Glen Park at Long Beach

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