 2024 · control 11-AS-20240419102426

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 15, 2024

87468.1 (a) (2) Personal Rights of Residents in All Facilities. To be accorded dignity in their personal relationships with staff, residents, and other persons. Staff engaged in an intimate relationship with a resident. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2024

Plan of correction: The Licensee is required to submit a written plan addressing residents' personal rights, ensuring residents are provided with dignity in their personal relationships with staff, residents, and other persons. The plan must be submitted by the POC deadline of, Monday, November 18, 2024.

Allegation investigated: Staff are not meeting resident's dietary needs

On 11/06/2024, the department conducted an unannounced subsequent visit to the facility listed above. The department met with Co-Executive Director, Jonathan Barrios, and the purpose of today’s visit was explained. During today’s visit the department toured the facility, interviewed Staff S9, interviewed Residents R2, R3, and R11, reviewed residents’ medication, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Dietitian Review of menu, electronic Medication Administration Record (eMAR), additional Dietary Order, Nurse Job Description, Medical Technician Job Description, and a copy or resident Admission Agreement. During a subsequent visit conducted on 10/22/24, the department conducted a facility inspection, interviewed Staff S1-S8, interviewed Residents R1, R4-R10, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Physician Report, Dietary orders, menus, and staff training. The investigation revealed the following: Substantiated Allegation: Staff are threatening resident The complaint allegation alleges that staff have threatened residents if they call and make a report to the Ombudsman. During the facility tour, LPA observed the Ombudsman and Community Care Licensing poster posted in the hallway near the entrance of the facility. During record review, LPA received and reviewed an Admission Agreement for residents that states on page 12 that residents have the right “to file a complaint regarding any licensed care facility,” and the information for Community Care Licensing, the Ombudsman office, and local police department information is listed. During interviews with Staff S1-S9, were asked if residents have the right to file a complaint with the Ombudsman’s Office or Community Care Licensing, nine (9) out of nine (9) stated residents have the right to file complaints. Additionally, during interviews Staff S1-S9, were asked if they have heard of or have threatened a resident if they called the Ombudsman or Community Care Licensing with a complaint, nine (9) out of nine (9) stated they have not heard of staff threatening a resident nor have they threatened a resident who has a complaint. During interviews with Residents R1- R11, were asked if staff have threatened them if they call the Ombudsman or Community Care Licensing with a complaint, ten (10) out of eleven (11) stated they have not been threatened if they make a complaint to the Ombudsman or Community Care Licensing. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Allegation: Staff did not administer resident’s medication The complaint allegation alleges a resident did not receive their prescribed medication for multiple days. During record review, LPA received and reviewed Resident R1-R10’s Centrally Stored Medication and electronic Medication Administration Record e(MAR) for the months of September and October 2024. During the facility inspection, the department reviewed the eMAR and residents’ medication for five (5) residents, the department observed five (5) out of five (5) residents eMAR and medication are consistent with properly documented records. During interviews with Staff S1-S9, were asked if residents receive their medications as prescribed, nine (9) out of nine (9) stated residents receive medications as prescribed. During interview with Residents R1-R11, were asked if they receive assistance with medication, eleven (11) out of eleven (11) stated they receive assistance with medications. Additionally, during interviews Residents R1-R11 were asked if they receive their medications as prescribed, three (3) out of eleven (11), stated they do not receive their medications as prescribed. Residents R1-R11 were asked if there was a time that they did not receive their prescribed medications, five (5) out of eleven (11) stated there has been times they did not receive their medications. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Co-Executive Directors, Jonathan Barrios and Gloriella Jara, and a copy of this report was provided. Allegation: Staff are not meeting resident’s dietary needs. The complaint allegation alleges that the facility does not accommodate residents’ diet regarding food allergies despite having a doctor’s orders. During record review, the department requested all dietary orders and dietary preferences that the kitchen staff have on file. Upon review, the department observed there was a dietary preference on file for R1 dated 10/25/2022 but no orders. The department inquired further, due to interviews with R1 who stated they provided S1 with a medical document indicating R1’s physician’s dietary order. During the visit, S2 was able to find the dietary order for R1 in a file stating R1’s dietary order dated on 12/21/2023. During an additional interview with S3 and S9, were asked if they have dietary orders regarding R1, two (2) out of two (2) stated we have a dietary preference not an order. Additionally, the department received and reviewed the report from RDs for Healthcare, Inc., Dietitian’s review form Sanitation and food Safety Checklist for Assisted Living conducted on 10/07/24 that states in the comments “Renal diets are eating regular foods.” “Diabetic diets not followed.” and “Not sure the “dietary preference” sheets are being followed.” Additionally, on the form under Food Preparation number “4. Modified diets are served as physician ordered” was marked no. During the facility inspection of the kitchen, the department observed R1 on the board with dietary preferences stating what they cannot eat and did not observe them on the board with dietary restrictions or orders. During interviews with Staff S1-S9, were asked if the facility accommodate residents’ dietary physician orders, nine (9) out of nine (9) stated yes, they make accommodations for residents with special dietary orders, restrictions, and preferences. During interviews with Residents R1-R11, were asked if they have any dietary restrictions or preferences on file, seven (7) out of eleven (11) stated they have dietary order from a physician or dietary preference forms. Additional interview questions were asked to Residents (R1, R4-R9) who have dietary orders or preferences, were asked if their dietary orders and/or preferences were met, two (2) out of seven (7), stated their dietary needs are not met and they are provided with foods they are not supposed to be eating. During the course of the investigation, the department was able to find evidence to support the allegation. Based on the departments observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Co-Executive Directors, Jonathan Barrios, and a copy of this report and the appeals rights was provided.the state’s words, verbatim · CDSS document, Nov 6, 2024 · control 11-AS-20241014104543

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(7) · Plan of correction due date: Nov 20, 2024

87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by: based on interview, observation, and record review the licensee failed to ensure R1 received accomodations for a modified dieat prescribed by residents physician as a medical necessity.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: Administrator will review Physicians report and orders and create a binder for the orders to be placed in and update the boards in the kitchen. Administrator will send LPA pictures of the new binder and boards updated in the kitchen, by the POC date via email at Wendy.Gibbs@dss.ca.gov.

Type of visit: Case Management - Deficiencies

On 11/06/24, the department made an unannounced visit to the facility listed above for an unrelated complaint. The department met with Co-Executive Director Jonathan Barrios, and the purpose of today’s visit was explained. During today’s visit the department reviewed the Staff Roster (LIC500) and the Guardian Employee Roster, that indicates Staff S1 is “not eligible-exemption denial.” During the time of the visit, this was brought to the attention of the Co-Executive Director, and staff departed the facility and was taken off the schedule. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. CIVIL PENALTY ASSESSED. An exit interview was conducted with Co-Executive Director, Jonathan Barrios and Gloriella Jara, and a copy of this report and Appeals Rights were provided.the state’s words, verbatim · CDSS document, Nov 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87356(a)(2)(3) · Plan of correction due date: Nov 7, 2024

87356 Criminal Record Exemption(a)The Department shall notify a licensee to act immediately to terminate the employment of, remove from the facility or bar from entering the facility any person described in Sections 87356(a)(1) through (5) below while the Department considers granting or denying an exemption. Upon notification, the licensee shall comply with the notice. (2) Any person who has been convicted of a felony;(3) Any person who has been convicted of an offense specified in Sections 243.4, 273a, 273d, 273g, or 368 of the Penal Code or any other crime specified in Health and Safety Code Section 1569.17(c)(3); This was not met based on observation, record review, and interview, the licensee failed to ensure S1 is fingerprint cleared prior to working in the facility. This poses a health, saftey, and/or persoanl rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: Administrator shall read Section 87356(a)(1) through (5) and shall self-certify understanding of the regulations and shall commit to comply. POC shall be submitted to CCLD via email to wendy.gibbs@dss.ca.gov by the POC due date.

Allegation investigated: Resident sustained fractures due to staff dropping resident while transferring.

The investigation consisted of the following: On 07/05/2024 Community Care Licensing Division (CCLD) staff requested records which include Staff Roster, Resident Roster, incident report(s), 4 months of past pest control invoice(s) and two (2) residents Admission Agreements. On 07/15/2024 CCLD staff reviewed records, toured the kitchen and interviewed 8 staff members which included the Executive Director, Memory Care Director, Cook, LVN, (2) MedTechs, Front Desk, and Care Partner. On 07/25/2024 CCLD staff reviewed the register of residents and interviewed five (5) residents. On 08/16/24, CCLD staff interviewed four residents. On 10/25/24, CCLD staff interviewed attempted to one resident and delivered findings. The investigation revealed the following: Regarding the allegation "Resident sustained fractures due to staff dropping resident while transferring,” It is being alleged that staff did not provide proper level of assistance when assisting residents which resulted to resident’s injuries. Continue to LIC9099-C. Substantiated Record reviews revealed the following: Resident records indicate that R1 requires assistance in transferring from chair to bed and has risks of falls. Incident reports indicate that on 08/12/22 around 2:15 PM an agency caregiver helped R1 transfer from R1’s wheelchair to the bed when R1 fell. R1 indicated that during the incident the "small lady" caregiver who was assisting R1 could not support R1’s weight, R1 lost balance, and fell during the process. The incident report revealed that Resident #2 (R2) witnessed the fall and indicated the caregiver tried to help R1 by moving R1's foot that would not move. Without supporting R1's balance, when R1's foot was pulled forward, R1 fell down. Hospital medical records indicate that on 08/13/2022, R1 was hospitalized at St. Mary’s Medical Center and during R1’s evaluation, it was discovered R1 had fractured her leg in two different places which required surgery. Interviews revealed the following: Staff indicated that the caregiver who assisted R1 during the fall was employed with an outside agency. Two out of four residents indicated they have witnessed staff struggle with residents who need transfer assistance. One out of the two residents indicated that they have fallen a couple of times while in care at the facility. Regarding the allegation “Resident sustained fractures due to staff dropping resident while transferring,” based on record reviews and interviews, the preponderance of evidence has been met therefore the allegation is Substantiated. At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49 (e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including but not limited to, the following: loss of consciousness, concussion, bone fracture, protracted loss or impairment of anybody member or organ, a wound requiring extensive suturing, and serious disfigurement.” An exit interview was conducted and a copy of this report and appeal rights was provided to with Executive Director Michael Mendoza.the state’s words, verbatim · CDSS document, Oct 25, 2024 · control 11-AS-20240702154711

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 29, 2024

(a) In addition to the rights listed in section 87468.1... residents... shall have all of the following personal rights: (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on interviews and record review the licensee did not ensure R1's individual needs were met and delivered by staff during transfer which posed an immediate health, safety, and personal rights risk to R1.the state’s words, verbatim · CDSS document, Oct 25, 2024

Plan of correction: The Administrator will email a plan of correction to regina.cloyd@dss.ca.gov by the POC due date.

Allegation investigated: Staff do not treat resident with dignity or respect Staff are not following resident's Admission Agreement Staff does not provide adequate food service

On 10/18/24, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Executive Director, Michael Mendoza and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility. The investigation consisted of the following: On 10/8/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Jonathan Barrios, Administrator. LPA requested LPA Shirley received copies of the following: LIC 500, Resident Roster, copies of resident file. On 10/22/24, LPA requested and received copies of: Weekly menus, Admission Agreement, and MAR. The investigation revealed the following: Con'd on 9099-C Unsubstantiated Allegation: Staff do not treat resident with dignity or respect It is being reported that residents are not being treated with dignity and respect. It is being alleged that a resident was not treated with respect and dignity by staff and that staff were very disrespectful to them and offered no assistance in their time of need. LPA Shirley attempted to interview R-1 several times but they refused to be interviewed. LPA Shirley mentioned this allegation about being treated with dignity and respect and resident responded that she had changed her mind and wanted to close the complaint as she hurried down the hallway. R-1 made it clear that she was no longer pursuing this complaint. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff treat residents with dignity and respect? Of those interviewed, 9 out of 9 answered yes. LPA interviewed Resident-2 thru Resident-9 (R-2 thru R-9). R-1 did not want to interview. LPA asked, does are you treated with dignity and respect?” Of those interviewed, 8 out of 9 answered yes and R-1 did not want to interview. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff does not provide adequate food service,” therefore the allegation is unsubstantiated. Allegation: Staff are not following resident's Admission Agreement On 10/22/24, LPA Shirley reviewed R-1’s Admission Agreement and did not observe an agreement to have TV service with cable nor telephone service in their room. Per interview with S-8, there are TVs in the common areas and there are phones located in the hallways for resident’s use. If a resident has a phone or TV in their room, the resident or family brought it in themselves and are paying for the service. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, do Administrators honor Admission Agreements, promises agreed upon during the time of admission? Of those interviewed, 8 out of 9 answered yes, 1 staff did not know. LPA interviewed Resident-2 thru Resident-9 (R-2 thru R-9). R-1 did not want to interview. LPA asked, does Administration honor your Admission Agreement?” Of those interviewed, 8 out of 9 answered yes and R-1 did not want to interview. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff does not provide adequate food service,” therefore the allegation is unsubstantiated. Con'd on 9099-C Allegation: Staff does not provide adequate food service On 10/22/24, LPA Shirley toured the kitchen and interviewed the Cook, S6 and the Dietary Aid, S7. LPA observed that both were wearing a hair net as required. LPA observed all food preparers Certificate of Training from California Food Handlers Course posted on the kitchen wall. LPA Shirley reviewed the weekly menus and found that they contained all important food groups. LPA observed refrigerated food and did not observe any expired foods nor were there any foul odors. LPA observed, beef, chicken, pork and fish stored in the freezers and did not observe any food items that are not customary. LPA Shirley interviewed staff-1 thru staff-9 (S-1 thru S-9). LPA asked, does staff provide adequate food service? Of those interviewed, 9 out of 9 answered yes. LPA interviewed Resident-2 thru Resident-9 (R-2 thru R-9). R-1 did not want to interview. LPA asked, does staff provide adequate food?” Of those interviewed, 6 out of 9 answered yes, 2 answered no and R-1 did not want to interview. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff does not provide adequate food service,” therefore the allegation is unsubstantiated. There were no deficiencies cited during this visit. LPA Shirley conducted an exit interview and a copy of this report was signed by Interim Administrator, Melissa Flores.the state’s words, verbatim · CDSS document, Oct 22, 2024 · control 11-AS-20241002160648

Allegation investigated: Licensee did not ensure the facility has a qualified Administrator on site.

The purpose of this amendement is to edit details listed on the LIC9099 and LIC9099-C and it does not change the findings of this complaint. The investigation consisted of the following: On 10/11/2024, Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegations. LPA met with Co-Executive Director Gloriella Jara and explained the purpose of the visit. Executive Director Michael Mendoza joined later. LPA conducted staff and resident interviews and reviewed staff and facility records. Allegation: Regarding the allegation "Licensee did not ensure the facility has a qualified Administrator on site," it is being alleged that the Executive Director/Staff #1 (S1) does not have an Administrator’s certificate and does not have a degree to work at the facility. S1 has been the Administrator for a year. Administrator Certification Bureau (ACB) record review revealed S1's active certification covers certification cycles 12/31/2020 - 12/30/2022 and 12/31/2022 - 12/30/2024. S1's RCFE certification will expired on 12/20/2024. Continue to LIC9099-C. Unsubstantiated Regarding the allegation “Licensee did not ensure the facility has a qualified Administrator on site," based on record review, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Executive Director Michael Mendoza.the state’s words, verbatim · CDSS document, Oct 11, 2024 · control 11-AS-20241003141025

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.

Type of visit: Case Management - Other

On Friday, September 27, 2024 at 8:25am LPA Zina Brown made an unannounced visit to facility to amend a report from May 30, 2024. LPA Zina Brown spoke with Michael Mendoza for the phone to inform him of the complaint investigation report - Unsubstantiated (visit date: May 30, 2024). Executive Director Michael Mendoza gave Office Manager Tyshima Bonner permission to off sign on the document. No deficiencies cited were cited during today. Exit interview was conducted with Tyshima Bonner and a copy of the report.the state’s words, verbatim · CDSS document, Sep 27, 2024

Type of visit: Required - 1 Year

On 09/26/2024 at 09:00am, Licensing Program Analyst (LPA) Zina Brown and Lizeth Villegas conducted an unannounced annual visit to the above facility. LPAs met with Michael Mendoza , Administrator and the purpose of the visit was discussed. Facility is licensed to serve 4 ambulatory, 174 non-ambulatory residents and 30 bedridden residents. 17 of the residents are diagnosed with dementia and 32 of the resident are incontinent. Facility fees are current. The two-story commercial building consists of one hundred (100) resident bedrooms, multiple resident bathrooms, three (3) common bathrooms, dining room, commercial kitchen, staff room, office area, media room, garden area, washer and dryer/ storage area, backyard with umbrella with table and chairs. There is a Dementia unit that was inspected and approved by the department. At 11:00am, LPA Zina Brown went on a tour with Michael Mendoza of the inside and outside of facility grounds. The resident bedrooms had the required furniture, pull style call buttons, bed linens and closet/drawer space to accommodate each resident comfortably. The resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured at 114.3 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. The commercial kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors and carbon monoxide were working properly, and fire extinguisher was fully charged. First Aid kit was available. There are no bodies of water, security bars, nor fire arms are on the premises. A discrepancy was observed and documented on 809-D page Exit interview conducted, appeal rights explained, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 26, 2024

Allegation investigated: Staff did not safeguard resident's funds. Staff is acting as the payee for several independent residents. Staff do not treat residents with dignity or respect.

On 9/16/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Michael Mendoza /Administrator. LPA explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Resident’s interviews (R#1-R#8) and Staff Interviews (S#1-S#2). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#6) Identification and Emergency Information,(R#1-R#6) Safeguard for Property and Valuables or LIC 621 ,(R#1-R#6) Record of Client's/Resident's Safeguarded Cash Resources of LIC 405 from 1/1/24-9/4/24,, (R#1-R#6) Physicians Report for Residential Care Facilities for the Elderly or LIC 602A, (R#1-R#6) Social Security Letters, and (R#1)’s invoice clothing receipt dated 7/15/24. Evaluation Report continues LIC 9099-C Unsubstantiated Investigation Revealed the Following: Allegation: Allegations: Staff did not safeguard resident's fund. The details of the complaint alleged that facility staff is not safeguarding (R#1)’s funds properly. During the records review, LPA Iniguez reviewed (R#1-R#6) copies of the Record of Client's/Resident's Safeguarded Cash Resources of LIC 405; LPA Iniguez observed that the facility has a record of all (R#1-R#6) expenditures from January 2024 until Now. In addition, LPA observed (R#1) 's P&I ledger; it is written that there was an expenditure record from 7/18/2024 for $810.25 check number (CK15509) for (R#1) 's clothing. Moreover, LPA observed a copy of an invoice from Professional Fit Clothing (Clothing Company) dated 7/15/2024. This company provided (R#1) (5) pairs of pants, (5) designer polos, and (2) 3-pack undershirts; the total amount for all this was $810.25. Also, LPA Iniguez observed copies of (R#1)’s Personal Property Inventory created by the facility, on this form it is listed all (R#1)’s personal property. During an interview with the Administrator (A#1), he stated that the facility safeguards (R#1) 's and the other residents' belongings using an itemized list on-site and a P&I list. Also, (A#1) stated that the facility could give the residents cash if requested as part of their P&I. In addition, (A#1) stated that the $810.25 was used to buy (R#1) 's clothes in July of this year. During interviews with staff 1 (S#1), they stated that the facility keeps a ledger for all the residents, including (R#1), who need assistance with their finances. Also, (S#1) stated that the $810.25 was used to buy (R#1)' ’s clothes back in July. During an Interview with (R#1), they stated that they got new clothes recently. Also, (R#1) stated that they think they can get access to their P&I finds; they just did not know they had money. Evaluation Report continues LIC 9099-C During interviews with residents (R#2-R#6), (5) out of (5) residents stated that they can get access to their P&I funds every week. During an interview with Witness 1 (W#1), they requested P&I money from (R#1) and found $810.25 to buy them clothes. However, (W#1) spoke with (R#1), and they stated that they had not gotten new clothes, and there was no receipt showing that the new clothes had been purchased on behalf of (R#1). Allegation: Staff is acting as the payee for several independent residents. The details of the complaint alleged that facility staff is acting as the payee for several residents in care. During the records review, LPA Iniguez reviewed (R#1)’s Physicians Report for Residential Care Facilities for the Elderly or LIC 602A; it is written that (R#1) is not confused or disoriented, able to follow instructions and to communicate their needs, on the other hand, (R#1) is not able to manage their cash resources. Also, LPA observed (R#2-R#6) LIC 602A, indicating they cannot manage their finances. In addition, LPA observed copies from the Social Security Administration, and it is written that the facility is the payee for (R#1-R#6). During an interview with the Administrator (A#1), he stated that the facility is the payee for (R#1). The Social Security Administration appointed us to be (R#1)’s payee on 7/15/2022. During interviews with staff 1 (S#1), they stated that the facility is the appointed payee by the Social Security Administration for (R#1-R#6). Evaluation Report continues LIC 9099-C Allegation: Staff do not treat residents with dignity or respect. The details of the complaint alleged that facility administrator does not treat residents with dignity and respect. During an interview with the Administrator (A#1), he stated that he treats the residents in care with dignity and respect and that does not intimidate them. During interviews with staff (S#1-S#5), (5) out (5) facility staff stated that (A#1) treats the residents in care with dignity and respect and does not intimidate them. During interviews with residents (R#1-R#6), (6) out of (6) residents stated that (A#1) treats them with dignity and respect and they do not feel intimidated by him. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Michael Mendoza /Administrator.the state’s words, verbatim · CDSS document, Sep 16, 2024 · control 11-AS-20240912101113

Allegation investigated: Staff yelled at resident in care. Staff does not ensure resident is administered medications. Staff does not follow resident's dietary orders. Staff does not ensure resident's room is clean.

On 08/16/2024 Licensing Program Analyst (LPAs) Regina Cloyd and Hollie Enriquez conducted a subsequent complaint investigation at the above facility to address the following allegation. LPA Cloyd met with Assistant Administrator Tonantzin Martinez and explained the purpose of the visit. During today’s investigation, LPA Cloyd interviewed five (5) staff members and LPA Enriquez interviewed ten (10) residents. On 07/31/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation. LPA Cloyd met with Executive Director Michael Mendoza and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA Cloyd reviewed food menus and incident report, one resident record, and interviewed five (5) staff members which include the Executive Director, MedTech, Housekeeper, Cook/Server and Caregiver/MedTech. Due to positive COVID cases in the facility, the above allegation needs further investigation. An exit interview was held with Executive Director Michael Mendoza and a copy of this report was provided. Continue to LIC9099-C. Unsubstantiated Allegation(s): Staff yelled at resident in care. The investigation revealed the following: Regarding the allegation " Staff yelled at resident in care,” it is being alleged that a nurse yelled and interrupted resident #1 (R1). Eight (8) out of (8) eight staff interviews indicated that they have not witness staff yelling at residents. Eight (8) out of (9) nine resident interviews indicated that they like the staff and have never been yelled at. Regarding the allegation “Staff yelled at resident in care,” based on interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Allegation(s): Staff does not ensure resident is administered medications. The investigation revealed the following: Regarding the allegation "Staff does not ensure resident is administered medications,” it is being alleged that Resident #1 (R1) did not receive R1’s noon medication on 07/13/24. One LVN, Two MedTech, and One Caregiver interview indicated that medication is passed out in the dining hall and staff will go to residents’ room if they miss medication at mealtimes. Staff #5 (S5) indicated that S5 gave R1’s medication in R1’s room on 07/13/24. S5 stated that S5 observed R1 take R1’s medication. Record review revealed that S5 had a technical issue with scanning R1’s medication and S5 indicated that the medication record is blank because of the technical issue. Seven (7) out of (9) nine resident interviews indicated that staff have not forgotten to give them medication. Regarding the allegation “Staff does not ensure resident is administered medications,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Continue LIC9099-C. Allegation(s): Staff does not follow resident's dietary orders. The investigation revealed the following: Regarding the allegation " Staff does not follow resident's dietary orders. ,” it is being alleged that staff has not adhered to Resident #1’s (R1) dietary restrictions as of 07/18/24. Record review revealed that the facility’s menu offers a variety meal and beverage options that meet R1’s dietary restrictions. Two (2) out of (9) residents do have a dietary restriction and indicated that the staff meets their needs. Six (6) out of (9) nine residents do not have any dietary restrictions and indicated that they are satisfied with their meals and indicated that alternatives are provided. Eight (8) out of (8) staff interviews indicated that the facility provides alternatives to residents who have dietary restrictions. The Cook indicated that residents can have cranberry or orange juice, water, ice tea, hot tea, baked chicken, fish, tuna, mayo, and/or mustard as alternatives. Regarding the allegation “Staff does not follow resident's dietary orders,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Allegation(s): Staff does not ensure resident's room is clean. The investigation revealed the following: Regarding the allegation "Staff does not ensure resident's room is clean,” it is being alleged that housekeeping services was not provided on 07/11/24, 07/12/24, and 07/14/24. Four (4) staff interviews, including one Housekeeper, indicated that housekeeping services are provided daily, and Resident #1 (R1) room is clean. Eight (8) out of (9) nine resident interviews indicated that housekeeping does some daily sweeping, mopping, taking out trash, and cleaning the bathroom. Eight residents also indicated that housekeeping changes their beddings and provides fresh towels if needed or at least twice a week. Regarding the allegation “Staff does not ensure resident's room is clean,” interviews, the Department found no evidence to support the allegation mentioned above. Continue to LIC9099-C. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Executive Director Michael Mendoza.the state’s words, verbatim · CDSS document, Aug 16, 2024 · control 11-AS-20240725105353

Allegation investigated: Staff do not ensure that a resident's toileting needs are met. Staff are not addressing pests at the facility. Staff do not answer a resident's call button in a timely manner. Staff do not monitor a resident for change in condition.

On 08/16/24, Licensing Program Analysts (LPAs) Regina Cloyd and Hollie Enriquez conducted a subsequent complaint investigation at the above facility to address the following allegations. LPA Cloyd spoke Assistant Administrator Tonantzin Martinez and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA Enriquez interviewed four residents. On 07/25/2024 LPA Regina Cloyd conducted a subsequent complaint investigation at the above facility to address the following allegation. LPA Cloyd spoke with Executive Director Michael Mendoza over the phone and explained the purpose of the visit. LPA met with the Memory Care Director Gloriella Jara. The investigation consisted of the following: During today’s investigation, LPA Cloyd reviewed the register of residents and interviewed five (5) residents. On 07/15/2024 LPA Cloyd conducted a subsequent complaint investigation at the above facility to address the following allegation. LPA Cloyd met with Executive Director Michael Mendoza and explained the purpose of the visit. Continue to LIC 9099-C. Unsubstantiated The investigation consisted of the following: During today’s investigation, LPA Cloyd reviewed records, toured the kitchen and interviewed 8 staff members which included the Executive Director, Memory Care Director, Cook, LVN, (2) MedTechs, Front Desk, and Care Partner. On 07/05/2024 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced visit to the facility listed above. LPA was met with Administrator, Michael Mendoza (S1), and later by Office Manager Tyshima Bonner (S2), and the purpose of today’s visit was explained. During today’s visit, LPA requested documents pertinent to the investigation. The following documents received include Staff Roster, Resident Roster, incident report(s), 4 months of past pest control invoice(s) and two (2) Admission Agreements. Allegation(s): Staff do not ensure that a resident's toileting needs are met. Regarding the allegation "Staff do not ensure that a resident's toileting needs are met,” it is being alleged that facility staff does not check on resident(s). Seven (7) out of (7) seven staff interviews, including the Memory Care Director, indicated that residents are checked on every two hours and they have not received complaints. Memory Care Director indicated that she has not seen any internal reports concerning toileting and that she tours the facility to speak with residents and there has not been any complaints. Seven (7) out of seven (7) resident interviews indicated that they do not have toileting complaints and that they are checked occasionally because of their independence. LPAs did not smell urine in the facility nor on the interviewees. Regarding the allegation “Staff do not ensure that a resident's toileting needs are met,” based on interviews and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Allegation(s): Staff are not addressing pests at the facility. The investigation revealed the following: Regarding the allegation "Staff are not addressing pests at the facility,” it is being alleged that there are rodents in the kitchen and they have eaten through food products before. Record review reveals that the facility receives monthly pest control services of work completed and recommendations. Continue to LIC9099-C Interview with Accounting indicated that the facility has had pest control services since May 2020. Interview with the Executive Director indicated that traps are set but the facility hasn’t witnessed any rodents in the kitchen area. LPA toured and observed kitchen and storage closet. LPA saw multiple freezers and an organized storage closet with canned goods and items in plastic containers. LPA did not observe signs of rodents. Six (6) out of (8) eight staff interviews, including the Cook, indicated that they have not witnessed any rodents nor received rodent complaints. Six (6) out of (8) eight resident interviews indicated that they have not seen any rodents in the kitchen. Regarding the allegation “Staff are not addressing pests at the facility,” based on observation, record review, and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Allegation(s): Staff do not answer a resident's call button in a timely manner. Regarding the allegation "Staff do not answer a resident's call button in a timely manner,” it is being alleged that facility staff does not respond for approximately twenty minutes. Seven (7) out of (7) seven staff interviews, including the Front Desk, indicated that calls are responded to in 5 – 15 minutes. Memory Care Director indicated that residents know how to call the receptionist’s desk if resident thinks there is a problem with his/her call light. Six (6) out of (8) eight resident interviews indicated that staff responds within 3 – 10 minutes. Regarding the allegation “Staff do not answer a resident's call button in a timely manner,” based on interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. Continue to LIC9099-C. Allegation(s): Staff do not monitor a resident for change in condition. Regarding the allegation "Staff do not monitor a resident for change in condition,” it is being alleged that the Licensee did not provide additional staff assistance to Resident #1 (R1) when transferring to their wheelchair on 08/11/22. R1’s Assisted Living Waiver (ALW) assessment on 10/20/21 and on 12/06/23 does not reveal that R1 needs more than one person for transfers. Interview with the Executive Director indicated that the ALW Program sends a representative out every six months to complete an individualized service plan (ISP) and ALW determines the tier level for each resident and covers the cost. Record review also revealed that R1’s physician’s report was completed on 01/25/24. Regarding the allegation “Staff do not monitor a resident for change in condition,” record review and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Executive Director Michael Mendoza.the state’s words, verbatim · CDSS document, Aug 16, 2024 · control 11-AS-20240702154711

Allegation investigated: Resident's dietary needs are not being met

This report supersedes the report dated 08/10/2023 to clarify the circumstance for the allegations. This report supersedes the previous report the investigation finding for the allegation “Residents dietary needs have are not being met remains Substantiated, the investigation finding for the allegation “Facility is infested with cockroaches.” is Unsubstantiated (please see LIC9099A). Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Glen Park at Long Beach Facility on 08/10/2023 and was greeted by Assistant Administrator (A1)Tonantzin Martinez. LPA spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. The investigation consisted of the following: On 08/10/2023 LPA Calderon interviewed Administrator (A1), residents (R1-R8), and staff (S1-S4). LPA also obtained and reviewed copies of the following: Pest control reports for (date April – July 2023) and meal plan for residents. LPA also toured common areas of facility. On 02/07/2024 LPA Calderon obtained and reviewed House Call MD Physician order form (date 4/3/2021, 7/22/2022 and 1/31/2023) for R8. Substantiated The investigation revealed the following: Regarding allegation: “Resident dietary needs are not being met.” It is being alleged that residents with diabetes are served the same food as all other residents. Staff interviews conducted indicate the following: A1 indicates that the facility does not provide a separate meal plan for diabetic residents. Resident interviews indicate the following: 7 out of 8 residents indicates that they are diabetic and that the facility does not offer them a diabetic meal plan. R8 indicates, R8 is not diabetic. LPA Calderon reviewed the meal plan for the facility, there is no meal plan found for diabetic residents. Based interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation “Residents dietary needs are not being met” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are cited on the attached LIC 9099D. An exit interview was conducted, and plan of correction was developed with Administrator Michael Mendoza. A copy of the Complaint Report and Appeal Rights were provided to Administrator Michael Mendoza. Regarding Allegation: “Staff are injecting insulin for residents.” It is being alleged that inappropriately skilled staff are injecting residents with insulin. Staff interviews indicate the following: A1 indicates that only a Licensed Vocational Nurse (LVN) is allowed to give insulin injections to residents in care. A1 and S3 indicates that at no time do inappropriately skilled staff inject residents with insulin as they are not trained. S3 added that the home health care nurse comes 2 times per day and injects residents with insulin. Resident interviews revealed the following: 7 out of 8 residents indicates that they are diabetic and that the nurse with home health care services come to the facility 2 times per day and gives them their insulin injections. 7 out 8 residents denied that facility staff has given them the insulin injection. R8 indicates that R8 is not a diabetic. Regarding Allegation: “Non-skilled staff are performing manual fecal impaction removal on resident.” It is being alleged that manual fecal impaction is being done by non-skilled staff. Staff interviews indicate the following: Steward Home Health Care LVN staff comes to the facility and performs fecal removal on resident R8. A1 states that no facility staff have the training to perform the fecal removal on residents in care, and no facility staff would be allowed to perform the fecal removal on any resident in care. Resident interviews revealed the following: S3 confirmed that the Steward Home Health Care LVN performs the fecal removal on R8, and no facility staff would be allowed to perform the fecal removal on any resident in care. LPA Calderon conducted an interview with R1-R8. Seven out of eight residents do not have fecal removal done by staff or home health care nurses. Resident interviews revealed the following: R8 indicates that Steward Home Health Care LVN performs the fecal removal, and no staff has ever performed the fecal removal on R8. Record reviews indicate the following: House Call MD (dated 4/2/2021, 7/22/2022, 1/31/2023) indicates that R8 was serviced for catheter, decompaction stool and UTI. Regarding Allegation: Facility is infested with cockroaches. It is being alleged that there is a cockroach infestation all over the facility. Staff interviews indicate the following: The pest control company “All Out Extermination” comes one time per month and sprays for pests in the common areas. Staff also addresses any reports of roaches and will spray any arear where roaches are found. S1-S4. 4 out of 4 staff interviewed (S1-S4) indicates that there are water roaches that come from the water pipes and in the hallway, and they spray for roaches weekly. Resident interviews revealed the following: R1 and R8 indicates that there are no roach problems. 6 out of 8 resident indicates that they although they have seen roaches in the facility the pest control does spray for insects and staff also sprays for roaches. LPA observations indicate the following: During the investigation LPA Calderon did not see the presence of roaches in the facility. Record Reviews indicate the following: “All Out Extermination” pest control report (dated April to July 2023), roach bait placed in common areas. There are no mention of roaches found by pest control. Regarding Allegation: Residents are prohibited from using a home health agency of their choosing. It is being alleged that the facility is only allowing one home health agency to provide services to the residents in care. Staff interviews indicate the following: A1 indicates that residents are given 5 options for home health care services and one option is Steward Home Health Care, and that resident are not prohibited from using other home health care companies. Resident interviews revealed the following: 7 out of 8 residents did not know the name of their home health care company. Record Reviews indicate the following: 30 out of 86 residents have Home Health Care services of which 16 out 30 residents receive home health services through Steward Home Health Care and 14 out of 30 receive Home Health Care services from other companies. Based on interviews, observations, and record reviews, the preponderance of evidence standard has not been met; The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations of “staff are injecting insulin for residents” “non-skilled staff are performing manual fecal impaction removal on resident” “resident are prohibited from using a home health agency of their choosing” and “facility is infested with cockroaches” is found to be Unsubstantiated. No deficiencies were cited. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Michael Mendoza (A1).the state’s words, verbatim · CDSS document, Aug 1, 2024 · control 11-AS-20230802112635

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(5) · Plan of correction due date: Aug 19, 2024

87555 General Food Service Requirements (b)The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned... requirement was not met as evidenced by: Based on interviews and record reviews the licensee did not ensure that a diabetic meal plan is provided to 7 out of 8 residents who had diabetes, who poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 1, 2024

Plan of correction: The administrator agreed to create a plan to ensure that a diabetic meal plan is provided to residents. Proof of corrections will be submitted to LPA via email at jose.calederon@dss.ca.gov.

Allegation investigated: Staff did not safeguard a resident's personal belongings. Staff do not ensure that a resident's medical condition is properly managed. Staff do not assist resident with showering.

On 05/30/24, at 10:00am, Licensing Program Analyst (LPA) Perry Scott conducted a 10-day complaint visit to the facility and was greeted by Michael Mendoza, Executive Director. LPA explained the purpose of this visit is to gather information about the complaint and deliver findings for the allegations mentioned above. The investigation consisted of the following: LPA investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S4) and residents (R1-R9). Resident Roster (Dated 5/29/24), Staff Roster (Dated 5/15/24), ID/Emergency Information (Not Dated), Physicians Report (Dated 4/24/2024), Shower Schedule (Dated 5/29/24), Appraisal/Needs And Services Plan (Dated 10/23/2023), Internal Resident Incident Report (Dated 5/26/2024), and Personal Property Inventory (Dated 4/25/2017) for R1 were obtained from the facility. The investigation revealed the following: Allegation #1- Staff did not safeguard a resident's personal belongings. Report continued on LIC9099-C Unsubstantiated The details of the complaint alleged that in January or February of 2024 someone at the facility stole R1s paint supplies and paperwork .On 05/30/24, from 10:00am-2:00pm, LPA interviewed staff (S1-S4) and residents (R1-R9) regarding the allegation. 4 of 4 staff denied the allegation that the Staff did not safeguard a resident's personal belongings. All staff (S1-S4) stated that all measures are taken to safeguard the residents’ belongings. Staff stated that the facility has installed new locks on all resident’s doors that feature more security measures; the facility has a safe for resident’s if they want to store valuables; and the facility has lock boxes for the residents who wish to have it. All staff stated they have no knowledge of any reported items stolen from R1. LPA interviewed residents R1-R9 about the allegation and 8 of 9 residents that were interviewed denied the allegation that Staff did not safeguard a resident's personal belongings. The majority of the residents stated that they have not had any issues with theft in the facility. Based on interviews, there is insufficient evidence to support the allegation that the Staff did not safeguard a resident's personal belongings. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #2- Staff do not ensure that a resident's medical condition is properly managed. The details of the complaint alleged that R1s medical condition is not properly managed. It is stated that R1 has a Foley Catheter, and the resident can care for R1s catheter by R1s self. However, R1 has developed several Urinary Tract infections that may be due to inadequate catheter care. It is alleged that staff are not monitoring R1s catheter care. On 05/30/24, from 10:00am-2:00pm, LPA interviewed staff (S1-S4) and residents (R1-R9) regarding the allegation. 4 of 4 staff denied the allegation that the Staff do not ensure that a resident's medical condition is properly managed. All staff (S1-S4) stated that whenever R1 needs assistance with R1s medical care it is provided but R1 has a history of UTI before R1 had a Foley Catheter. Staff also state that R1 has been trained by R1s physician to take care and manage R1s Foley Catheter. Staff states further that every measure is taken to keep R1s medical condition properly managed by getting timely medical care, follow up visits, assistance with personal care when needed, and taking regular showers. LPA interviewed R1-R9 about the allegation and 8 of 9 residents that were interviewed denied the allegation that Staff do not ensure that a resident's medical condition is properly managed. Residents stated that their medical condition is properly managed by the staff and are happy with the care and supervision given by the staff. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff do not ensure that a resident's medical condition is properly managed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Allegation #3- Staff do not assist resident with showering. The details of the complaint alleged that R1 neglects to take showers thereby creating a condition that allows for urinary tract infections to occur. However, it is reported that R1 is capable of showering by R1s self, but only needs supervision. It is alleged that staff does not encourage R1 to take showers to prevent future infections from occurring. On 05/30/24, from 10:00am-2:00pm, LPA interviewed staff (S1-S4) and residents (R1-R9) regarding the allegation. 4 of 4 staff denied the allegation that the Staff do not assist resident with showering. All staff (S1-S4) stated that every resident has a shower schedule according to their care plan. Staff state that every resident is encouraged to take showers and take care of their personal care needs. If the resident needs assistance, the caregivers are here to assist them. However, staff says sometimes residents do refuse to take a shower and will put it off until another day. When this occurs an incident report is written for the resident. LPA reviewed the shower schedule and incident report for R1 and found that R1 is scheduled for showers but sometimes refuses to be showered. LPA interviewed R1-R9 about the allegation and 8 of 9 residents that were interviewed denied the allegation that Staff do not assist resident with showering. Residents stated that they have not had any problems with staff not assisting them with showers when assistance is needed. Residents state that they are happy with the care and supervision provided by the staff. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Staff do not assist resident with showering. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted with Michael Mendoza, Executive Director, and a hard copy of this report was provided.the state’s words, verbatim · CDSS document, May 30, 2024 · control 11-AS-20240522152056

Allegation investigated: Staff mismanaged resident's medications. Staff did not administer medication as prescribed.

On 02/05/2025, the department conducted a subsequent complaint visit to amend the original LIC9099 and LIC9099Cs dated 04/18/2024, but this does not change the findings of this complaint. The department met with Office Manager Shenick Jackson and explained the purpose of the visit was to amend the original LIC9099 and LIC9099Cs dated 04/18/2024. The original LIC9099 and LIC9099Cs dated 04/18/2024 are being amended. The revised LIC9099 and LIC9099Cs dated 08/07/2024. On 04/18/2024, Licensing Program Analyst (LPA) Antonine Richard conducted a complaint visit to deliver findings regarding the above allegations. LPA Richard met with Receptionist/MedTech Claudia Magana and later was joined with assistant Administrator Tonantzin Marines and Executive Director Michael Mendoza and explained the reason for the visit. The investigation consisted of the following: On 04/18/2024, LPA Richard and Receptionist/MedTech Martinez toured the facility inside and out. LPA Richard reviewed and requested, staff and resident's roster. Preplacement Appraisal Information, Individual Services Plan (ISP), Physician's Report for Residential Care for the Elderly (RCFE). Admission Agreement, Transfer Discharged Report. New Telephoned Prescription. Basic Medication Shadow training. LPA interviewed seven (7), residents (R1-R7), and three (3) staff (S1-S3). LVN, and Med Tech. LPA Interviewed the Nurse Practitioner (NP) Vartan Bekerian. Unsubstantiated Regarding the allegation: Staff mismanaged the resident's medication. The Investigation revealed the following: Regarding the allegation, “Staff mismanaged the resident’s medication”, it is being alleged Resident #1’s (R1) medication A (Haldol) was not discontinued. Medication Administration Record (MAR) revealed medication A was still being administered since R1 was admitted on 03/26/24. Interview with the Med Tech indicated that: on 03/26/2024, R1 was admitted to the facility from a skilled nursing facility with a medication list that included medication A; on 04/12/2024, R1’s Power of Attorney (POA) called the facility requesting medication A to be discontinued, but the facility refused since there wasn’t a doctor’s order; on 04/15/2024, the facility received a new prescription order from the R1’s doctor and pharmacy about discontinuing medication A. The department reviewed the MAR dated 03/26/2024 to 04/18/2024 and observed medication A was discontinued on 04/15/25. The department interviewed three staff #S members (S1-S3) and 3 out of 3 stated that they could not stop giving medications to residents unless it’s from a doctor’s order. The department interviewed seven residents #R (R1-R7) 6 out of 7 stated that they do not have any problem with the facility managing their medications. Based on interviews, and records reviewed the department did not find sufficient evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. (Evaluation Report Continues LIC 9099-C) Allegation: #2 The staff did not administer medication as prescribed. Regarding the allegation: “The staff did not administer medication as prescribed,” it is alleged that the staff continued to give medication B (Zoloft) in the morning instead of the evening. Medication Administration Record (MAR) revealed that R1’s medication B is to be administered in the morning and staff distributed it in the morning. The department interviewed the Med Tech (MT) about the allegation, and MT denied the allegation and stated that (R1) was admitted to the facility on 03/26/2024 and R1’s medication B was administered per the physician’s directions on time, and the right doses. On 04/18/2024, the department reviewed seven residents' medication administration records (MARs) and 7 out of 7 records show that medication was given to the residents in the correct dosage and at the proper times. The department Interviewed the Licensed Vocational Nurse, (LVN) they denied the allegation and stated that we cannot stop giving or changing the time of administering (R1) medication because a family member or Power of Attorney (POA) wants us to. Based on interviews and records reviewed the department did not find sufficient evidence to support the allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated (Evaluation Report Continues LIC 9099-C) No deficiencies cited. Exit interview conducted and a copy of this report was provided to Office Manager Shenick Jackson.the state’s words, verbatim · CDSS document, Apr 18, 2024 · control 11-AS-20240412162721

Allegation investigated: Resident abuse. Altering/falsifying records. Resident’s personal supplies being distributed to other residents. Uncleared staff working at facility.

On 01/12/24 at 9:00 am, Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit to deliver complaint investigation findings regarding the allegation above. LPA met with Executive Director (ED) Michael Mendoza as the purpose of today's visit was explained. The investigation consisted of the following; On 03/28/2022 (LPA) Cardenas conducted initial complaint visit. On 05/06/22 LPA Cardenas was unable to interview Resident #1 (R1) due to communication barriers. On 05/18/23 LPA Villegas and LPM Hammond interviewed ED, staff # 2-5(S2-S5) and obtained the following records for R1;admission agreement, Identification and emergency information, physician reports, resident appraisal, preplacement appraisal, consent forms, functional capability assessment and residents incident report notes.LPA obtained (S1) file (resume, job application, health screening, administrator certificate), (S5) file( resume, job description, health screening), (S6) file( resume, job description, health screening, administrator certification), for (S7) LPA obtained Termination statement, and for (S8) LPA obtained employment dates. On 03/08/24 LPA interviewed residents 2-11 (R2-R11) and obtained a copy of the staff Unsubstantiated and resident roster. The investigation revealed the following: Allegation- Resident abuse It is alleged in February or March 2020, NOC shift Staff #1(S1) dragged Resident #1 (R1) across the floor by his feet from the elevator to R1’s bedroom. On 05/18/23, LPA interviewed ED regarding the allegation, ED stated he was not working at the Glen Park at Long Beach in 2020. ED denied any physical abuse occurring since he has been the Administrator. On 05/18/23, LPA interviewed Staff #2-5, 4 of the 4 staff interviewed denied the allegation. On 03/08/24, LPA interviewed R2-R1 regarding the allegation and 10 of 10 residents interviewed denied the allegations. LPA attempted to interview R1 but was unsuccessful due to communication barriers. On 05/18/23, LPA conducted a file review of the facility incident reports from 2020 and a review of R1 file and did not observe any incident reports for physical abuse. LPA conducted a file review of S1 file and did not observe any write ups for physical abuse. Allegation-Altering/falsifying records. It is being alleged the facility engages in fabrication and or forgery of facility records. On 5/18/23 LPA interviewed ED regarding the allegation above, ED denied the allegation stating there has been no falsifying of records at the facility. On 05/18/23 LPA interviewed S2-S5 regarding the allegation above, 4 of 4 staff interviewed denied the allegation above. On 03/08/24 LPA interviewed R2-R11 regarding the allegation above, 10 or 10 residents interviewed denied the allegation above. LPA conducted a review of files obtained and did not observe any alterations made. Allegations- Resident’s personal supplies being distributed to other residents. It is being alleged that residents supplies provided by family members are distributed to other residents. On 5/18/23 LPA interviewed ED regarding the allegation above, ED denied the allegation above. Per ED donations made by family members are distributed to residents who need clothes. On 05/18/23 LPA interviewed S2-S5 regarding the allegation above, 3 of 4 staff interviewed denied the allegation above. 1 of 4 staff interviewed reported that each resident has their own cognitive supplies in their own room. On 03/08/24 LPA interviewed R2-R11 regarding the allegation above, 9 or 10 residents interviewed denied the allegation above and reported never receiving any items that do not belong to the. 1 of 10 residents interviewed reported receiving items that do not belong to resident when laundry is distributed but reports providing the items back to staff right away. Allegation: Uncleared staff working at facility. It is being alleged that S7, former staff did not get a fingerprint clearance. On 5/18/23 LPA interviewed ED regarding the allegation above, ED denied the allegation and reported never meeting the staff in question. On 05/18/23 LPA interviewed S2-S5 regarding the allegation above, 3 of 4 staff interviewed denied the allegation above and reporting not having any knowledge of a staff member by that name. 1 of 4 staff interviewed reported S7 was from a staffing agency during covid and was not directly employed by Glen Park at Long Beach and should have been finger printed by staffing agency. On 03/08/24 LPA interviewed R2-R11 regarding the allegation above, 10 of 10 residents interviewed denied the allegation above and stated not recalling S7. On 05/06/23 LPA Villegas conducted a review of LIC 500 personnel report and compared it to licensing guardian system and confirmed all staff employed by Glen Park at Long Beach are fingerprint cleared. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Executive Director Michael Mendoza, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 8, 2024 · control 11-AS-20220325125918

Allegation investigated: Staff did not prevent a resident from physically assaulting another resident in care. Staff did not administer medication as prescribed.

On 02/07/24 LPA Villegas conducted a sebsequent visit to render inestigation findings regarding the allegation(s) above. LPA met with Executive director (ED) Michael Mendoza as the purpose of todays visit was explained. The investigation consisted of the following: On 02/02/24 LPA interviewed Executive Director (ED), staff #1-6 (S1-S6), and interviewed residents # 3-8 (R3-R8). LPA obtained copies of the following for R1, R2 and R3; emergency Identification form, care plan, physicians report, med list, E-mar for January 2024, and preplacement appraisal information. On 02/02/24 LPA also obtained a staff and resident roster, a copy of the incident report for 01/19/24, SOC 341, copies of internal incident reports for 01/19/24, and conducted a medication review. The investigation revealed the following: Allegation: Staff did not prevent a resident from physically assaulting another resident in care. It is being alleged staff did not prevent a resident from physically assaulting another resident in care. Unsubstantiated 02/02/24 LPA interviewed ED regarding the above allegation, ED denied the allegation above stating that residents are separated, redirected, investigation is conducted, and additional support is provided. Ed continued to report that the facility has a zero tolerance policy for violence therefore if a assault occurs POA's are contacted immediately and asked to pick up the resident in question. On 02/02/24 LPA interviewed S1-S6 regarding the allegation above, 6 of 6 staff interviewed denied the allegation above stating that staff will separate residents, will talk to each resident individually, offer activities and will report the situation to upper management right away. On 02/02/24 LPA interviewed R3-R8 regarding the allegation above, 6 of 6 residents interviewed denied the allegation and reported feeling safe at the facility. On 02/02/24 LPA was unable to interview R2-R3 as R2-R3 where not in the facility, on 02/05/24 LPA was able to interview responsible party (W2) for R1, W2 reported there are no concerns at this time. On 02/06/24 LPA was able to interview R2, R2 denied having any altercations with R1. R1 was unable to provide details on incident in question. Allegation: Staff did not administer medication as prescribed. It is being reported that staff did not administer medication as prescribed. 02/02/24 LPA interviewed ED regarding the above allegation, ED denied the allegation above stating that medications are being provided as directed by Doctor. ED continued to report that there have not been any complaint regarding medications, however residents have complained about not being able to store medications in their rooms. On 02/02/24 LPA interviewed S1-S6 regarding the allegation above, 2 of the 6 staff interviewed denied the allegation reporting Doctors orders are being followed. 2 of 6 staff interviewed continued to report there is a 1 hour window where the medication can be administered 1 hour before or 1 hour after the documented medication time, 2 of 6 staff also indicated that some residents may be provided their medications first when a resident has an urgency. 4 of the 6 staff interviewed reported not they do not assist with medication administration. On 02/02/24 LPA interviewed R3-R8 regarding the allegation above, 5 of 6 resident's denied the allegation above and reported receiving medications daily and on time. 1 of 6 residents reported medication administration has improved but there are still issues that need to be fix. On 02/02/24 LPA conducted a medication review and did not observe any discrepancies, medication administrations, medication times and signatures were observed. on 02/05/24 LPA was able to interview responsible party (W2) for R1, W2 reported there are no concerns at this time. On 02/06/24 LPA was able to interview R2, R2 denied the allegation above and reported receiving medications daily and on time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Executive Director Michael Mendoza, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 11-AS-20240124103401

Allegation investigated: Staff did not prevent a resident from physically assaulting another resident in care. Staff did not administer medication as prescribed.

On 02/07/24 LPA Villegas conducted a sebsequent visit to render inestigation findings regarding the allegation(s) above. LPA met with Executive director (ED) Michael Mendoza as the purpose of todays visit was explained. The investigation consisted of the following: On 02/02/24 LPA interviewed Executive Director (ED), staff #1-6 (S1-S6), and interviewed residents # 3-8 (R3-R8). LPA obtained copies of the following for R1, R2 and R3; emergency Identification form, care plan, physicians report, med list, E-mar for January 2024, and preplacement appraisal information. On 02/02/24 LPA also obtained a staff and resident roster, a copy of the incident report for 01/19/24, SOC 341, copies of internal incident reports for 01/19/24, and conducted a medication review. The investigation revealed the following: Allegation: Staff did not prevent a resident from physically assaulting another resident in care. It is being alleged staff did not prevent a resident from physically assaulting another resident in care. Unsubstantiated 02/02/24 LPA interviewed ED regarding the above allegation, ED denied the allegation above stating that residents are separated, redirected, investigation is conducted, and additional support is provided. Ed continued to report that the facility has a zero tolerance policy for violence therefore if a assault occurs POA's are contacted immediately and asked to pick up the resident in question. On 02/02/24 LPA interviewed S1-S6 regarding the allegation above, 6 of 6 staff interviewed denied the allegation above stating that staff will separate residents, will talk to each resident individually, offer activities and will report the situation to upper management right away. On 02/02/24 LPA interviewed R3-R8 regarding the allegation above, 6 of 6 residents interviewed denied the allegation and reported feeling safe at the facility. On 02/02/24 LPA was unable to interview R2-R3 as R2-R3 where not in the facility, on 02/05/24 LPA was able to interview responsible party (W2) for R1, W2 reported there are no concerns at this time. On 02/06/24 LPA was able to interview R2, R2 denied having any altercations with R1. R1 was unable to provide details on incident in question. Allegation: Staff did not administer medication as prescribed. It is being reported that staff did not administer medication as prescribed. 02/02/24 LPA interviewed ED regarding the above allegation, ED denied the allegation above stating that medications are being provided as directed by Doctor. ED continued to report that there have not been any complaint regarding medications, however residents have complained about not being able to store medications in their rooms. On 02/02/24 LPA interviewed S1-S6 regarding the allegation above, 2 of the 6 staff interviewed denied the allegation reporting Doctors orders are being followed. 2 of 6 staff interviewed continued to report there is a 1 hour window where the medication can be administered 1 hour before or 1 hour after the documented medication time, 2 of 6 staff also indicated that some residents may be provided their medications first when a resident has an urgency. 4 of the 6 staff interviewed reported not they do not assist with medication administration. On 02/02/24 LPA interviewed R3-R8 regarding the allegation above, 5 of 6 resident's denied the allegation above and reported receiving medications daily and on time. 1 of 6 residents reported medication administration has improved but there are still issues that need to be fix. On 02/02/24 LPA conducted a medication review and did not observe any discrepancies, medication administrations, medication times and signatures were observed. on 02/05/24 LPA was able to interview responsible party (W2) for R1, W2 reported there are no concerns at this time. On 02/06/24 LPA was able to interview R2, R2 denied the allegation above and reported receiving medications daily and on time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated. Exit interview conducted with Executive Director Michael Mendoza, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 7, 2024 · control 11-AS-20240124103401

Allegation investigated: Facility staff did not safeguard resident's personal belongings.

On 01/27/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent visit at this facility to deliver findings for this complaint. LPA was greeted by Receptionist Claudia Magana who contacted the Administrator Michael Mendoza. LPA explained the purpose of the visit and read the findings to Mr. Medoza. Investigation cosisted of the following: Licensing Program Analyst (LPA) Jose Calderon conducted the initial complaint visit on 12/27/23. LPA Calderon interviewed Administrator Michael Mendoza A1, R1-R10, S1-S2. This interview was conducted on 12/27/2023. On 12/27/2023 LPA Calderon obtained and reviewed copies of the following: Incident report (dated 12/09/2023) and (dated 12/11/2023). Physician report (dated 11/15/2021 and 10/19/2021), Needs and Service (dated 10/25/2023), (11/25/2023) Video (date 12/08/2023). *This report serves as an amendment to the report created 12/27/23. This report supersedes the complaint investigation findings reflected in the report created 12/27/23. (Evaluation Report continues LIC 9099-C) Substantiated INVESTIGATION REVEALED THE FOLLOWING: Regarding Allegation #1: Facility staff did not safeguard residents’ personal belongings. This complaint alleged staff did not safeguard R1’s belongings. LPA Calderon interviewed with A1. A1 stated that A1 spoke to R1's family members and was advised that personal items were missing from R1's room. A1 stated that A1 reviewed the video for 12/08/2023 around 8:30 am. A1 reported that A1 watched R2 use a key to enter the room of R1 three times. A1 stated that the video showed R2 taking a stuffed animal, a small painting, and markers. A1 claimed that A1 searched R2's room and found R1's items. A1 expressed that S1 found R1's wallet with money in the laundry area. A1 stated that R1's family members counted the money, and the money was never stolen. A1 stated that R2 was shown the video and R2 stated that the video was not R2 and it someone else. LPA Calderon interviewed with S1-S2. S2 communicated that S2 picked up R1's dirty clothes when R1 was in the hospital. S1 said that S1 found an unknown amount of money, two silver coins, a credit card, and two rings. S1 stated that S1 gave items to the manager for safekeeping. S2 stated that S2 received an order to change all the resident room locks with a self-locking door to prevent residents wandering to enter unlocked rooms. LPA Calderon interviewed with R1-R10. LPA Calderon called R1 at the hospital and left two messages. R2 recalled that R2 did not use any key or enter the room of R1. R2 stated that the video showed R2 entering R1’s room with a key and taking items that are not R2. 8 out of 10 residents reported that no one has taken or stolen any items from the resident room and 8 out of 10 state that staff safeguards their personal belongings. LPA Calderon reviewed the video dated 12/08/2023. The video showed R2 using a key to enter R1's room. The video showed R2 taking items from the room. LPA Calderon reviewed the video with R2 who claimed the unknown person is not R2. LPA Calderon toured the facility with S2 and noted new locks for residents’ doors. LPA Calderon reviewed the needs and service plan for R1 and R2 (date 10/25/2023 and 11/15/2023). R1 has no cognitive issues while R2 has health issues. Reviewed incident reports (dated 12/09/2023 and 12/11/2023). Incident reports suggest that R2 did use a key to enter R1's room. The incident report indicated that $91.00 was returned to R1 and was never stolen or taken by R2. (Evaluation Report continues LIC 9099-C) *This report serves as an amendment to the report created 12/27/23. This report supersedes the complaint investigation findings reflected in the report created 12/27/23. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the allegation that “Facility staff did not safeguard residents’ personal belongings” is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citations issued (ref LIC9099D). An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the receptionist Claudia Magana. *This report serves as an amendment to the report created 12/27/23. This report supersedes the complaint investigation findings reflected in the report created 12/27/23.the state’s words, verbatim · CDSS document, Jan 27, 2024 · control 11-AS-20231222170043

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 9, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interview, observation, video, and record review the licensee failed to secure R1’s room after viewing R2 entering R1’s room 3 times and taking R1’s personal property which posed a potential health and safety to residents in care.the state’s words, verbatim · CDSS document, Jan 27, 2024

Plan of correction: Administrator is to change lock for R1’s room and confirm R2 does not have any copies of R1’s door key or keys. Administrator to give notice to R2 regarding taking R1 property. Proof of correction (POC) must be sent to: jose.calderon@dss.ca.gov by due date: 02/09/24

Allegation investigated: Staff did not meet resident's showering needs. Staff did not seek resident timely medical attention. Staff did not ensure security of resident's personal belongings. Staff gave an explanation of circumstances at the time of resident's death, different from what a doctor reported.

THIS REPORT SUPERSEDES THE REPORT DATED 11/18/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: UNSUBSTANTIATED Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Glen Park at Long Beach on 11/16/2023 and was greeted by Administrator Michael Mendoza (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. Investigation consisted of the following: LPA Calderon interviewed Administrator Michael Mendoza A1, R1-R10, S1-S2. These interviews were conducted on 11/16/2023 and 02/07/2024. On 11/16/2023 LPA Calderon obtained and reviewed copies of the following: Shower log notes (date 11/13/2023), Incident reports (date 10/30/2023, 10/31/2023, 11/02/2023), St Mary’s email (date 11/14/2023), Personal Property Inventory (date 09/28/2023), Physician Report (dated 08/23/2023) for R1. The investigation revealed the following: Unsubstantiated Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “staff did not meet residents showering needs”, “staff did not seek resident timely medical attention”, “staff did not ensure security of residents personal belongings”, “staff gave an explanation of circumstance at the time of residents death different from wat a doctor reported” is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Michael Mendoza A1. Regarding Allegation #3: Staff did not ensure security of resident’s personal belongings. This complaint alleged that staff did not secure R11 purse. LPA Calderon conducted an interview with Administrator Michael Mendoza (A1). A1 states that when R11 passes away on 11/14/2023 R11 personal belongings are collected and stored for safety. A1 states that R11 purse was moved to the office and never was missing or stolen. A1 states that a property log is taken of exactly what the staff collects for the resident’s room. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff state that when an R11 passes away staff collects the personal belongings of the resident, and a property log is kept for the facility records. 2 out of 2 staff state that R11 purse was never stolen or missing and was moved to the office for safety. LPA Calderon conducted an interview with R1-R11. 10 out of 11 residents state that none of their personal belongings have gone missing or been stolen while living at the facility. 10 out of 11 residents state that staff do make sure the facility is secure and safe. LPA Calderon could not interview R11 as R11 had passed away on 11/14/2023. Reviewed personal property inventory (date 09/28/2023). 12 items noted for R11 personal belongings. No mention of R11 purse found. Regarding Allegation #4: Staff explained circumstances at the time of resident’s death, different from what a doctor reported. This complaint alleged that staff gave explanation of R11 passing that was different than the hospital records. LPA Calderon conducted an interview with Administrator Michael Mendoza (A1). A1 states that A1 was called to R11 room by S2. A1 states that R11 was found unresponsive in bed and CPR was performed until the fire department arrived. A1 states that R11 pulse was found, and R11 was transported to the hospital for evaluation. A1 states that that A1 called the R11 family and spoke to R11 son. A1 states that A1 advised R11 son that R11 had a heart attack and was transported to the hospital. A1 states that A1 confirmed a DNR with the hospital and that the hospital would not provide any extraordinary lifesaving procedures due to the DNR. LPA Calderon conducted an interview with S2. S2 states that R11 was found unresponsive, and CPR was performed. S2 states that R11 was transported to the hospital for evaluation. S2 states that the front office contacted R11s’ families and advised of R11 medical status. LPA Calderon conducted an interview with R1-R11. 10 out of 11 residents state that staff inform their families of any medical status or updates. LPA Calderon could not interview R11 as R11 had passed away on 11/14/2023. Reviewed email from A1 to St. Mary’s Hospital (date 11/14/2023). A1 was requesting more information on R11 passing. Regarding Allegation #1: Staff did not meet resident’s showering needs. This complaint alleged that staff did not meet R11 showering needs. LPA Calderon conducted an interview with Administrator Michael Mendoza (A1). A1 states that all residents can take a shower when they want to. A1 states that R11 can take a shower with no help from staff and just need to be reminded by staff when to take a shower. A1 states that the facility keeps a shower log for the residents that do not take a shower or need to be reminded. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff state that R11 could take a shower by themselves. 2 out of 2 staff state the R11 need to be reminded to take a shower. 2 out of 2 staff state that they cannot force a resident to take a bath or shower. 2 out of 2 staff state that the facility keeps a shower log for those residents that refuse or forget to take a shower weekly. LPA Calderon conducted an interview with R1-R11. 10 out of 11 residents state that they can take a shower when they want, and staff have never told them not to take a shower. LPA Calderon could not interview R11 as R11 had passed away on 11/14/2023. LPA Calderon reviewed physician report (date 08/23/2023) for R11. The report states that R11 were able to shower with no aid from staff. Reviewed shower logs (date 11/13/2023) for resident. Log notes suggest that R11 was reminded 2 times to take a shower and records suggest that R11 took a shower 7 days a week. Regarding Allegation #2: Staff did not seek resident timely medical attention. This complaint alleged that staff did not seek CPR timely on R11. LPA Calderon conducted an interview with Administrator Michael Mendoza (A1). A1 states that on 11/02/2023 approximately 8 am S2 found R11 unresponsive in R11 bed. A1 states that S2 called A1 who came to R11 room. A1 states that S2 was performing CPR on R11. A1 states that they moved R11 to the floor where A1 continued CPR on R11. A1 states that 911 was called and A1 was able to find a pulse when the fire department arrived. A1 states that R11 was taken to the hospital and passed away on 11/14/2023. A1 states that R11 had a DNR and A1 and S2 only performed CPR on R11. A1 states that R11 was taken to the hospital and passed away from a heart attack. LPA Calderon conducted an interview with S2. S2 states that on 11/02/2023 around 8:15 am S2 found R11 unresponsive in R11 bed. S2 states S2 started CPR on R11 and called 911. S2 states that S2 called A1 who arrived minutes later. S2 states A1 and S2 moved R11 to the floor and A1 continued CPR and A1 found a pulse. S2 states that R11 was transported to the hospital for evaluation. A1 states that R11 passed away from a heart attack per hospital. LPA Calderon conducted an interview with R1-R11. 10 out of 11 residents state that when residents need medical attention staff provides timely medical services. LPA Calderon could not interview R11 as R11 had passed away on 11/14/2023. Reviewed incident report (date 11/02/2023) report states that S2 found R11 unresponsive in bed. S2 called 911 and helped A1 move R11 to the floor. S2 started CPR on R11 and A1 continued CPR on R11 until fire department arrived.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 11-AS-20231113122915

Allegation investigated: Staff did not assist resident withing obtaining care. Staff do not answer resident's call button in a timely manner Staff speaks to resident in an inappropriate manner Staff did not allow resident to possess personal belonging Staff do not assist resident with showering

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Glen Park at Long Beach on 01/11/2024 and was greeted by Administrator Michael Mendoza (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. Investigation consisted of the following: LPA Calderon interviewed Administrator Michael Mendoza A1, R1-R8, S1-S3. This interview was conducted on 01/10/2024. On 01/10/2024 LPA Calderon obtained and reviewed copies of the following: Physician Report (dated 10/10/2023), Shower logs (date 12/22/2023), Front desk logs (date 12/24/2023) for R1. The investigation revealed the following: Unsubstantiated Regarding Allegation #5: Staff do not assist residents with showering. This complaint alleged that staff do not assist R1 with showering. LPA Calderon conducted an interview with Administrator Michael Mendoza (A1). A1 states that R1 is given 3 showers per week. A1 states that R1 needs help to shower due to R1 medical issues. A1 states that R1 is never refused by staff to help take a shower. LPA Calderon conducted an interview with S1-S3. 3 out of 3 staff state that R1 is given 3 showers per week and that staff helps R1 with showering needs. LPA Calderon conducted an interview with R1-R8. R1 states that there are no issues with R1 showering needs. R1 states that staff does help R1 take a shower 3 times per week. 7 out of 7 residents state that they can take a shower any time they want, and staff are there to help if needed. Reviewed the physician report (date 10/10/2023), R1 needs help from staff to take a shower. Reviewed the shower logs (date 12/22/2023), logs note that staff helps R1 take a shower 3 times per week. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “staff did not assist resident with obtaining care” “staff do not answer residents call button in a timely manner” “staff speaks to resident in an inappropriate manner” “staff did not allow resident to possess personal belongings” “staff do not assist resident with showering” is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Michael Mendoza A1. Regarding Allegation #4: Staff do not allow residents to possess personal belongings. This complaint alleged that staff do not allow R1 to have shower towels and extra toilet paper. LPA Calderon conducted an interview with Administrator Michael Mendoza (A1). A1 states that each resident is given 2 shower towels and 2 rolls of toilet paper per week. A1 states that if a resident purchases their own towels or toilet paper there is no reason that residents can not keep them. A1 states that the towels and toilet paper in question are purchased by the facility and no resident can keep more than 2 towels or toilet paper per week. A1 states that A1 spoke to R1 and advised R1 that A1 would replace any personal items owned by R1. LPA Calderon conducted an interview with S1-S3. 3 out of 3 staff state that residents do purchase extra towels and toilet paper and it is possible when housekeepers clean the resident’s room and pick up the dirty clothes that the residents’ towels are also picked up and taken to the wash. 3 out of 3 staff state that no extra toilet paper is collected unless the resident tells them they purchased the extra rolls. LPA Calderon conducted an interview with R1-R8. R1 states that R1 friend purchased 4 towels and they were a gift from R1 friend. R1 states that R1 friend also purchased toilet paper. R1 states that R1 needs extra towels and extra toilet paper, and the facility only supplies 2 towels and 2 rolls of toilet paper per week. R1 states that staff took the extra towels and toilet paper away from R1 room and would not return R1 belongings. 7 out of 7 residents state that they have purchased extra towels and toilet paper and staff do not take their items. 7 out of 7 residents state that staff does clean their dirty towels and some time they are not returned. 7 out of 7 residents state that staff do allow them to possess personal items that they purchase. Regarding Allegation #3: Staff speaks to resident in an inappropriate manner. This complaint alleged that Administrator Michael Mendoza A1 speaks to R1 in English and not in Spanish which R1 cannot understand. LPA Calderon conducted an interview with Administrator Michael Mendoza (A1). A1 states that A1 does not speak Spanish and many times A1 has spoken to R1 with no issues. A1 states that R1 does understand what A1 is saying and anytime there is something important to tell R1 there is another staff member that speaks Spanish to translate for R1 and A1. A1 states that A1 does not believe that A1 speaks to R1 in an inappropriate manner. LPA Calderon conducted an interview with S1-S3. 3 out of 3 staff state that they have spoken to R1 in Spanish many times and there are many Spanish speaking staff that R1 can communicate with or help A1 translate if needed. LPA Calderon conducted an interview with R1-R8. R1 states R1 only speaks Spanish. R1 states that A1 speaks to R1 in English and R1 can not understand what A1 is saying to R1. R1 states that R1 does not speak English and R1 has a hard time communicating with A1. R1 states there is no staff R1 can speak to in Spanish. 7 out of 7 residents state that there are many staff that only speak Spanish and they have a hard time communicating with those staff. 7 out of 7 residents state no issues communicating with A1. Regarding Allegation #2: Staff do not answer residents call button in a timely manner. This complaint alleged that staff do not answer the R1 call button in a timely manner. LPA Calderon conducted an interview with Administrator Michael Mendoza (A1). A1 states that A1 has no record of R1 falling on 12/24/2023. A1 states that if R1 had fallen and hit R1 head on the bathroom doorknob 911 would have been called and R1 would have been taken to the hospital for evaluation. A1 states that if R1 had pushed the call button staff would have responded to R1 room within minutes. A1 states that the facility does not keep call log records for residents, but A1 checked the front desk log notes for 12/24/2023 and there is no record of a call or button pushed by R1. A1 states that there is no way staff would take 30 minutes to respond to a call from any resident. LPA Calderon conducted an interview with S1-S3. 3 out of 3 staff state that they have no record of R1 pushing R1 call button on 12/24/2023. 3 out of 3 staff state that on average it takes 10 to 15 minutes for staff to respond to a residents call for help and 3 out of 3 staff state that if R1 needed help it would not take 30 minutes to respond. LPA Calderon conducted an interview with R1-R8. R1 states that R1 lost R1 balance and fell hitting R1 head on the bathroom doorknob. R1 states that this happened on 12/24/2023 around 9pm. R1 states that R1 pushed the call button for help, and it took staff 30 minutes to arrive and help R1. R1 states that in the 30 minutes that passed R1 got off the floor under R1 own power. 7 out of 7 resident states that they have pushed the call button and it takes 10 to 15 minutes for staff to arrive and help. 7 out of 7 residents state that they are happy with the services provided by staff. Reviewed the front desk log notes (date 12/24/2023), there is no record of R1 calling or pushing the call button for help. There is no record of R1 falling on 12/24/2023. Regarding Allegation #1: Staff did not assist resident with obtaining care. This complaint alleged that staff did not help R1 after falling in room and did not supply pain medication. LPA Calderon conducted an interview with Administrator Michael Mendoza (A1). A1 states that there is no incident report for R1 falling on 12/24/2023. A1 states that A1 checked with A1 staff and no one knew of any unwitnessed fall from R1. A1 states that if R1 had advised staff of a fall, A1 staff would have called 911 and taken R1 to the hospital for evaluation. A1 states that if R1 had pain from the fall and requested Tylenol A1 staff would have given R1 the medication as the Tylenol is on R1 medication list. LPA Calderon conducted an interview with S1-S3. 3 out of 3 staff state to have no record of R1 falling and hitting R1 head on the bathroom doorknob on 12/24/2023. 3 out of 3 staff state they could not find any incident report for 12/24/2023 regarding R1 falling. 3 out of 3 staff state that if R1 had requested Tylenol for pain that the LVN would have given R1 the medication. LPA Calderon conducted an interview with R1-R8. R1 states that on 12/24/2023 R1 lost R1 balance and hit R1 head on the bathroom doorknob. R1 states that R1 got off the floor under R1’s own power and no staff came to help R1. R1 states that R1 asked for Tylenol for pain and staff would not give R1 the medication for pain. 7 out of 7 residents state that staff does take care of their medical needs and if they request medication staff takes care of their medication needs. Reviewed physician report (date 10/10/2023). R1 medication list lists Tylenol extra strength, dispensed 09/18/2023, 1 to 2 tablets for pain.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 11-AS-20240102083125

Allegation investigated: Staff did not meet resident's dietary needs. Staff did not clean resident's room. staff yelled at resident. Staff made inappropriate comment toward resident.

On 12/20/2023, Licensing Program Analyst (LPA) Antonine Richard conducted a complaint visit to deliver findings regarding the above allegations. LPA Richard met with Administrator Michaell Mendoza and explained the reason for the visit. The investigation consisted of the following: On 12/20/2023, LPA Richard and Administrator Mendoza toured the facility inside and out. LPA Richard reviewed and requested, staff and resident's roster. Internal resident incident report, Individual Services Plan (ISP), Winter Menus 2023, Sanitation and Food Safety Checklist for Assisted Living, Daily Housekeeping Schedule, R1 hand writing note, Physician's Report for Residential Care For the Elderly (RCFE). LPA interviewed tens (R2-R10) residents, and seven staff (S1-S7). LPA Richard toured the kitchen and spoke to S2 about resident's dietary needs. This report is cotinued, please see LIC9099C. Unsubstantiated Allegation #1: Staff did not meet resident's dietary needs. On 12/20/2023, LPA Richard conducted an interview with seven staff (S1-S7), all staff stated that the cook follows a meal plan and serve nutritious meals 3 times per day. 7 days a week. S2 stated that not all resident love the food served but the menu has a choice that resident could choose if they don't like what was the main dish. LPA Richard conducted an interview with S2. S2 states that his has been a cook for over 8 years and a cook for the facility for 1 year. S2 stated that S2 follows a meal plan and serves nutritious meals every day. LPA Richard conducted an interview with R1-R10. R1 stated that staff refuses to serve R1 lunch when R1 is out of the facility. R1 stated that the food is not good and not nutritious. 9 out of 10 residents stated that the food is delicious and 9 out of 10 residents have no issues with the food served. LPA Reviewed facility meal plan of residents. Based on interviews, observations and records reviews the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation of “Staff did not meet resident's dietary needs" is UNSUBSTANTIATED. Allegation #2: Staff did not clean resident's room. On 12/20/23, LPA Richard conducted an interviewed with seven staff (S1-S7) all staff and Administrator Michael Mendoza (S1) stated that staff does clean residents’ room 5 days a week. S1 stated that (S2-S3) clean residents’ room 5 times a week and touch every room 4 times a week by taking out the trash and cleaned the bathroom. LPA Richard conducted an interview with (S2-S7). 3 out of 7 staff stated that they clean R1 room 5 times a week and make sure trash is picked up every time. LPA Richard conducted an interview with R1-R10. 9 out of 10 residents stated that staff clean their rooms 4 times a week. 8 out of 10 residents stated that the staff deep clean twice a week. LPA Richard reviewed R1 admission agreement there is no documentation stated how many time the facility need to clean resident’s room. Based on interviews, observation and record reviews the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation staff did not clean resident's room is UNSUBSTANTIATED. Allegation #3: Staff yelled at resident. On 12/20/23, LPA Richard conducted an interview with seven staff (S1-S7) and Administrator Michael Mendoza (S1). S1 stated that he has spoken to R1 many times and has never yelled at R1. S1 stated that he has an open-door policy and has spoken to R1 many times with no issues. S1 stated that he treats all staff and resident with respect, yelling at someone wouldn’t resolved any issue. LPA Richard conducted an interview with ten Residents (R1-R10). R1 stated that Administrator Michael Mendoza is very rude and yells at all the residents all the time. R1 stated that most of the staff doesn’t yell at residents R1-R10 when speaking to them R1-R2. 9 out of 10 residents stated they have no issues or concerns about S1. LPA Richard reviewed incident reports there is no mention of yelling at residents. Based on interviews, observations, and record reviews the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation staff yelled at resident is UNSUBSTANTIATED. Allegation #4: Staff made inappropriate comment toward resident. On 12/20/23, LPA Richard conducted an interview with seven staff (S1-S7) and Administrator Michael Mendoza (S1). S1 stated that he has spoken to R1 many times and has never made inappropriate comments towards anyone, staff or resident. S1 stated that he has not spoken inappropriate mean and loudly when speak to resident. LPA Richard interviewed ten Residents (R1-R10). R1 stated that most of the staff are nice and considerate toward residents when speaking to them. 9 out of 10 residents stated they have not experienced inappropriate comment from S1 since they’ve being living here. LPA Richard reviewed incident reports there is no mention of S1 made inappropriate comment toward resident. Based on interviews, observations, and record reviews the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation staff made inappropriate comment toward resident is UNSUBSTANTIATED. An Exit interview was conducted with the Administrator Michael Mendoza and a copy of the report was providethe state’s words, verbatim · CDSS document, Dec 20, 2023 · control 11-AS-20231218161430

Allegation investigated: Staff handled resident in a rough manner. Staff does not respond to resident’s call for assistance. Staff does not serve nutritious meals. Staff served resident expired milk

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Glen Park at Long Beach on 12/18/2023 and was greeted by Administrator Michael Mendoza (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. During this investigation, LPA Calderon interviewed A1, S1-S3, R1-R9. These interviews were conducted on 12/18/2023. On 12/18/2023 LPA Calderon obtained and reviewed copies of the following: PACE level of care determination (date 09/01/2023), Incident report (date 12/08/2023), Meal Plan (date 12/1/2023 to 12/31/2023). On 12/18/2023 LPA Calderon toured the kitchen. The investigation revealed the following: Unsubstantiated Regarding Allegation #1: Staff handled resident in a rough manner. This complaint alleged that S1 handled R1 in a ruff manner injuring R1 left leg and arm area. LPA Calderon conducted an interview with A1. A1 states that S1 has been working for the facility for 1 year and helps care for residents. A1 states that S1 was pushing R1 wheelchair who was leaving the facility for the morning. A1 states that that R1 has an old wheelchair and as S1 was pushing R1 chair R1 foot got caught in the front wheelchair wheel and R1 left foot was not injured. A1 states that A1 advised R1 social worker of the situation and that R1 was not injured. A1 states that the incident was an accident and not abuse on S1 part. LPA Calderon conducted an interview with S1 who states that S1 does not remember what happened to R1 foot. LPA Calderon conducted an interview with S3 who states that S1 is a professional and has no history of abuse and the incident was an accident. LPA Calderon conducted an interview with R1-R9. R1 states that S1 was in a hurry to get R1 into the van and R1 foot got caught in the front wheel of the chair. R1 states that this is the second time S1 has rushed and injured R1 body. R1 does not remember the date, but that the incident happened in R1 room and R1 left arm was injured. 8 out of 8 residents states no issues with service provided and staff have never been unprofessional. Regarding Allegation #2: Staff does not respond to residents call for assistance. This complaint alleged that staff does not respond to R1 call for assistance. LPA Calderon conducted an interview with A1. A1 states that the facility does not keep call button logs, but that staff do respond to resident request for services within 10 to 15 minutes depending on the time of the call. A1 states that staff do not take 45 minutes to respond as R1 claims. LPA Calderon conducted an interview with S3. S3 states that depending on when the resident pushes the service button it may take 10 minutes or 15 minutes for staff to respond for service, but staff do not take 45 minutes to respond for residents’ services. LPA Calderon conducted an interview with R1-R9. R1 states that R1 pushed the call button and staff took 45 minutes to respond. R1 states that R1 yelled out from the bathroom area with no response from staff. R1 states that R1 roommate R7 had to help R1 into and out of the bathroom. 8 out of 8 residents state that staff takes 10 to 15 minutes to respond when the call button is pushed. R7 states that R7 does not remember how long it took staff to arrive for service and R7 had nothing to say on the incident. Regarding Allegation #3: Staff does not serve nutritious meals. This complaint alleged that staff do not serve R1 nutritious meals. LPA Calderon conducted an interview with A1. A1 states that A1 has 2 cook who follow a meal plan and serve nutritious meals 3 times per day, 7 days a week. A1 states that not all resident love the food served but A1 states that A1 cooks speak to residents and get feed back on the food served. LPA Calderon conducted an interview with S2. S2 states that S2 has been a cook for over 8 years and a cook for the facility for 1 year. S2 states that S2 follows a meal plan and serves nutritious meals every day. S2 states that S2 has 3 dining staff taste S2 food prior to serving to make sure the food is nutritious and taste good. S2 states that most resident love S2 food but not all. LPA Calderon conducted an interview with R1-R9. R1 states that staff refuses to serve R1 lunch when R1 is out of the facility. R1 states that the food is not good and not nutritious. 8 out of 8 residents state that the food is ok and 8 out of 8 residents have no issues with the food served. Reviewed facility meal plan (date 12/01/2023 to 12/31/2023), meal plan appears to be balanced and meets the needs of residents. Regarding Allegation #4: Staff served R1 expired milk. This complaint alleged that staff served R1 expired milk. LPA Calderon conducted an interview with A1. A1 states that no dining staff would or does serve expired milk to residents in care. A1 states that dining staff check for expired foods and rotate the food stores to make sure no expired food is served. LPA Calderon conducted an interview with S2. S2 states that S2 has been the facility cook for 1 year. S2 states that S2 checks daily food stores and makes sure to rotate foods. S2 states that no dining staff would serve expired food or milk. S2 states that staff taste the milk prior to service and makes sure the milk taste good and is not expired. LPA Calderon conducted an interview with R1-R9. R1 states that R1 eats cold cereal in the morning and the milk served is off and does not taste good. 8 out of 8 residents state to have no issues with the milk served and the milk taste fine. LPA Calderon toured the kitchen and inspected the 1-gallon milk bottles. LPA Calderon could not find any expired milk. Based on interviews, observations and supporting documents. The preponderance of evidence standard has NOT been met; therefore, the allegation of “Staff handled resident in a rough manner” “Staff does not respond to residents call for assistance”, “Staff does not serve nutritious meals”, “Staff served resident expired milk” is found to be UNSUBSTANTIATED. A face-to-face meeting was conducted with Administrator Michael Mendoza and a hard copy was provided.the state’s words, verbatim · CDSS document, Dec 18, 2023 · control 11-AS-20231211112444

Allegation investigated: Staff are allowing residents with prohibited health conditions to reside in the facility. Staff are not preventing residents from sustaining skin tears while in care. Staff are yelling at the residents. Staff are abusing the residents while in care. Staff denied residents the right to get a Covid-19 Vaccine. Staff are stealing money and personal belongings from residents. Staff are stealing residents medications. Staff are denying residents food. Staff are not treating residents with dignity.

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (S1: Tyshima Bonner, Office Manager); as Administrator (A1: Michael Mendoza) was unavailable. LPA/RA conducted a risk assessment prior to entering facility. S1 informed LPA/RA that the facility has no COVID cases nor do the residents nor staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day visit was conducted by LPA Martessa Brown on 03/23/23 who was met by the Administrator. During today’s visit, LPA/RA re-interviewed the Administrator (via landline), Staff #1 - Staff #5 (S1-S5) and Residents #1 - Resident #8 (R1-R8). LPA/RA toured the facility's physical plant for health and safety purposes of residents in care. LPA/RA reviewed the following documents: Admission Agreements, Physician’s Reports, Resident Appraisals, Medication Administration Records (October 2023), COVID-19 Vaccine cards, and Personal Property Inventory for Resident #9 - Resident #12 (R9-R12). LPA/RA Unsubstantiated reviewed the Trust Account/P & I Ledgers (March 2023 & October 2023), Incident Reports (02/21/23 – 03/01/23), Staff In-service Training Records, Monthly Menu (October 2023), Facility Staff (S1-S5) and Residents (R9-R12) files, Facility Staff and Residents' rosters (dated 02/23/22 & 10/06/23). LPA/RA toured the facility's physical plant: memory care unit, medication room, and commercial-size kitchen. LPA/RA observed the security monitors and camera system and delayed egress doors. Regarding Allegation #1: this investigation revealed that the facility is a vendor of the Harbor Regional Center (HRC) and participant of the Assisted-Living Waiver program. Residents who require 24/7 level of care reside in the facility’s secured unit on the 2nd floor that requires a key-card system. Interviews conducted of seven (7) staff corroborated that the facility does not have residents with a prohibited health condition. Executive Director stated that whenever a resident requires a higher level of care, facility staff will call 9-1-1 or non-emergency ambulance. If the facility receives a call regarding accepting/returning a resident with a prohibited health condition, they are advised that the facility is not a medical facility. Interviews conducted of eight (8) residents, corroborated that they did not have a prohibited health condition nor had they known of residents living in the facility with a prohibited health condition. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of LEVEL OF CARE: Staff are allowing residents with prohibited health conditions to reside in the facility is found to be UNSUBSTANTIATED. Regarding Allegation #2: this investigation revealed based on interviews conducted of seven (7) facility staff who corroborated that whenever a resident has sustained a skin tear, the med techs will provide first-aid. Interviews conducted of eight (8) residents corroborated that they are provided with first aid by the med techs whenever they have sustained a skin tear. LPA/RA reviewed facility staff in-service training record on the topic of How to Manage Elderly Skin, Skin Integrity, and First Aid. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff are not preventing residents from sustaining skin tears while in care is found to be UNSUBSTANTIATED. Regarding Allegation #3: this investigation revealed based on interviews conducted of seven (7) facility staff members corroborated that often a resident cannot hear so facility staff often has to raise their voice in an effort to communicate to the resident(s). There has been no complaints made to facility staff from residents regarding facility staff yelling at them. Interviews conducted of eight (8) of the residents corroborated that they have not been yelled at by a facility staff member nor observed other residents in care being yelled at by facility staff. LPA/RA reviewed the facility staff rosters (dated 02/23/22 & 10/06/23) that did not document a staff member by the first name of “Brenda” or “Marina” or “April”. LPA/RA reviewed facility staff in-service training records on the topic of Mandated Reporting. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff are yelling at the residents is found to be UNSUBSTANTIATED. Regarding Allegation #4: this investigation revealed a tour of the facility’s physical plant was conducted upon arrival to ensure the health and safety of residents in care. Interviews conducted of seven (7) facility staff members corroborated that there has not been reports of abuse from residents or their representatives (ALW, PACE, HRC) or responsible person(s). Interviews conducted of eight (8) residents corroborated that they have not been abused by facility staff nor have they observed a resident in care being abused by a facility staff member. LPA/RA reviewed the facility staff rosters (dated 02/23/22 & 10/06/23) that did not document a staff member by the first name of “Brenda” or “Marina” or "April". LPA/RA reviewed facility staff in-service training records on the topics of Non-violent Crisis Intervention and Mandated Reporting. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff are abusing the residents while in care is found to be UNSUBSTANTIATED. Regarding Allegation #5: this investigation revealed based on interviews conducted of seven (7) facility staff that 95 of the 97 residents in care have received both of their COVID-19 vaccines. Interviews conducted of eight (8) residents corroborated that they were not denied and have received both of their COVID-19 vaccinations. Administrator stated that residents from the PACE program received their vaccines through PACE and all other residents in care either received their vaccinations from the facility’s in-house doctor or CVS. LPA/RA observed facility’s Incident Reports to CCLD regarding COVID-19, staff in-service training record on the topic of Reducing Risk Keeping Safe & Preventing Spread, and (R9-R12) COVID-19 vaccination cards. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff denied residents the right to get a Covid-19 Vaccine is found to be UNSUBSTANTIATED. Regarding Allegation #6: this investigation revealed based on interviews conducted of seven (7) staff members that there has not been complaints from residents in care that staff stole their money or personal belongings. Interviews conducted of eight (8) residents in care corroborated that they have not had money or personal belongings stolen by facility staff. Administrator stated that the facility maintains a trust account for every resident in care. LPA/RA reviewed facility’s Trust Account Ledgers (March 2023 and October 2023) for 45 residents. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS Staff are stealing money and personal belongings from residents is found to be UNSUBSTANTIATED. Regarding Allegation #7: this investigation revealed based on interviews conducted of A1, A2, S1, and S2 that once the med techs administer residents’ medication(s), the med tech will initial the MAR. Interviews conducted of eight (8) residents corroborated that the med techs do administer their medications and have not been known to have missed medication(s). LPA/RA toured the medication room for observation of the medications and review of the medication administration records for R9-R12 that had been administered during the month of October 2023. LPA/RA reviewed facility staff in-service training on the topic of medication administration for Staff #2. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of MEDICATIONS: Staff are stealing residents’ medications is found to be UNSUBSTANTIATED. Regarding Allegation #8: this investigation revealed based on interviews conducted of seven (7) staff members corroborated that they have not received complaints from residents that they were denied food. Staff #4 (Kitchen Aide/Server) indicated that if a resident should miss their mealtime (breakfast, lunch and/or dinner) there is always optional meals to select. Interviews conducted of eight (8) residents corroborated that they have not been denied a meal nor have they heard of a resident denied a meal. LPA/RA toured the commercial-size kitchen and observed a sufficient food supply of perishables and non-perishables including the posted monthly menu. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of FOOD SERVICE: Staff are denying residents food is found to be UNSUBSTANTIATED. Regarding Allegation #9: this investigation revealed based on interviews conducted of seven (7) staff members corroborated that they have not received a complaint from residents in care that facility staff are not treating them with respect. Interviews conducted of eight (8) residents corroborated that facility staff are compliant and compassionate to their needs and have not been intimidated or bullied or threatened by a facility staff member. LPA/RA reviewed the facility staff rosters (dated 02/23/22 & 10/06/23) that did not document a staff member by the first name of “Brenda” or “Marina” or "April". LPA/RA reviewed facility staff in-service training record on the topics of Non-violent Crisis Intervention, Personal Rights, and Mandated Reporting. Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Staff are not treating residents with dignity is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report provided to Staff #1 (Tyshima Bonner, Office Manager).the state’s words, verbatim · CDSS document, Oct 25, 2023 · control 11-AS-20230315135635

Allegation investigated: Staff is not following resident's dietary needs Staff is not providing housekeeping services to resident in care Staff do not treat resident with dignity and respect

THIS REPORT SUPERSEDES THE REPORT DATED 10/10/2023 FOR CLARIFYING THE CIRCUMSTANCE FOR THE ALLEGATIONS. ALTHOUGH THIS REPORT SUPERSEDES THE PREVIOUS REPORT THE COMPLAINT INVESTIGATION FINDINGS REMAIN THE SAME: UNSUBSTANTIATED. Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Glen Park at Long Beach on 10/10/2023 and was greeted by Administrator Michael Mendoza (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. Investigation consisted of: LPA Calderon interviewed Administrator Michael Mendoza A1, R1-R8, S1-S2. This interview was conducted on 10/10/2023 and 02/07/2024. On 10/10/2023 LPA Calderon obtained and reviewed copies of the following: Admission Agreement (dated 10/25/2022), Physician Report (dated 07/27/2023), Incident report (dated 3/18/23, 8/16/23, 8/17/2023), Dietary Preference (dated 10/25/2022), Menu for February 2024, Tour R1 room for R1. The investigation revealed the following: Unsubstantiated Regarding Allegation #1: Staff are not following residents’ dietary needs. This complaint alleged that staff are feeding bell peppers and red meat to R1 and not following a dietary plan. LPA Calderon conducted an interview with Administrator Michael Mendoza (A1). A1 states that R1 is not diabetic and would not have a diabetic meal plan based on R1 physician report (dated 07/27/2023). A1 states that R1 did not report to A1 that R1 was allergic to bell peppers or red meat. A1 has requested an updated physician report for R1 diet needs. A1 states that he has spoken to the dining staff and advised them to not serve R1 with peppers or red meat. A1 has given R1 a weekly food menu so that R1 can decide as to what R1 wants to eat. LPA Calderon conducted an interview with R1-R8. R1 states that R1 never advised A1 or staff that R1 was allergic to bell peppers or red meat. R1 states that he is not diabetic and R1 never received any physician order regarding R1 meal plan. R1 states that dining staff have worked with him regarding the peppers and red meat and A1 has given R1 a copy of the menu so that R1 can decide for R1 meals. 7 out of 8 residents state to have no issues with the food served in the dining room. LPA Calderon reviewed the R1 dietary preferences (dated 10/25/2022). Restrictions none, lactose intolerant, does not like red meat. There is no documentation that R1 is allergic to bell peppers or red meat. LPA Calderon reviewed physician report (07/27/2023) for R1. There is no documentation that R1 is diabetic or allergic to bell peppers or red meat. Reviewed incident report (date 10/25/2022) report mentions R1 not a red meat eater, does not like bones or ham. Regarding Allegation #2: Staff is not providing housekeeping services to resident in care. This complaint alleged that staff are not cleaning R1 room. LPA Calderon conducted an interview with Administrator Michael Mendoza (A1). A1 states that staff do not clean any residents room 7 days a week. A1 states that S1-S2 clean residents’ rooms 3 to 4 times a week and touch every room 6 times a week by taking out the trash. LPA Calderon conducted an interview with S1-S2. 2 out of 2 staff state that they clean R1 room 4 times a week and make sure trash is picked up 6 times a week or as needed. LPA Calderon conducted an interview with R1. R1 states that staff do pick up trash from R1 room. R1 states that staff clean R1 room 5 times per week. LPA Calderon conducted an interview with R2-R8. 7 out of 8 residents state that staff clean their rooms 4 times a week. 7 out of 8 residents state that the staff clean their rooms 3 times a week. LPA Calderon reviewed R1 admission agreement (dated 10/25/2022). There is no documentation of how many times staff are too clean R1 room, there is documentation which state, “cleaning bed and bath linens weekly or as often as needed” and “cleaning of residents room”. On 02/07/2024 LPA Calderon inspected R1 room. R1 lives alone and R1 room is clean and there is no trash found on the floor. LPA Calderon noted staff cleaning R1 bathroom and R1 bathroom was clean. Regarding Allegation #3: Staff do not treat residents with dignity and respect. This complaint alleged that Administrator Michael Mendoza A1 has been disrespectful when speaking to R1. LPA Calderon conducted an interview with Administrator Michael Mendoza (A1). A1 states that A1 has spoken to R1 many times and has never been rude or disrespectful. A1 states that A1 has an open-door policy and has spoken to R1 many times with no issues. A1 states that A1 treats R1 with dignity and respect. LPA Calderon conducted an interview with R1-R8. R1-R2 states that Administrator Michael Mendoza is rude and disrespectful to R1-R2. R1-R2 states that all other staff treat R1-R2 with dignity and respect when speaking to R1-R2. 6 out of 8 residents states to have no issues or concerns about A1 or staff and all staff deal with them professionally. LPA Calderon followed up with R1-R2 on complaint. R1 states that A1 had been rude to R1 by interrupting what R1 had to say, but A1 has been professional with R1 and takes care of R1 needs. R2 states that in the past A1 would interrupt what R2 was trying to say, but was never unprofessional with R2. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegations of “staff is not following residents’ dietary needs” “staff is not providing housekeeping services to residents in care” “staff do not treat resident with dignity and respect” is found to be UNSUBSTANTIATED. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator Michael Mendoza A1.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 11-AS-20231003150531

Type of visit: Required - 1 Year

On 10/07/2023 at 8:45AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at Glen Park at Long Beach Facility. LPA Calderon was allowed entry into the facility by Administrator Michael Mendoza. The facility is licensed for 208 residents aged 60 and over. Currently, there are (91) residents residing in the facility 60 years or older. LPA Calderon explained to Administrator Michael Mendoza, the purpose of the 1-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: six (6) resident service records, six (6) resident medication records, and LPA Calderon interviewed six (6) residents and six (6) staff members for visit. LPA Calderon inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 09/08/2023. The two-story commercial building consists of one hundred (100) resident bedrooms, one hundred (100) resident bathrooms, three (3) common bathrooms, dining room, commercial kitchen, staff room, office area, library, Media room, Garden area, washer and dryer/ storage area, backyard with umbrella with table and chairs. No weapons are stored in the premises. Commercial Kitchen was inspected and observed to be clean and operational. A 2-day supply perishable and 7-day supply of non-perishable foods are present in the facility kitchen. Emergency Water Storage is in found inside locked shed of the facility grounds. LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s rooms #101, #103, #106, #201, #206, #210: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 113 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 111 degrees Fahrenheit, and Bathroom #3 hot water temperature properly measured at 110 degrees Fahrenheit. Commercial kitchen hot water temperature properly measured at 118 degrees Fahrenheit. Facility sixty (60) Carbon Monoxide and sixty (60) Smoke Detectors hard wired and connected were tested and are working properly. The facility twenty (20) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked medication room. Facility first aid kits (10) is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. Six (6) staff files were checked and have the required documents. The facility does handle resident's money/cash resources. Western Surety Bond Company #7170749 for $10,000.00 was valid at time of inspection. All the required documents are posted in the facility in a clearly visible area. LPA Calderon noted the Administrator Michael Mendoza Certification # 6021836740 expiration date of 12/30/2020 was NOT valid at time of visit (ADMINISTRATOR HAS 83 TRAINING HOURS FROM MARCH TO JUNE 2023 AND IS WAITING HIS NEW ADMINISTRATOR CERTIFICATION). Commercial General Liability Policy #LTC-21200055-02 policy period from 12/05/2022 to 12/05/2023 underwritten by Healthcare Professional Long Term Care Insurance company coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Administrator Michael Mendoza who will email full copy of insurance contact which shows all coverages to LPA Calderon no later than 10/20/2023. All the required documents are posted in the facility in a clearly visible area to all staff, clients, and guests. LPA Calderon reviewed LIC500 and noted all staff associated to facility per LIS. LPA Calderon reviewed the resident roster, LPA Calderon confirmed residents’ interview are on resident roster. LPA advised the Administrator Michael Mendoza to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. . According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Michael Mendoza.the state’s words, verbatim · CDSS document, Oct 7, 2023

Allegation investigated: Residents are being sexually abused while in care Residents are being physically abused while in care Staff mismanage residents’ medication Residents are being financially abused while in care Residents are being neglected while in care Residents’ rights are being violated Staff failed to provide adequate food service Residents are being confined to their rooms

On 09/29/23 Licensing program analyst (LPA) Lizeth Villegas and Licensing program manager (LPM) Janae Hammond conduced a subsequent complaint visit to render investigation findings. During todays visit LPA and LPM met with Executive Director Michael Mendoza and the purpose of todays visit was explained. The investigation consisted of the following: On 04/04/23 LPA Gibbs obtained copies of the following documents: Resident Roster, Staff Roster, Staff training in Medication Administration, Staff training in Personal Rights, Menu, Dietician/Nutritionist review of menu report, Assisted Living Waiver Resident list, any resident financial records for money entrusted to the facility and Staff Record (Files to be emailed). On 09/29/23 LPA and LPM conducted interviews with Staff #1-9, interviews with residents # 1-9, obtained copies of staff and resident rosters, P&I ledgers and receipts and conducted review of 9 medication administratoin records. Unsubstantiated The investigation revealed the following: Allegation:Residents are being sexually abused while in care It is being alleged residents are being sexually abused while in care, there was no specific resident identified, no date nor time indicated and no specific details provided. On 09/29/23 LPA and LPM interviewed S1-9, 9 out of 9 staff denied the above allegation and reported being unaware of any resident being sexually abused. On 09/29/23 LPA and LPM interviewed R1-9, 9 out of 9 residents denied the allegation. LPA conducted file review and there were no incident reports on file for the above allegation. Allegation: Residents are being physically abused while in care It is being alleged residents are being physically abused while in care, there was no specific resident identified, no date nor time indicated and no specific details provided. On 09/29/23 LPA and LPM interviewed S1-9, 9 out of 9 staff denied the above allegation and reported being unaware of any resident being physically abused while in care. On 09/29/23 LPA and LPM interviewed R1-9, 9 out of 9 residents denied the allegation. LPA conducted file review and there were no incident reports on file for the above allegation. Allegation: Staff mismanage residents’ medication On 09/29/23 LPA and LPM interviewed S1-9, 9 out of 9 staff denied the above allegation. 2 of 9 staff interviewed reported being responsible for conducting quality assurance and reported not findings and discrepancies. On 09/29/23 LPA and LPM interviewed R1-9, 8 out of 9 residents denied the allegation. 1 of 9 residents interviewed reported having 1 pill missing and error was fixed. On 09/29/23 LPA conducted review of 9 medication administration records and did not observe any discrepancies. On 04/04/23 LPA Gibbs reviewed staff records and obtained a copy of medication training for staff that administer medications. Allegation: Residents are being financially abused while in care On 09/29/23 LPA and LPM interviewed S1-9, 9 out of 9 staff denied the above allegation. On 09/29/23 LPA and LPM interviewed R1-9, 9 out of 9 residents denied the allegation of being financially abused. 4 out of 9 residents interviewed reported family or self being financially responsible for finances, 5 out of 9 residents interviewed reported the facility is responsible for their finances. On 04/04/23 and 09/29/23 LPA reviewed P&I ledgers and receipts and did not observe any discrepancies. Allegation: Residents are being neglected while in care It is being alleged residents are being neglected while in care, there was no specific resident identified, no date nor time indicated and no specific details provided. On 09/29/23 LPA and LPM interviewed S1-9, 9 out of 9 staff denied the above allegation. On 09/29/23 LPA and LPM interviewed R1-9, 9 out of 9 residents denied the allegation. Allegation: Residents’ rights are being violated It is being alleged residents rights are being violated, no specific or additional details provided. On 09/29/23 LPA and LPM interviewed S1-9, 9 out of 9 staff denied the above allegation. On 09/29/23 LPA and LPM interviewed R1-9, 9 out of 9 residents denied the allegation. Allegation: Staff failed to provide adequate food service It is being alleged facility staff is denying residents food. On 09/29/23 LPA and LPM interviewed S1-9, 9 out of 9 staff denied the above allegation. S1-9 stated dinning room is always open for residents to obtain food whenever they like. On 09/29/23 LPA and LPM interviewed R1-9, 9 out of 9 residents denied the allegation and reported receiving meals 3 times a day and snacks 2 times a day. On 04/04/23 LPA Gibbs obtained copies of Menu, Dietician/Nutritionist review of menu report. On 04/04/23 LPA Gibbs conducted tour of facility kitchen and inspected food supply, LPA observed food to be adequately stocked at the time of visit. Allegation: Residents are being confined to their rooms On 09/29/23 LPA and LPM interviewed S1-9, 9 out of 9 staff denied the above allegation. 9 of 9 staff interviewed reported residents were asked to stay in their rooms during Covid per policy. On 09/29/23 LPA and LPM interviewed R1-9, 9 out of 9 residents denied the allegation. 3 of 9 residents interviewed reported residents were asked to stay in their rooms during covid. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted with Executive Director Michael Mendoza, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 11-AS-20230403154927