Glen Park at Valley Village

Allegation investigated: Staff sexually assaulted resident

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegation. The LPA arrived at 10AM and met with Interim Executive Director (ED) Virginia Sumulong. Entrance interview conducted. On 02/03/2026, the Department received a notification of an alleged staff on resident sexual assault that occurred on the evening of 01/30/2026. On 02/04/2026, LPA Huynh conducted a Case Management Incident visit. Between 10:32AM and 11:26AM, the LPA conducted a physical plant tour and obtained pertinent documents including facility camera footage. Report Continued on LIC 9099-C Substantiated Between 02/05/2026 and 05/07/2026, the Department interviewed facility staff and residents, Los Angeles Police Department (LAPD) Detectives, and obtained and reviewed pertinent documents. On 07/02/2026, LPA Huynh conducted a subsequent complaint visit. Between 11:39AM and 2:03AM the LPA conducted a physical plant tour, and interviewed five (5) staff, one (1) resident, and the ED. During today’s visit at 10:06AM, the LPA and ED conducted a physical plant tour, and no immediate concerns were observed. The following was then determined: Allegation: “Staff sexually assaulted resident” It was reported that Staff #1 (S1) sexually assaulted Resident #1 (R1) through forced oral copulation on the evening of 01/30/2026. Physician’s Report dated 09/25/2025 documented R1 with hypertension, cardiomegaly, cardiac arrythmia, diabetes mellitus type 2, hypothyroidism, and COPD. R1 had no diagnosis of cognitive impairment but experienced major depressive disorder and psychosis. They were noted to be non-ambulatory but able to follow directions and communicate their needs. According to R1’s Appraisal/Needs and Services Plan dated 10/02/2025, Staff were to monitor R1 for unusual and uncontrolled behaviors due to their mental health history. The plan also documented periods of forgetfulness requiring staff queueing for daily hygiene and social activities. Record review of S1’s employment revealed multiple disciplinary actions and internal staff incident reports. S1 frequently ignored resident and staff requests for assistance and was often observed conversing or “relaxing” instead of performing assigned duties. Reports also documented conflicts with peers, difficulty working as part of a team, and a pattern of calling out or leaving shifts early. Report Continued on LIC 9099-C Interviews with staff and residents revealed no additional concerns regarding S1. Staff described S1 as often unavailable, including hiding in resident rooms, and characterized their work habit as unreliable and “lazy.” Staff #2 (S2), who was supervising S1 on 01/30/2026, reported that during the final check-in at approximately 9:30PM, S1 exhibited no unusual behavior. Staff also reported that R1 had a history of occasional “strange behavior” and one (1) past incident of inappropriately touching staff, which was addressed with no further occurrences. R1 reported that after receiving their evening snack on 01/30/2026, they were resting in their room when they felt a hand moving up and down their leg. R1 reported being lifted by their armpits, placed into their wheelchair, and subjected to forced oral copulation by S1. R1 stated they attempted to push S1 away multiple times but was unsuccessful. They reported that the incident lasted approximately five (5) to ten (10) minutes and that they preserved S1’s bodily fluids on toilet paper as evidence. R1 further reported that S1 threatened to “come back and hurt [R1]” if they disclosed the incident. After S1 left the room, R1 checked the hallway to ensure S1 was gone and stated they were afraid to leave their room until it was safe. The following morning on 01/31/2026, R1 reported the incident to Staff #3 (S3), who immediately contacted law enforcement. R1 stated they had not previously experienced any inappropriate behavior from staff and described minimal interactions with S1. R1’s statements remained consistent across interviews conducted by facility staff, law enforcement, and the Department. Facility camera footage captured S1 entering the hallway at 8:54:11PM on 01/30/2026 carrying a black trash bag. S1 walked towards R1’s room and at 8:54:36PM placed the trash bag on the floor and looked down the hallway as they unlocked R1’s door using facility keys. S1 entered the room at 8:54:45PM, briefly returned to retrieve the trash bag, and re-entered R1’s room. Between 8:57:12PM and 9:09PM, one (1) resident and two (2) staff passed through the hallway. At 9:13:50PM, S1 exited R1’s room with a wheelchair, food tray, and trash bag. S1 walked out of view and returned at 9:16:17PM carrying a trash bag and clothing. Report Continued on LIC 9099-C S1 dropped the trash bag, entered a second resident room at 9:16:38PM, and at this time R1 exited their own room in a wheelchair, appearing to look up and down the hallway. S1 exited the second room at 9:17:34PM empty handed, observed R1 in their doorway, and walked towards R1. R1 then backed their wheelchair into their room, with S1 following at 9:17:48PM. At 9:18:09PM, S1 re-entered the hallway and closed R1’s door. Review of LAPD Detective’s Crime Report showed that law enforcement responded on 01/31/2026, arranged a sexual assault exam, and collected forensic swabs and the preserved bodily-fluid evidence. On 02/03/2026, S1 voluntarily went to the police station for an interview. S1 initially denied the allegation, provided a DNA sample, and later admitted to consensual sexual contact, claiming R1 initiated the act by removing their clothing. S1 admitted to oral copulation but denied the use of force and threats. S1 was arrested and charged with oral copulation by force or fear. Detectives informed the Department that S1 attempted to discredit R1 by falsely claiming R1 had dementia and confirmed that R1 was assessed as a credible witness. They also reported no evidence of additional sexual assault victims at the facility. DNA analysis confirmed that the bodily fluids collected belonged to S1. No further information was available due to an active case. On 03/12/2026, the Department interviewed S1, who described their job duties as assisting residents with feeding, bathing, and cleaning. S1 stated that they were not present during resident bathing and that incontinence care was either witnessed by other staff or performed with doors open. S1 denied any past allegations of sexual abuse. S1 reported one (1) prior interaction with R1 in which R1 touched S1’s shoulder and lower back; S1 did not report this incident. On the evening of 01/30/2026, S1 stated they entered R1’s room to discard a food tray and that R1 requested additional assistance moving their wheelchair and removing trash. S1 stated they also provided R1 with medication pills but did not recall how long they remained in the room. Despite multiple attempts, S1 denied the sexual assault allegation and would not clarify why they had been incarcerated. Report Continued on LIC 9099-C Based on interviews and record review, the preponderance of evidence standard has been met; therefore, the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 9099-D). The ED was advised that civil penalties may be assessed based on Health and Safety Code Section 1569.49. Exit interview conducted. A copy of the appeal rights and report was reviewed and provided. Allegation: “Staff do not treat resident with dignity and respect” It was reported that Resident #1 (R1) was not accorded dignity and respect after reporting a sexual assault. R1 stated that facility staff made disrespectful remarks toward them and expressed disbelief about R1’s report. R1 further stated that after disclosing the assault, the ED commented, “nothing like this has ever happened before.” R1 reported that following the incident, they chose not to discuss the details with staff and residents because “it wasn’t their business.” Interviews with five (5) staff revealed that after R1 reported the assault, the facility implemented a two (2) person assist to protect both R1 and staff during care. Staff reported that R1’s level of care did not change and that staff continued to respond to R1’s requests as usual. Staff denied making or overhearing any disrespectful remarks related to the allegation. Some staff stated they were unaware whether R1 spoke about the incident, while others stated that R1 voluntarily shared details with staff and residents. The ED reported that their only interaction with R1 occurred when R1 initially made the report and denied making any disrespectful statements. The ED stated that they interviewed R1 to gather necessary information to report to their superiors and the Department. Due to the active investigation, the ED conducted an in-service training reminding staff of confidentiality requirements and instructing staff not to engage in conversations about the assault. The ED later received reports from staff that R1 was voluntarily discussing the incident. Interview with Resident #2 (R2) confirmed that staff and residents did not treat R1 disrespectfully. R2 stated that while some residents didn’t believe R1’s allegation due to their history of “odd” behavior, they did not express these opinions to R1. R2 reported that following the incident, R1 made inappropriate comments to residents and openly discussed the details in the dining room. R2 stated that some staff and residents appeared hesitant to interact with R1 due to the ongoing investigation, but R1 was not treated differently regarding care or services. Based on interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the violation did or did not occur; therefore, the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 29-AS-20260217151650

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Jul 29, 2026

(a) In addition to the rights listed in Section 87468.1… (8) To be free from neglect… and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: Based on interviews and record review the Licensee did not comply with the above cited section as R1 was not free from sexual abuse which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 28, 2026

Plan of correction: The Licensee will schedule staff training on sexual abuse and staff conduct with a third party vendor and provide CCLD proof by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Quoc Huynh conducted a Case Management visit to deliver findings for a self-reported sexual assault. The LPA arrived at 10AM and met with Executive Director (ED) Virginia Sumulong. Entrance interview conducted. On 02/03/2026, the Department received a notification of an alleged staff on resident sexual assault that occurred on the evening of 01/30/2026. On 02/04/2026, LPA Huynh conducted a Case Management Incident visit. Between 10:32AM and 11:26AM, the LPA conducted a physical plant tour and obtained pertinent documents including facility camera footage. On 02/17/2026, the Department received Complaint Control #29-AS-20260217151650 and on 02/18/2026, LPA Huynh conducted an initial complaint visit. During today’s visit, the LPA and ED conducted a physical plant tour at 10:06AM, and no immediate concerns were observed. The following was then determined: On the evening of 01/30/2026, it was reported that Resident #1 (R1) was sexually assaulted in their room by Staff #1 (S1). R1 provided consistent statements of the events to facility staff, law enforcement, and the Department. R1, who is non-ambulatory but able to communicate their needs, described being forcibly assaulted and threatened, and later reported the incident, prompting immediate law enforcement involvement. Report Continued on LIC 809-C Facility camera footage showed S1 entering and remaining in R1’s room during the time of the alleged incident, and DNA analysis confirmed that bodily fluids collected belonged to S1. While S1 initially denied the allegation, they later admitted to oral copulation but claimed it was consensual and attempted to discredit R1 by falsely stating R1 had dementia. Staff interviews revealed no additional abuse concerns but documented S1’s history of poor performance and unreliability. Considering R1’s consistent statements, corroborating video footage, forensic evidence, and S1’s conflicting accounts, the evidence supported the allegation. A citation was issued via report for Complaint Control #29-AS-20260217151650. Throughout the course of the investigation, it was noted that the facility did not report the sexual assault to the Department in a timely manner. Per reporting requirements, physical abuse that does not result in serious bodily injury shall be reported to the Ombudsman, the Department, and local law enforcement within twenty-four (24) hours. The sexual assault occurred on 01/30/2026 and reported to staff on 01/31/2026. Staff responded by notifying the ED and law enforcement which prompted the ED to visit the facility. The Department received notification approximately three (3) days after the discovery of the incident, on 02/03/2026. Interview with the ED and Office Manager (OM) revealed that the events surrounding the incident occurred on a weekend and both the ED and OM were not scheduled to work. Additionally, there was miscommunication on the placement of the incident report for the ED’s approval which resulted in the delay. Pursuant to Title 22 CA Code of regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Jul 28, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(c) · Plan of correction due date: Aug 4, 2026

(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported… within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above cited section as the Department did not receive notification of R1’s sexual abuse within 24 hours which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 28, 2026

Plan of correction: The Licensee will review reporting requirements and submit a statement of understanding to CCLD by POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case Management-Other visit to deliver findings for the allegation listed above. During today’s visit, LPA Urena met with … and explained the reason for the visit. On 03/12/2025, the Community Care Licensing Department (CCLD) received an Incident Report for Residents (R1) and (R2) submitted by facility staff. The report indicated that a Detective with the Los Angeles Police Department (LAPD) arrived at the facility to investigate an incident involving residents (R1 and R2). On 03/17/2025, the case was referred to the Investigations Branch (IB) and Investigator Laura Garcia was assigned. On 03/19/2025, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case Management - Incident visit to follow up on the Incident Report received by the Department. LPA Urena met with Executive Director (ED) David Aguiniga and Assistant Administrator (AA), Virginia (Gigi) Sumulong explained the reason for the visit. At approximately 11:30 a.m., LPA Urena and the AA conducted a physical plant tour, and obtained documents pertinent to the investigation (Video, staff and resident roster). The ED was advised that the case was referred to the Investigation Branch (IB). Continues on LIC 809C...page 2. Page 2. On 04/15/2025, at approximately 1:30 p.m., an interview was conducted with Executive Director, David Aguiniga. Aguiniga reported that they received a text message from staff indicating that residents (R1 and R2) were observed inappropriately touching each other while watching a movie in the Theatre room located on the second floor of the facility. Aguiniga explained that while monitoring the surveillance camaras, a staff member noticed that the residents were touching each other inappropriately. Facility staff immediately went to separate the residents and proceeded to escort R2 to R2’s room and conducted a visual examination of R2’s body. Additionally, staff immediately dialed 911 and filed a police report with Los Angeles Police Department (LAPD). Staff also contacted R2’s’ relatives and informed them of the incident. Aguiniga denied the allegations of neglect/ lack of care and stated that as soon as staff noticed that the residents were engaging in inappropriate behaviors, staff intervened and separated the residents. Aguiniga stated that staff are required to assist the residents and conduct hourly checks. Aguiniga confirmed that R2 did not require a one-on-one caregiver assist. Aguiniga indicated he would email a copy of the video footage for review to the IB Investigator. On 08/06/2025, at approximately 4:46 p.m., after several previous attempts, an interview was conducted with Assistant Administrator Virginia (Gigi) Sumulong via telephone. Sumulong denied the allegation of neglect/ lack of care and indicated that staff do an excellent job of caring for the residents. Facility staff are required to constantly monitor and check on the residents every two hours, however, staff are constantly monitoring and checking on the residents via door knocks or monitoring surveillance. Sumulong stated that on the date of the incident both residents (R1 and R2) were in the theater room watching a movie. As soon as the staff noticed that there was inappropriate touching, staff immediately responded and called for assistance. The residents were immediately separated, and R2 was evaluated for any bruises or marks. Additionally, staff made the necessary notifications including filing a police report. Sumulong stated that staff are constantly redirecting any type of inappropriate behaviors by residents. Sumulong denied witnessing any type of neglect/ lack of care by staff members. Additional facility staff interviews revealed that staff are required to check at least every hour, however, there is constant facility staff movement that allows every employee to constantly monitor and supervise the residents. Staff denied any neglect/lack of care by any of the staff members. Staff stated that there is always some sort of monitoring of the residents. Staff stated that there are surveillance cameras throughout the common areas and are constantly being monitored. Staff stated that a lapse of 16 minutes passed when they realized that the residents were engaging in inappropriate behavior. Continues on LIC 809C...page 3. Page 3. On 08/12/2025, at approximately 11:30 a.m. an interview was conducted with R2’s responsible party (RP). The following is a summary of the statements provided by RP. The RP indicated that there was not any type of neglect/ lack of care from the facility staff at Glen Park at Valley Village. RP stated that facility staff acted appropriately to the situation and were in constant communication with the RP. RP stated that they could not visit R2 often, however, the staff at the facility kept informing RP about R2’s condition and/or any type of incident. RP reiterated that they did not have any complaints or issues with the level of care and supervision that was provided to R2 by the facility staff members from Glen Park at Valley Village. On 08/13/2025, at approximately 11:30 a.m. an interview was conducted with the responsible party for Resident 3 (R3). The following is a summary of the statements provided by the RP. The RP indicated that R3 has been residing at the Glen Park at Valley Village facility for over two years. The RP denied having any issues or concerns with the level of care provided to R3. Furthermore, the RP indicated that R3 tells RP that if R3 needs anything, staff immediately tend to R3 and make sure that R3 is well taken care of. RP described the staff as having a “great line of communication” and stated that staff do a great job taking care of R3 and other residents. On 03/17/2025, the police report and other relevant documentation to the investigation were requested and reviewed. On 03/25/2025, at approximately 1:00 p.m., the Investigator reviewed the police incident report. On 04/15/2025, at approximately 2:53 p.m., from Glen Park Valley Village a copy of the mp4 videos via email, a copy of timestamps provided by the virtual security guard were received. On 04/22/2025, at approximately 8:30 a.m., the first video footage was reviewed. On 05/07/2025, at approximately 1:00 p.m., a review of a second video footage was conducted. Note: The total video footage length between two clips was approximately 16:80 minutes. The following is a summary of what was observed. The first video footage depicts two residents (R1 and R2) engaging in inappropriate touching, which appears to be consensual. The second video footage depicts R1 and R2 continuing to engage in inappropriate touching. On this video two facility staff are see entering the room and subsequently R1 and R2 stop touching each other. The two staff are seen assisting R2 and transferring R2 to the wheelchair, at the same time, R1 stands up and leaves the room. Staff exit the room with R2. Continues on LIC809C... page 4. Page 4. The first video footage depicts two residents (R1 and R2) engaging in inappropriate touching, which appears to be consensual. The second video footage depicts R1 and R2 continuing to engage in inappropriate touching. On this video two facility staff are see entering the room and subsequently R1 and R2 stop touching each other. The two staff are seen assisting R2 and transferring R2 to the wheelchair, and R1 stands up and leaves the room. Staff exit the room with R2. Although R1 and R2 engaged in inappropriate activity in a common area of the facility, the activity was stopped by facility staff and staff reported the incident to law enforcement, and the CCLD. Based on the information obtained though interviews and record review during the Department’s investigation, the investigation did not provide sufficient evidence to prove that the residents engaged in inappropriate activity due to the facility’s staff neglect and or lack of care. No deficiencies are being cited at this time. Exit interview was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 30, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management visit after the facility self-reported an alleged sexual assault. The LPA arrived at 9:51AM and met with Executive Director (ED) Virginia Sumulong. Entrance interview conducted. On 02/03/2026, the Department received a notification of an alleged staff on resident sexual assault that occurred on 01/30/2026 in the evening. During today’s visit, the LPA and LVN conducted a physical plant tour at 10:32AM and no immediate concerns were observed. Between 10AM and 11:26AM, the LPA reviewed and obtained pertinent documents and was provided additional information along with facility camera footage. During the visit, Los Angeles Police Department (LAPD) Detectives and the District Attorney arrived to continue investigations. The ED was advised that the case was referred to Community Care Licensing Division’s (CCLD) Investigations Branch (IB). The LPA determined further investigation is needed. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Feb 4, 2026

Allegation investigated: Staff sexually assaulted resident in care

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegation. The LPA arrived at 12:29PM and met with the Interim Executive Director (ED) Virginia Sumulong. Entrance interview conducted. On 08/12/2025, LPA Huynh conducted a Case Management visit after the facility self-reported an incident related to the above allegation. Beginning at 10:25AM, the LPA conducted a physical plant tour and reviewed and obtained pertinent documents. The case was referred to Community Care Licensing Division’s (CCLD) Investigations Branch (IB) and assigned to Investigator Douglas Real. Between 08/19/2025 and 09/04/2025, Investigator Real conducted interviews with Resident #1 (R1), Staff #1 (S1), Staff #2 (S2), the former ED, and R1’s family. Report Continued on LIC 9099-C Unsubstantiated During the assignment, S2 was initially identified as the alleged perpetrator, and R1 later identified S1; however, both staff denied the allegation. A full investigation was not opened at that time due to insufficient information and inconsistent statements from R1. On 10/03/2025, LPA Huynh conducted an initial complaint visit. Between 3:23PM and 4:07PM, the LPA conducted a physical plant tour and reviewed and obtained pertinent documents. The ED was informed that the complaint allegation was referred to CCLD’s IB. Between 10/06/2025 and 12/29/2025, IB Investigator Rocio Flores conducted interviews with relevant parties including facility staff, residents, and family. Investigator Flores also obtained and reviewed additional documents including hospital records, law enforcement reports, and sexual assault medical examination records. During today’s visit, the LPA and ED conducted a physical plant tour at 12:39PM, and no immediate concerns were observed. The following was then determined: Allegation: “Staff sexually assaulted resident in care” It was alleged that R1 was sexually assaulted by S1. Physician’s Report dated 08/07/2024 documented R1’s diagnoses, including bipolar disorder, schizophrenia, major depression, and mild cognitive impairment. An Individual Service Plan dated 03/17/2025 indicated R1 exhibited confusion, forgetfulness, a history of head trauma, and required staff redirection. R1 reported to Investigator Flores that on 08/02/2025, S1 entered their room and inserted their fingers or genitals into R1’s anus. R1 recalled feeling “internal pain” due to the use of force and expressed uncertainty, stating they may have been “hallucinating.” R1 further stated they were taken to the hospital on 08/06/2025 after Staff #3 (S3) observed blood in their feces. Report Continued on LIC 9099-C S3 confirmed they provided direct care to R1 but denied observing blood in R1’s diaper before, on, or after 08/08/2025. S1 denied the allegation and stated their job duties did not include providing direct care to residents, and that all tasks were documented in a log. S1 reported no conflicts with R1 and described R1 as calm and respectful toward them. S1 reported providing two (2) services in R1’s room between July 2024 and August 2024, and service logs were consistent with this statement. Staff interviews revealed that R1 frequently exhibited inappropriate sexual behaviors towards staff including vulgar comments, hand gestures, and requests during direct care. Staff reported these incidents and expressed discomfort providing care to R1. Staff confirmed that S1 did not provide direct care to residents and described S1 as respectful, caring, and hardworking. Resident interviews supported staff statements and revealed no concerns regarding S1’s conduct and resident interactions. On 08/08/2025, R1 was scheduled for transfer to the hospital for a psychiatric evaluation due to aggressive behavior toward staff. Medical Transportation advised facility staff to contact Emergency Medical Services (EMS) due to low blood pressure. During EMS evaluation, R1 reported they had been sexually assaulted and found blood in their diaper. According to Los Angeles Police Department (LAPD) report, a sexual assault investigation was opened. R1 told LAPD Officers that on 08/07/2025 at 10PM, R1 and S1 engaged in consensual oral sex, that S1 showed R1 pornographic videos, and S1 left the room and did not return. R1 stated they consented only to oral sex and refused to disclose when penetration occurred. R1 also reported that staff observed blood in their diaper the following morning. A sexual assault medical examination was conducted on 08/09/2025. R1 reported losing consciousness during the alleged assault and disclosed penetration and oral sex with S1 but did not provide additional details. A full physical examination—including head, neck, and genital assessment—alternate light source body scan, and oral and genital swabs revealed no findings. The examination did not document or address blood in R1’s diaper. Report Continued on LIC 9099-C An LAPD Detective reported that S1 was eliminated as a suspect because S1 was not on shift during the time R1 reported the incident occurred. LAPD Officers also reviewed facility video footage on various dates and observed S1 entering and exiting R1’s room only for seconds at a time while completing assigned duties, which did not allow sufficient time to commit a sexual assault. The Detective further stated that insufficient DNA evidence also cleared S2 as a suspect. Based on interviews and record review, R1’s statements were inconsistent, and medical examination revealed no findings. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Jan 20, 2026 · control 29-AS-20251003140908

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management visit after the facility self-reported a resident’s death. The LPA arrived at 12:29PM and met with Interim Executive Director (ED) Virginia Sumulong. Entrance interview conducted. On 01/15/2026, the Department received a death notification for Resident #1 (R1) who passed away on 01/14/2026. The notification did not document a cause of death to which the LPA contacted the ED on 01/16/2026. The ED stated they are awaiting a death report from the coroner’s office and that they were provided a preliminary cause of death of blood loss. Additionally, it was reported that local law enforcement responded to the facility and investigated R1’s death. During today’s visit beginning at 12:39PM, the LPA and ED conducted a physical plant tour, and no immediate concerns were observed. At 12:52PM, the LPA reviewed and obtained pertinent documents. The ED was advised that the case was referred to Community Care Licensing Division’s (CCLD) Investigations Branch (IB). The LPA determined that further investigation is needed. No deficiency cited. Exit interview conducted. A copy of today’s report was reviewed and provided.the state’s words, verbatim · CDSS document, Jan 20, 2026

Allegation investigated: Staff did not safeguard resident’s personal items Resident was not accorded dignity and respect in their personal relationships with staff

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegations. The LPA arrived at 9:16AM and met with Interim Executive Director (ED) Virginia Sumulong. Entrance interview conducted. On 12/29/2025, LPA Huynh conducted an initial visit. Between 1:19PM and 2:30PM, the LPA conducted a physical plant tour, interviewed one (1) resident and five (5) staff, and reviewed and obtained pertinent documents. During today’s visit, the LPA and ED conducted a physical tour at 9:28AM and no immediate concerns were observed. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegations: “Staff did not safeguard resident’s personal items” and “Resident was not accorded dignity and respect in their personal relationships with staff” It was reported that facility staff entered Resident #1’s (R1) room without permission and subsequently rearranged and removed R1’s personal items. Interview with R1 revealed that they observed one (1) item that was moved from their closet to the bed. R1 also confirmed that no personal items were missing or removed from their room. R1 initially reported wanting staff to communicate the reason for entering their room and to explain what they were doing while completing tasks. Later, R1 then stated they did not want staff to speak or communicate with them. Interviews with staff indicated that they treat R1 with respect and provide constant communication with R1 while performing care tasks. Staff reported that R1 keeps numerous personal items that obstruct their ability to provide direct care. When staff request to temporarily move the personal items, R1 often refuses and also declines daily housekeeping services. Staff stated they are aware that R1 does not want their belongings touched and therefore avoid doing so without permission. Staff also reported they have not observed other staff or residents entering R1’s room without their permission or knowledge. R1’s Appraisal/Needs and Services Plan dated 05/08/2025 and Individual Service Plan dated 06/20/2025 documented that R1’s living environment must remain safe and secure, with staff conducting regular safety assessments to prevent falls. The plans indicated that direct care staff maintain a clutter-free environment by removing potential hazards such as cords and spills. Report Continued on LIC 9099-C LPA Huynh observed that R1’s room contained multiple large boxes overflowing into the roommate’s side of the room, as well as food, miscellaneous trash, and power cords scattered on and under R1’s bed. When the LPA addressed these items, R1 stated that they needed these items and did not want staff to touch them. During today’s visit, staff and the ED informed the LPA of ongoing safety concerns in R1’s room and R1’s refusal to allow staff to assist with cleaning. The LPA explained the safety risks to R1 and requested that they allow staff to assist them. R1 then complied. Based on interview, record review, and observation, R1 provided inconsistent statements and confirmed personal belongings were not missing. Additionally, staff assistance was consistent with R1’s care plan and focused on safety measures. Although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Jan 8, 2026 · control 29-AS-20251222151805

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced for a required one-year visit. The LPA arrived at 9:16AM and met with Interim Executive Director (ED) Virginia Sumulong. Entrance interview conducted. At 9:28AM, the LPA and ED toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a two-story building. The following was observed: RESIDENT ROOMS: The LPA observed eight (8) randomly selected rooms on the first and second floors and no immediate health or safety hazards were observed. Appropriate furniture was observed in the units including clean linens and sufficient lighting. Restrooms were clean, with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Water temperature was tested throughout the units and measured between 108.1 degrees F and 120.7 degrees F. Resident pull cord was tested with a staff response of less than one (1) minute. COMMON AREAS: On the first floor there was a lobby/reception area, administrative offices, medication room, two (2) visitor restrooms, laundry room, beauty shop, shower room, and two (2) courtyards. On the second floor there was an activity room, library, two (2) visitor restrooms, staff lounge, and laundry room that contained extra linens. All required rooms were secured and inaccessible to residents. LPA Huynh observed all common areas to be clean, clear of obstructions, and furniture were in good condition. Required posting were observed on the first floor hallway and no bodies of water were observed. Report Continued on LIC 809-C KITCHEN/DINING ROOM: The main kitchen is located on the first floor and attached to the dining room. Facility dining room and kitchen were inspected and found to be in compliance with Title 22 regulations. Facility uses Sysco Foods for food deliveries which occur every Friday. There was a sufficient supply of perishable and non-perishable food. The LPA observed the refrigerators and freezers with food to be of good quality and labeled with expiration dates. An extra pantry was located in the rear of the building inside an unattached shed that contained non-perishable items and an extra freezer containing frozen meat. Emergency food and water were stored in supply closets near the kitchen. OUTSIDE: The facility had a rear patio with various tables and chairs for resident use. The furniture were in good condition. The perimeter of the facility was secured with two (2) remote driveway gates with built in doors. The rear of the facility also had parking spaces for staff and visitors. RECORDS: Resident records were reviewed at 10:17AM. LPA Huynh reviewed six (6) files for, but not limited to admissions agreements, medical assessment, appraisals, and consent forms. Resident records reviewed were in order at this time. The LPA reviewed six (6) personnel records for, but not limited to job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification, and appropriate trainings. Staff files reviewed were in compliance with regulation at this time. The LPA discussed with the ED about ensuring all in-service staff training contains the duration of the training completed. INFECTION CONTROL/EMERGENCY DISASTER: The LPA reviewed the facility's Infection Control Plan and Emergency Disaster Plan. LPA noted that the facility is in compliance with regulation with both plans reviewed annually. The facility conducts emergency disaster drills monthly, with the last drill documented on 12/30/2025. Fire extinguishers were observed throughout the facility and last serviced on 10/10/2025. Fire systems are inspected annually with the last inspection on 10/10/2025 by Fox Fire Life and Safety Inc. Report Continued on LIC 809-C MEDICATION: Medication review began at 1:03PM. The LPA reviewed medications for five (5) residents. Medications were maintained locked inaccessible to residents on the first floor. Resident medications reviewed were documented and stored in compliance with regulation at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Jan 8, 2026

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Resident was not accorded dignity and respect Staff withheld food from Resident

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent visit to deliver findings for the above allegations. The LPA arrived at 1:04PM and met with Interim Executive Director (ED) Virginia Sumulong. Entrance interview conducted. On 12/01/2025, an initial visit was conducted. Between 10:18AM and 3:16PM, the LPA toured the physical plant, interviewed five (5) residents and five (5) staff, and reviewed and obtained pertinent documents. During today’s visit, the LPA and ED conducted a physical plant tour and no immediate concerns were observed. The following was then determined: Report Continued on LIC 9099-C Unsubstantiated Allegations: “Resident was not accorded dignity and respect” and “Staff withheld food from Resident” It was reported that Staff #1 (S1) did not treat Resident #1 (R1) with respect and withheld food. Resident interviews revealed that S1 is generally respectful and has not been observed to yell. They reported that R1 often engages in conflict with staff, including following them around the facility and raising their voice. Residents noted that while R1 and S1 have daily disagreements, S1 typically responds by reminding R1 of facility policies. Residents also reported that they have not experienced food being withheld, even when arriving late to mealtimes. They indicated that when R1 arrives late, they sometimes request multiple meals at once, which can delay kitchen staff in completing other duties. R1 expressed feeling that they must avoid conflict with S1 and stated that S1 treats other residents respectfully but not them. R1 was unable to provide specific examples of disrespectful language. R1 acknowledged calling staff derogatory names when upset and videotaping staff interactions. R1 reported being late to mealtimes due to their health condition and initially claimed food was refused, but later clarified that meals are provided, though preparation may take additional time. Staff reported that R1 can be challenging to serve, often insisting on services according to their own preferences and timeline. Staff described R1 as frequently raising their voice and disregarding facility rules. Staff stated that S1 responds appropriately and does not yell at R1. S1 reported their role with R1 is limited to medication administration and that they do not engage further in R1’s behavior. Staff noted that R1’s videotaping of staff causes discomfort. Staff confirmed that although R1 is often late to meals, food is provided. Staff stated they anticipate R1’s tardiness and save meals or provide alternative options when necessary. Report Continued on LIC 9099-C Documentation indicated R1 has a diagnosis of Schizoaffective Disorder with mild cognitive impairment. The Appraisal/Needs and Services Plan dated 12/09/2024 noted periods of forgetfulness and non-compliance with dietary recommendations, with staff expected to provide reminders and simple instructions. R1’s Individual Program Plan (IPP) dated 06/02/2022 documented difficulty in understanding the consequences of actions, defensive reactions to feedback, and frequent arguments. The IPP noted disruptive behaviors interfering with social participation, with outburst occurring at least weekly, and included goals for R1 to work toward following facility rules and recommendations. Although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED at this time. The LPA discussed staff conduct and resident care needs with the ED to ensure continued understanding of resident behavior and appropriate staff responses. The ED acknowledged and understood. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.the state’s words, verbatim · CDSS document, Dec 29, 2025 · control 29-AS-20251124083836

Allegation investigated: Resident wandered away from the facility due to lack of care and supervision from staff

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced subsequent visit for the above allegation. LPA arrived at 1:23PM and met with Office Manager Leticia Flores. Entrance interview conducted. On 08/27/2025, LPA Huynh and the Executive Director Celia Garcia conducted a safety check tour at 10:06AM. Between 10:36AM and 11:38AM, LPA Huynh attempted one (1) resident interview, conducted three (3) staff interviews, obtained contact information for seven (7) staff, and reviewed and obtained pertinent documents. On 09/10/2025 between 1:59PM and 3:23PM, the LPA conducted a safety check tour, interviewed three (3) staff, attempted one (1) staff interview via telephone call, and obtained camera footage. Continued on LIC 9099-C Substantiated During today’s visit, the LPA and the LVN conducted a brief safety check tour at 1:33PM, and no immediate concerns were observed. The following was then determined: Allegation: “Resident wandered away from the facility due to lack of care and supervision from staff.” It was reported that on 08/01/2025, Resident #1 (R1) wandered away from their Assisted Living Facility and was discovered by a bystander who contacted the Los Angeles Police Department (LAPD). Los Angeles Fire Department (LAFD) arrived on scene at 8:16PM and transported R1 to St Joseph’s Hospital for further evaluation. Interviews with eight (8) out of ten (10) staff revealed that the facility’s protocol for a missing resident or elopement includes immediate notification of all Supervisors and the Med-Tech in charge. Staff are expected to conduct a room-to-room and facility grounds search. If the resident cannot be located, the Supervisors and Med-Tech are responsible for notifying law enforcement and the resident’s family. The reception desk is equipped with an “elopement book,” which contained photos and names of residents who are not permitted to leave the facility unassisted, per their Physician’s Report. Staff reported that identifying which residents can and cannot leave the facility unassisted was “general knowledge.” Staff #1 (S1) stated they were unable to identify which residents had clearance to exit the facility unassisted and had initiated the inquiry independently. S1 also expressed the belief that other staff were similarly uninformed unless they sought out the information. Staff #2 (S2) reported that an Agency staff worked the evening reception shift on 08/01/2025 and had previously assisted the facility in the past. The facility’s perimeter is secured against outside access; however, individuals inside the facility can exit freely. When a perimeter door is opened, reception staff are alerted through an auditory alarm, a visual blinking light, and TV monitors that focus on the open door. Continued on LIC 9099-C Interview with staff and record review confirmed that R1 was not authorized to leave the facility unassisted. R1 was known to wander within the facility, including occasional visits to the rear parking lot, but had no prior history of elopement. R1’s Physician’s Report noted that R1 was at times confused/disoriented, had wandering behavior, occasional sundowning behavior, and recent hospital documentation indicated that R1 was diagnosed with Alzheimer’s Disease. R1’s Appraisal specified that R1 experienced episodes of sundowning behavior which was manifested by wandering behavior. Those responsible for ensuring R1’s safety and understanding R1’s behavior included “nursing” and “all staff.” The facility’s camera footage captured the following on 08/01/2025: At 4:58:02PM, Agency staff and Staff #3 (S3) were present in the reception area. The Agency staff monitored facility cameras while S3 shredded documents. Nine (9) seconds later, R1 entered the camera frame and greeted both staff. At 4:58:23PM, R1 turned and walked away, making a lap around the first-floor hallways. R1 re-entered the lobby at 5:01:34PM. During this time, S3 was observed to be making copies at the printer, with their back facing the lobby, while the Agency staff was seated at the desk facing the lobby, turned to assist S3, also turning their back to the front door. At 5:01:45PM, R1 exited the facility through the front door with their walker. Visual and auditory alarms were triggered, and the TV monitors focused on the front door. At 5:01:50PM, S3 received a text message and proceeded to pull out their phone. The Agency staff returned to the desk at 5:01:51PM, disengaged the alarm, looked through the reception window at the front door, observed R1 walk away on the TV monitor, and then disengaged the TV monitor. During an interview with S3, they claimed they were not present during the elopement and had been notified of the incident by a coworker via telephone call. S3 did not provide further details. However, payroll records indicated that S3 worked from 6AM to 6PM on 08/01/2025. Staff #4 (S4) stated that they discovered R1 was missing at approximately 6PM and notified Staff #5 (S5), the Med Tech in charge of the evening shift. Continued on LIC 9099-C S5 also reported that they observed R1 was missing during the evening medication rounds and notified the Supervisors but did not notify law enforcement. S2 stated they received a call from facility staff at approximately 8:50PM regarding the missing resident and subsequently notified the Assistant Administrator and LVN. The three (3) Supervisors returned to the facility at approximately 9:15PM. Shortly thereafter, LAPD contacted the facility to report the missing resident. S3 returned to the facility during this time. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 9099-D). Exit interview conducted. A copy of the Appeal Rights and report were reviewed and provided.the state’s words, verbatim · CDSS document, Oct 15, 2025 · control 29-AS-20250818182949

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 16, 2025

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not comply with the section cited above as the Licensee did not meet R1’s care and supervision needs that resulted in an elopement which posed/poses an immediate health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: The Licensee will provide staff training on care and supervision needs as well as elopement protocols and submit proof along with a statement of understanding by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management visit in conjunction with Complaint # 29-AS-20250818182949. The LPA arrived at 1:23PM and met with Office Manager Leticia Flores. Entrance Interview conducted. Beginning at 1:33PM, the LPA and the LVN conducted a brief safety check tour, and no immediate concerns were observed. On 08/01/2025, Resident #1 (R1) eloped through the front door of the facility at 5:01PM. Between 8:50PM and 9:15PM, the Office Manager, Assistant Administrator (AA), and LVN were notified and returned to the facility. Shortly after arriving, Los Angeles Police Department (LAPD) contacted the facility and notified them that LAPD had found a missing resident and was transported to St Joseph’s hospital for evaluation. Community Care Licensing (CCL) did not receive notification of this incident until 08/18/2025, when a Complaint report was received. LPA Huynh requested an Unusual Incident Report (UIR) from the AA who provided the LPA with the report via email on 08/28/2025. Report Continued on LIC 809-C The report was dated 08/04/2025, when R1 returned to the facility, and was completed by the AA. It was later confirmed by record review and Staff that the UIR was faxed to R1’s Assisted Living Program, however, the report was not sent to CCL. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 809-D). Exit interview conducted. A copy of the Appeal Rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, Oct 15, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Oct 29, 2025

(a) Each licensee shall furnish to the licensing agency... (1) A written report shall be submitted to the licensing agency... within seven days of the occurrence … (D) Any incident which threatens the welfare, safety or health of any resident, …, or unexplained absence of any resident. This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not comply with the section cited above as the Licensee did not provide CCL notification of the incident which posed/poses a potential health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 15, 2025

Plan of correction: The Licensee will update staff training on reporting requirements and provide documentation and submit a statement of understanding by POC due date.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Quoc Huynh conducted an unannounced Case Management Incident visit to follow up on a SOC 341 report received by the department on 08/12/2025. LPA arrived at 9:56AM and met with Executive Director (ED) Celia Garcia. Entrance interview conducted. On 08/12/2025, the Department received a SOC 341 for Resident #1 (R1) and Staff #1 (S1), sent by facility staff. The report indicated that a Detective with the Los Angeles Police Department (LAPD) arrived at the facility on 08/11/2025 to investigate an incident that occurred, involving R1 and S1. At 10:25AM, LPA Huynh and the ED conducted a physical plant tour to ensure the health and safety of the residents. No immediate concerns were observed. Beginning at 10:47AM, LPA Huynh reviewed and obtained pertinent documents of resident and staff files. The ED was advised that the case was referred to the Investigation Bureau (IB). The LPA has determined that further investigation is needed. No deficiency cited. Exit interview conducted. A copy of today’s report was reviewed and provided.the state’s words, verbatim · CDSS document, Aug 12, 2025

Allegation investigated: Staff did not assist resident with care needs in a timely manner.

Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegation. LPA arrived at 10:22AM and met with the Executive Director (ED) David Aguiniga and explained the reason for the visit. Entrance interview conducted. On 07/01/2025, LPA conducted an initial complaint visit at 9:12AM. LPA toured the facility at 10:07AM and reviewed and obtained pertinent documents. Between 10:07AM and 5:05PM, LPA interviewed ten (10) residents and eight (8) staff. Report Continued on LIC 9099-C Substantiated On 07/07/2025, LPA conducted a subsequent visit at 9:30AM. Beginning at 9:41AM, LPA reviewed and obtained additional documents and interviewed two (2) staff between 11:08AM and 11:40AM. At 11:23AM, the LPA and Front Office Receptionist conducted a tour of the facility. During today’s visit, the LPA and the ED toured the facility at 10:32AM to ensure there are no health and safety hazards. No immediate concerns were observed. The following was determined: Allegation: “Staff did not assist resident with care needs in a timely manner.” It was reported that Resident #1 (R1) did not receive showers or assistance with care needs when requested. R1 revealed that Staff refused to help with their wheelchair and claimed Witness #1 (W1) stated R1 can manage themselves independently. R1 also stated that Staff claimed R1 was not on the shower list when they requested a shower. W1 stated that R1 can complete tasks such as walking and wheeling themselves in their wheelchair, but did not instruct Staff not to assist R1. Interviews with seven (7) Staff confirmed that R1 frequently requested assistance but often changed their mind, and Staff did not report denying assistance. R1 is offered showers twice a week but commonly refuses them. Staff #1 (S1) explained that R1 requested to move their morning showers to the afternoon. After the adjustment was made, R1 then changed their preference back to the mornings, and Staff scheduled accordingly. S1 noted that Staff attempted to accommodate to R1’s needs, although R1 often contradicts themselves. Interviews with nine (9) residents indicated that Staff generally assist residents with their needs but can be slow to respond and fall behind on showers, depending on their current tasks. Resident #2 (R2) stated they had to shower without help once due to the Staff being occupied. Resident #3 (R3) reported missing scheduled showers because of staffing issues. According to Staff #2 (S2), all showers are required to be logged before the end of each shift, indicating whether the residents received or refused the offered shower. Refusals must also be reported internally. Agency Staff are also trained in this procedure, however S2 noted they fail to complete the logs. Report Continued on LIC 9099-C A record review of June 2025 showed inconsistencies in documentation for several residents. Residents #4 (R4) and Resident #5 (R5) did not have shower logs. Resident #6 (R6), Resident #7 (R7), and Resident #8 (R8) were expected to have eight (8) showers documented but had three (3) entries each. Resident #9 (R9) had four (4) entries and Resident #10 (R10) had one (1) entry logged. The following residents were expected to have nine (9) documented entries in their shower logs: R3 had five (5) entries, R1 and Resident #11 (R11) each had four (4) entries. Additionally, Resident #12 (R12) had one (1) logged, Resident #13 (R13) had three (3) logged, and Resident #14 (R14) and Resident #15 (R15) each had six (6) entries logged. In the first week of July 2025, the shower logs also showed inconsistencies. No logs were documented for R6, R9, R15, and Resident #16 (R16). Resident #17 (R17), Resident #18 (R18), and Resident #19 (R19) were expected to have two (2) shower entries but had one (1) entry each. Furthermore, logs were created for R4, R5, and Resident #20 (R20), but no entries were documented for them during that period. The Resident’s Admission Agreement stated showers should be received twice a week, which is included in the basic services. The ED stated that all shower logs should be reviewed at the end of the day by Staff #3 (S3), however based on the LPA’s record review, it is not being done. The ED stated they would have a discussion with S3 regarding their duties. It was also stated that Agency Staff do not complete the logs despite receiving the training, and it is difficult to mandate it when they are typically assisting at the facility for the day. However, the facility’s Staff should know the requirements and their duties. Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency is cited (Refer to LIC9099-D). Exit interview conducted. A copy of the appeal rights and today’s report was reviewed and provided. On 07/07/2025, LPA conducted a subsequent visit at 9:30AM. Beginning at 9:41AM, LPA reviewed and obtained additional documents and interviewed two (2) staff between 11:08AM and 11:40AM. At 11:23AM, the LPA and Front Office Receptionist conducted a tour of the facility. During today’s visit, the LPA and the ED toured the facility at 10:32AM to ensure there are no health and safety hazards. No immediate concerns were observed. The following was determined: Allegations: “Staff did not allow resident to possess their personal belongings” and “Staff interfered with resident’s visit(s).” It was reported that Resident #1 (R1) was told by Staff and the Assistant Administrator (AA) that they were not allowed to have their personal belongings. It was alleged that the facility’s Staff and AA also accused R1 of being a “dirty hoarder” and informed R1 that they were not allowed to receive visitors due to this. LPA interviewed ten (10) residents and observed each resident had personal belongings in their units. Eight (8) out of ten (10) residents stated they have not experienced, or observed, Staff inform them or others that they cannot possess their personal belongings. R1 stated the AA informed them they will not be allowed visitors until they organize their belongings. Interview with Witness #1 (W1) revealed that the AA and Executive Director (ED) had not restricted their visitation to the facility. W1 chose to not visit R1 on their own accord and expressed they were in a tough situation regarding the ongoing issues of R1’s personal belongings. W1 expressed that they are more than happy to bring R1 any additional belongings they need, however W1 is aware that R1 already had too much in their room and had no space for more items. The facility’s Staff, the AA, and the ED have not communicated to W1 that they were not allowed to bring additional items. Resident #2 (R2) stated that when they first moved into the facility, the Staff told R2 that they needed to throw away a few of their items. R2 also stated that Staff threatened to throw away their belongings when R2 was out of the facility. Since then, R2 stated they have not experienced that treatment outside of that initial incident. Report Continued on LIC 9099-C Interview with ten (10) Staff revealed that residents have the right to their personal belongings as well as receiving visitors. Staff #1 (S1) stated residents can have visitors, but the facility must be notified of the visit. Additionally, S1 added that residents’ visitation can be restricted by their Responsible Party if they notify the facility of specific individuals who cannot have access to the resident. Staff #2 (S2) stated the visitor’s procedure should be to sign in/out at the office and afterwards the visitor can make their way to the resident’s unit. S2 specified that residents can receive visitors unless they are actively quarantining, then their visitation will be placed on a hold. Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED at this time. No deficiency cited for the above allegations. Exit interview conducted. A copy of today's report was reviewed and issued.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 29-AS-20250623102141

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jul 18, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident ... pre-admission appraisal, with those activities of daily living such as ... bathing ... This requirement was not met as evidenced by: Based on interviews and record review, the Licensee did not comply with the section cited above as the licensee did not assist residents with showers which posed/poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: The Executive Director (ED) will have Staff ensure shower logs are being completed at the end of each shift as well as update Staff training. The ED will submit a statement of understanding to CCLD by POC due date.

Allegation investigated: Staff do not ensure residents’ hygiene needs are met. Staff did not follow residents’ needs and services plan.

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced visit to deliver the findings for the allegations listed above. The LPA met with the Executive Director David Aguiniga and Virginia Sumulong explained the reason for the visit On 01/24/2025, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced 10-day visit to investigate the allegations listed above. The LPA met with the Executive Director David Aguiniga and Virginia Sumulong and explained the reason for the visit. At 10:37 a.m., LPA Urena requested records pertinent to the investigation, and conducted interviews from 10:35 a.m. to 11:34 a.m. Continues on LIC 9099C... Unsubstantiated Staff do not ensure residents’ hygiene needs are met. It is alleged that the resident does not receive baths as needed. To investigate the allegation the LPA conducted interviews and requested records pertinent to the allegation. The residents’ interviews revealed that they receive showers two times a week and more if necessary. The facility administrator provided a calendar that indicates the day residents get assistance with showers, however the calendar did not indicate the time of the day when showers are provided. The interview with the staff revealed that they have scheduled days to assist residents with showers, and shower time is usually after breakfast or lunch. The staff stated that R1 required a two (2) person assist, and that the RP did not want a Hoyer being utilized for showers. The LPA interviewed the RP, and the RP stated that staff refused to give showers to R1 unless the RP was present. The RP stated that R1 is ambulatory with the assist of two (2) people. Although the allegation may have happened or is valid, based on the interviews, and record review, there is not sufficient evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation is deemed Unsubstantiated at this time. Staff did not follow residents’ needs and services plan. It is alleged that the facility staff leave the resident unsupervised/unattended when the resident cannot be alone. To investigate the allegation the LPA reviewed pertinent records. Record review of the Physician’s Report (LIC 602) dated and signed on 09/20/2024, indicates that R1 is ambulatory, does not require continuous bed care, and is able to transfer independently to and from bed. The record review of the Appraisal/Needs and Services Plan (LIC 625) dated 11/26/2024, revealed that R1 needed total assist with Activities of Daily Living (ADL’s), was wheelchair bound and was non-ambulatory. Furthermore, the LIC 625 indicates that R1 needed assistance to attend activities in the Activity Room, staff was to assess R1’s needed due to R1 inability to express their needs, and staff was to assist with showers and medications and eating. However, the LIC 605 does not indicate that R1 cannot be left alone. The LIC 605 was signed by the RP and dated 11/26/2024. Base on the information obtained through record review, there is not sufficient evidence to prove that R1 could not be left alone. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted. A copy of the report was issued. Staff do not ensure that an appropriately skilled professional is on duty to meet the resident’s needs for injectable medications. It is alleged that the facility staff did not respond in a timely manner to the RP regarding the qualified staff needed to provide medical care for R1 during the weekend since the facility does not have a skilled medical staff available on weekends to administer an injectable medication to R1. LPA Urena conducted interviews, and record review. The interview with the RP revealed that the Administrator stated that the facility did not have skilled medical staff to provide the injections to R1 once R1 returned to the facility from the hospital. Per the RP, R1’s physician was going to change one of the medications from tablet form to liquid form (injectable). Per the RP the facility staff stated that they had a License Vocational Nurse (LVN) during the week but not on weekends. The facility staff was going to look into getting a LVN to come out on weekends for the injectable medication. However, one day before the release of R1 from the hospital, the RP still had not heard from facility staff. The interview with the facility administrators revealed that they spoke with the RP about the injections and stated that the facility could not provide that type of service during the weekend, and that the LVN present at the facility Monday through Friday is for the oversight of medications assistance for all residents at the facility. The administrators stated that R1 was never on an injectable medication while R1 resided the facility prior to going to the hospital. Furthermore, R1 was discharged and returned to the facility without physician’s orders for the injectable medication. Record review of discharge papers revealed that R1 was admitted back to the facility on oral medications only. Based on the information obtained through interviews and record review, R1 was never on an injectable medication while residing at the facility. Therefore, the allegation is deemed Unfounded at this time. Exit interview was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Jun 3, 2025 · control 29-AS-20250123164514

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case Management - Incident visit to follow up on a LIC 624 Incident report and SOC 341 received by the department on 03/12/2025. LPA Urena met with Executive Director (ED) David Aguiniga and Assistant Administrator (AA), Virginia (Gigi) Sumulong explained the reason for the visit. On 03/12/2025, the Department received a LIC624 for Resident #1 (R1) and Resident #2 (R2) along with a SOC 341, both sent by facility staff. The report indicated that a Detective with the Los Angeles Police Department (LAPD) arrived at the facility to further investigate an incident that occurred on 03/06/2025, involving residents (R1 and R2). At approximately 11:30 a.m., LPA Urena and the AA conducted a physical plant tour, obtained documents pertinent to the investigation (Video, staff and resident roster). LPA did not observe any immediate or potential health and safety concerns at this time. The ED was advised that the case was referred to the Investigation Bureau (IB). The LPA has determined further investigation is needed. Exit interview conducted and copy of report issued.the state’s words, verbatim · CDSS document, Mar 19, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case Management - Annual Continuation Inspection at the facility today continuing the inspection that began on 01/24/2025. The LPA met with David Aguiniga and Virginia Sumulong and explained the reason for the visit. RECORDS: Records review began at 11:45 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 1:40 p.m.; medications are centrally stored and locked in a cabinet in the medication romm; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster - Liability Insurance -Emergency Disaster Plan No deficiencies were cited. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Jan 30, 2025

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived unannounced to conduct a required annual inspection. The LPA met with the Executive Director David Aguiniga and the Executive Assistant Virginia Sumulong and explained the reason for the visit. LPA Urena and the Executive Assistant toured the physical plant areas inside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: The reception area and reception area furniture were observed to be in good and clean condition. The facility maintained a comfortable temperature of 74 degrees. The fire extinguishers were observed throughout the facility on the first and second floor. The fire extinguishers were fully charged and were last serviced on 10/15/2024. The LPA observed required postings throughout the common spaces. The smoke detector(s) and carbon monoxide detectors were tested by the company Fox Fire Life and Safety Inc. on 11/19/2024. RESTROOMS: The facility has two common/visitors’ restrooms located on the first floor. The restrooms were observed to be clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway restroom at 113.8 degrees Fahrenheit. Hallways were brightly lighted and are equipped with night lights. LAUNDRY AREA: The washer and dryer were observed to be functional and are located on the second floor. All cleaning supplies and disinfectants are kept in locked cabinets. BEDROOMS/ BATHROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Each bedroom has a bathroom. Call system is functional. Continues on LIC 809C... KITCHEN/DINING ROOM: The kitchen area is located adjacent to the dining room. The facility has a sufficient supply of non-perishable and perishable food items. Appliances appeared to be in operable condition. The menu was posted. The kitchen and dining room area was observed to be clean and in good condition. The fire extinguisher in the kitchen was serviced on 10/15/2024. The refrigerator and freezer were observed to be within the required temperatures of 40 degrees and 0 to below 0 degrees. Overall dining room temperature was kept at 74 degrees. The dining room and dining room furniture were observed to be in good condition. OUTDOOR AREA: The facility has an outdoor area next to the dining room. The outdoor area has tables with patio umbrellas for client use. No bodies of water noted. This is part-one of the annual inspection; due to time constraints, a continuation annual inspection visit will be conducted at a later date. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 24, 2025

Allegation investigated: Staff physically assaulted resident which resulted in injuries

Licensing Program Analyst (LPA) Esther Cortez arrived unannounced at 12:00 p.m. to deliver findings for the allegation listed above. The LPA met with Administrator David Aguiniga and Assistant Administrator Virginia "Gigi" Sumulong and explained the reason for the visit. On 11/28/2023, the LPA interviewed the Assistant Administrator (AA) at 11:17 a.m. and toured the facility from 12:01 p.m. - 12:15 p.m. with them. The LPA collected pertinent documents and conducted two (2) staff interviews between 12:17 p.m.-01:25 p.m. On 11/05/2024 the LPA conducted one (1) staff phone interview and one (1) phone interview with R1’s authorized person. On 11/06/2024, the LPA toured the facility with the AA from 11:05 a.m. - 11:20 a.m. The LPA conducted a file review, collected pertinent documents, and conducted three (3) staff, and five (5) resident interviews between 11:20 a.m.-02:50 p.m. On 11/07/2024 the LPA conducted one (1) phone staff interview. On 11/08/2023 the LPA conducted one (1) phone staff interview. On 11/19/2024 the LPA conducted one (1) staff phone interview. On 11/20/2024 the LPA conducted (2) staff phone interviews. Report will continue on LIC9099-C, 2nd page. Unsubstantiated On 12/11/2024 the LPA reviewed R1’s subpoena medical records and conducted one (1) phone staff interview. On the allegation " Staff physically assaulted resident which resulted in injuries."; it is the concern of the reporting party (RP) that Resident 1 (R1) stated that they were hit in the chest and grabbed on the right arm by a staff member at the community, which led to bruising and pain on the right arm and chest. Name of the staff was not provided. To investigate the allegation the LPA conducted file reviews and interviews. A review of R1’s physician’s report, dated 11/09/2023, indicated R1’s primary and secondary diagnoses were listed as base of L femur fracture s/p surgery, and Dementia/ Alzheimer’s disease. History of fall, Parkinson’s disease, anxiety, depression, and other diagnoses were also listed on the physician’s report. The report indicated that R1 had mild cognitive impairment, was confused/disoriented, able to follow directions as well as communicate needs, R1 could dress and eat on their own, was able to transfer to and from bed independently and was identified as ambulatory. A review of R1’s head-to-toe assessment form for any physical change, dated 07/08/2023, and R1’s preplacement appraisal, dated 11/16/2023, did not reveal any sign of redness or purple discoloration on R1’s body. A review of R1’s admission agreement revealed that R1 was admitted to the community on 11/20/2023. A review of R1’s medical records obtained from Providence St Joseph Medical Center, revealed that R1 was seen in the Emergency Department on 11/23/2023 due to chief complaints of chest pain and wrist injury with bruising noted to L chest and R hand and wrist. R1 was awake, alert, and oriented x 3 and in no apparent distress. R1 reported to hospital staff some chest pain starting around noon time but did not have any chest pain at the current time. No reported shortness of breath, nausea, vomiting, or diaphoresis. R1 informed hospital staff that they were struck in the left chest at their assisted living facility by staff member and then their right wrist was grabbed. A physical exam revealed R1’s chest wall, R1’s location of pain, had a large area of ecchymosis that looked approximately a week old. The physical exam also revealed there were some mild soft tissue swelling to the distal aspect of the forearm with some mild ecchymosis. Lab work indicated R1 had mild anemia. R1 was asked if they feel safe in their living/school environment, R1 denied concerns. It was noted R1 did not show signs of physical or sexual abuse, medical neglect, untreated STI’s and or torture. R1 was noted as a high fall risk based on their morse fall risk level assessment. Report will continue on LIC9099-C, 3rd page. During R1’s skin assessment at the hospital, it was noted R1 “has a golf ball sized bruise to left side of chest in healing stages, looks at least several days old.” Medical records revealed that R1 met with a social worker and reported that on Tuesday 11/21/2023 around 1:00 a.m. an employee of Glen Park woke R1 up and requested for R1 to take their medication. R1 then reported that R1 did not want to take their medication as they were tired, and that staff member allegedly grabbed their left wrist and “pushed on” their chest and forced R1 to take medication. R1 reported that this had been the only incident that happened at the facility. A review of the self-reported Unusual Incident/Injury Report (UIR) and a Report of Suspected Dependent Adult/Elder Abuse (SOC341) report, dated 11/24/2023, documented that on 11/21/2023 around 12:00 a.m., Staff 1 (S1) knocked on R1’s room to give them their night medication. S1 introduced themselves and gave R1 medications, R1 got upset and started to yell, kicked S1 and screaming, telling S1 I don’t want to take the medications, because they did not know who S1 was. S1 stepped back because R1 would not stop hitting and kicking them. S1 left the room. At about 12:55 a.m. S1 was passing medications to the other residents when R1 came out of their room and approached S1, stating that someone came into their room and tried to give them medication. S1 told R1 it was them who went to their room for their medication. R1 said no, I don’t feel safe if someone will come to my room. A review of a UIR, dated 11/23/2023, revealed that R1 was transferred to the hospital on 11/23/2023 due to chest pain and shortness of breath. The LPA obtained (3) photos, that were reported to be of R1, however the face is not shown in any of the photos. Photo #1 appears to be a person sitting down who is holding their shirt down and showing their chest, the chest has purple discoloration. Photo #1 has a time stamp of 11/21/2023 at 10:14 a.m.. Photo #2 appears to be the same person holding their right hand up with what appears to be a closed fist, there is two round spots where the skin is purple. Photo #2 has a time stamp of 11/21/2023 at 10:14 a.m. Photo #3 appears to be a person’s chest, with their hands holding their shirt down, the chest has dark purple discoloration. Photo #3 has a time stamp of 11/22/2023 at 3:21 p.m. During the investigation, the LPA conducted interviews with various residents and staff. All staff and residents interviewed revealed that they did not witness any incident between R1 and S1. Five (5) out of five (5) residents interviewed revealed that staff have never been abusive towards them, and they have never seen any staff be abusive towards other residents. All residents interviewed also revealed that they have never been forced to take medications. Report will continue on LIC9099-C, 4th page. Furthermore, one of the residents revealed that they have been living at the community for 13 years and have never seen or heard S1 be abusive towards the residents and has always seen S1 cheerful, hugging residents and stated S1 is kind. Eight (8) out of Eight (8) staff interviewed revealed that they have never seen any staff be abusive towards the residents. S1 denied attacking R1, denied touching R1’s chest and revealed that they were passing R1’s night medication, they knew it was R1’s first night at the community and introduced themselves, and the resident woke up and started yelling and hitting them. They re-introduced themselves and advised R1 why they were in their room, however R1 continued to yell for her to get out of their room, and S1 placed their hand on R1’s hand to prevent them from hitting them, asked if they were refusing to take their medication, R1 said yes and S1 left. S1 further revealed that during the same night, after the incident R1 approached them in the hallway when they were passing medications to other residents and R1 told them that someone had gone into their room and did not recognize it was them. S1 informed R1 it was them passing their night medication. Interviews conducted with Rafael Silva, who was the Interim Administrator at the time of the incident in 2023, revealed that the morning of the incident between S1 and R1, approximately around 8:00/8:30 a.m., R1’s daughter voiced concerns to him that R1 had told them that staff had attacked them. According to Mr. Silva, R1 was assessed in his office by him, with R1’s daughter present, and he does not recall observing any bruises on R1’s chest or arms. The community conducted an internal investigation and submitted a UIR and SOC341 to the Department. As part of their investigation, Mr. Silva watched the camera footage of the hallways from the night of the incident and revealed that he saw a friendly interaction between R1 and S1 in the hallway after the incident in R1’s room; saw them hugging and laughing and pointing at R1’s room. S1 documented their account of the incident. Furthermore, Mr. Silva revealed that there were no witnesses to the incident and their investigation did not reveal any sign of abuse. Both Mr. Silva and the Assistant Administrator (AA) revealed that S1 has not been involved in any other incident and is well liked by the residents. The Assistant Administrator further revealed that in S1’s seven (7) years at the community no other resident had complained about them, and that “all of the residents loved S1”. The AA also revealed that R1 did not return to the community after their visit to the hospital on 11/23/2023. Interview conducted with current Administrator David Aguiniga revealed that prior to admission, they conducted a head-to-toe assessment for R1 on 08/08/2023, at R1’s skilled nursing facility and they did not observe any cuts, wounds, or redness on R1’s body or anything unusual. Although R1 was not admitted to the facility until 11/20/2023. Mr. Aguiniga stated they did not conduct a subsequent head-to-toes assessment again prior to R1’s admission. Report will continue on LIC9099-C, 5th page. The Department’s investigation did not provide sufficient evidence to substantiate the allegation that " Staff physically assaulted resident which resulted in injuries”. R1 was admitted to the facility on 11/20/2023, and on 11/23/2023 R1 was seen at the Emergency Department where a physical exam revealed R1’s chest wall, R1’s location of pain, had a large area of ecchymosis that looked approximately a week old. R1’s body was assessed by Mr. Aguiniga on 08/08/2023, over three (3) months prior to being admitted to the community and R1’s body was not re-assessed again prior to being admitted to the community. There were no witnesses to the incident. The Emergency Department documented that R1 did not show signs of physical or sexual abuse, medical neglect, untreated STI’s and or torture. Staff and residents interviewed stated that there were no safety concerns with S1 prior to the incident. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Dec 12, 2024 · control 29-AS-20231127091642

Allegation investigated: . Resident sustained pressure injuries while in care 2. Staff do not meet resident's incontinence needs 3. Administrator is not at the facility sufficient hours to permit adequate attention to management 4. Staff do not assist resident with grooming 5. Staff do not follow infection control protocol 6. Staff do not report incidents to appropriate parties 7. Staff do not communicate with responsible party regarding resident's care

Licensing Program Analyst (LPA) Christine Yee conducted a subsequent unannounced complaint visit to continue investigation into the above allegations and initially met with Virginia Sumulong, Assistant Administrator. The Executive Director arrived at 12:09pm to participate in the visit. The reason for today's visit was explained. On 3/2/23 Angel Ascencio conducted an initial 10-day visit. LPA met with Executive Director Tillman Pink at 10:23 a.m. and explained the reason for visit. During the initial visit, LPA Ascensio reviewed resident files at 10:30 a.m., conducted resident interviews starting at 11:11 a.m., and recieved pertinent documents. LPA determined that further investigation is needed. LPA will return at a later time to conclude the investigation. Staff member was authorized to sign documents. Exit interview conducted and a copy of the report was issued to Executive Director. continued on LIC9099-C Unsubstantiated Page 2 On today's visit LPA Yee conducted additional interviews. LPA conducted interviews with Virginia Sumulong, Assistant Administrator at 11:50am, Staff #1 at 12:37pm and the Executive Director at 3:36pm and reviewed and obtained additional facility files throughout the visit. Per information received regarding Allegation #1 - Resident sustained pressure injuries while in care, the investigation revealed that the resident was observed with a open wound on their coccyx on 11/28/22 and a scar between the buttocks. The wound was cleaned, treated with incontinence cream, resident was re-positioned to take pressure of the wound and a home health referral was requested. Per review of hospice records, Resident #1 was receiving wound care and the nurse notes "in addition to poor circulation, neuropathy and difficulty moving, factors that contribute to chronic wounds include systemic illness, age and repeated trauma. Patient was instructed on factors that may contribute to chronic wounds is old age. The skin of older people is more easily damaged, and older cells do not proliferate as fast and may not have an adequate response to stress in terms of gene up regulation of stress related proteins." Incontinence may have been a contributing factor but there is no conclusive evidence that it was sole reason for the cause of the pressure injury. The report does not indicate that the wound was the result of neglect on the part of facility staff. Staff interviewed deny that residents are left unattended for long periods of time in their soaked diapers. This may or may not have happened, but there is no preponderance of evidence to conclusively say it was neglect on the part of the staff's failure to timely change the resident. Therefore, allegation is UNSUBSTANTIATED at this time. Investigation into Allegation #2 - Staff do not meet resident's incontinence needs, per Staff interviewed, incontinent residents are checked every 2 hours or 1 hour if they are observed to get wet more frequently or when they pull the signalling system. The signalling system is monitored in the front office and staff is sent to change the resident. There are 3 caregivers on schedule for the first two shift and 2 on the night. If one caregiver is helping a resident, the next available staff will handle the call. Per staff interviewed, if someone calls out and there is not staff available to do overtime, they use agency staff. Per the investigation, it may or may not have happened, but there was no preponderance of evidence to support the allegation that the staff do not meet the residents' incontinence needs therefore, the allegation is UNSUBSTANTIATED at this time. continued on LIC9099-C Page 3 Regarding Allegation #3 - Administrator is not at the facility sufficient hours to permit adequate attention to management, per interviews conducted with Staff #1, a long time employee since 2016, Tillman Pink III, Administrator was in the office daily. His regular hours were from 9am - 5:30pm. However, he would be in the office for a couple hours or longer and would leave, sometimes to do resident assessments or for other reasons. When he was in the facility, he would have his office doors closed the whole time so people would not know he was at the facility. When he was in the office of away from the office, Janice Pink, Assistant Administrator was in the facility and she provided management needs. She was in the office, Monday through Friday from 9am - 5:30pm. Based on information received, the facility may have or may not have had adequate management attention, there was no preponderance of evidence to conclusively support the allegation that the Administrator is not at the facility sufficient hours to permit adequate attention to management. Therefore, the allegation is UNSUBSTANTIATED at this time. Per investigation into Allegation #4 - Staff do not assist resident with grooming, interviews with staff indicated that they give residents their baths on a schedule. The residents get baths 2 times a week. Once the residents are given their baths, the staff complete the shower log for the date that the shower was provided. If the resident refuses to shower, the reason is noted on the resident's shower log. Per review of Resident #1's Internal Incident Report for February 2023, Resident #1 refused to shower even after multiple attempts. Per information received during the investigation, there was insufficient evidence to support the allegation that the staff do not assist the resident with grooming as the resident has the right to refuse service or assistance with care. Therefore, the allegation is UNSUBSTANTIATED at this time. Per investigation in Allegation #5 - Staff do not follow infection control protocol - per the reporting party, the facility does not have gloves, masks, wipes readily available for staff use. The investigation revealed that the facility has plenty of PPE's. They have gloves, surgical mask, N95s, wipes and gowns. They do provide staff with especially gloves to do their job. Based on the information provided, there was insufficient evidence to support the allegation the staff do not follow infection control protocol. PPE may or may not have been used by staff but there is no preponderance of evidence to support the claim that staff do not follow infection control protocol at this time. Therefore, the allegation is UNSUBSTANTIATED at this time. Investigation into allegation #6 - Staff do not report incidents to appropriate parties, complainant was told by an unknown someone, who may or may not be a reliable source that the facility is not reporting incidents to Page 4 the appropriate parties. Without the specific details of the incidents being referred to LPA Yee was not able to verify if those incidents did or did not occur or when they occurred. The complainant refers to a fall sustained by Resident #1 on 11/12/23 but no further details were provided. Was Resident #1's fall witnessed by staff and which staff observed the fall and was the staff made aware of the fall. One specific incident that was referred to was that the facility had a Covid-19 outbreak in December 2022, LPA Yee was able to verify with Department records that the facility did report the outbreak to the Department on 12/29/22. Without further information, there is insufficient evidence to support the allegation that Staff do not report incidents to appropriate parties, therefore the allegation is UNSUBSTANTIATED at this time. Investigation into Allegation #7 - Staff do not communicate with responsible party regarding resident's care, LPA Yee was unable to verify if attempts were made with the previous Administrator to discuss Resident #1's care as the previous Administrator is no longer employed at the facility. At the time that this complaint was received, the facility also had a Assistant Administrator that the reporting party could have communicated with. Failure to reach the Administrator to discuss the resident's care should not have prevented the reporting party from communicating with other facility staff regarding Resident #1's care. Based on the investigation, there is insufficient evidence to support the allegation that staff do not communicate with responsible party regarding resident's care therefore the allegation is UNSUBSTANTIATED at this time. No deficiencies cited on today's visit. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 15, 2024 · control 29-AS-20230227151830

Allegation investigated: . Staff are verbally abusing residents 2. Staff are not providing residents with medication in a timely manner

Licensing Program Analyst (LPA) Christine Yee conducted a subsequent unannounced complaint visit to conduct further investigation for the above allegation and met with David Aguiniga, Administrator. The reason for today’s visit was explained. On 10/5/23, Licensing Program Analyst (LPA) Christine Yee conducted an initial unannounced complaint visit to investigate the above allegations and met with Virginia Sumulong, Assistant Administrator. Rafael Silva, Administrator was contacted by Staff and he arrived back to the facility at 10:08am. The reason for the visit was explained. On the initial visit, LPA conducted interviews with Resident #1 - Resident #6 beginning at 10:08am - 1:04pm, Staff #1 was interviewed at 1:05pm, Staff #2 was interviewed at 3pm and documents were requested and obtained throughout the visit. Based on the information received during the initial visit, it was determined that further investigation is needed before a finding can be made for the above allegations. Exit interview was conducted and copy of the report was provided. Substantiated Page 2 On today’s visit, LPA Yee reviewed resident files and collected copies of facility files at 2:04pm, interviewed David Aguiniga, Executive Director at 11:10am, Assistant Administrator at 11:57am and Staff #5 at 4:17pm, Per information gathered from the interviews conducted regarding Allegation #1 – staff are verbally abusing residents, some of the residents that were interviewed stated that they are not verbally abused by staff. Staff are cold, have attitudes and some just ignore the residents. Some residents indicated the staff are nice and respectful. Resident #1, who is specifically named in the complaint as being one of the residents who was verbally abused by staff, was interviewed and they stated that they don’t remember being verbally abused. Per staff interviewed, including Staff #1, they all deny verbally abusing the residents in care. They state that it is the residents that verbally abuse them. Resident #1, Resident #7 and Resident #8 curse out the staff However, per interviews conducted with Staff #2 on 10/5/23, they walked in on Staff #4 having a heated conversation with Resident #1 during medication time. This happened about 2 weeks ago, around 8:30pm or 8:45pm. They were short staffed since one of the Medication Tech was out on disability. Resident #1 was asking for their medication and told Staff #4 "I wanted my f...medications" and Staff #4 responded to Resident #1 "I'm trying to give medications, f....you too." Resident #1 walked away. Per information obtained from Staff interviewed, Staff #4 is regularly called into the office and is talked to about their treatment of the residents. One of the office meetings involved Staff #4 cursing out a resident but the resident was not identified as the meetings are confidential. Based on the information received, there is sufficient evidence to support the allegation that staff are verbally abusing residents. Therefore the allegation is SUBSTANTIATED at this time. Per interviews conducted with staff and residents regarding Allegation #2-Staff are not providing residents with medication in a timely manner- staff deny that medications are not dispensed in a timely manner. Per Staff #1, if medications are late, it is only for a few minutes but no more than 10 minutes. Per the information provided on the complaint, the medications are dispensed late on the 2:30pm-11pm shift. Per interviews conducted with residents at the time the complaint was received, they get their medications sometimes before lunch, during lunch, at 9pm or at 10:30pm. When the complaint was received the facility was short staffed and short a Medication Technician due to going on disability leave. Medication Technician that was working on the second shift was also observed on personal calls on their cell phone and ignoring the residents who were requesting their medications. Since the complaint was received, 2 Medication Technicians have been terminated and one quit. Based on the information received from the investigation, there is sufficient evidence to support the allegation that the staff are not providing residents with medication in a timely manner, therefore the allegation is SUBSTANTIATED at this time. Page 3 Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8 Exit interview was conducted, APPEALS RIGHTS discussed and a copy was provided. On today’s visit, LPA Yee reviewed resident files and collected copies of facility files at 2:04pm, interviewed David Aguiniga, Executive Director at 11:10am, Assistant Administrator at 11:57am and Staff #5 at 4:17pm Per the Investigation regarding Allegation #3 - Staff are not ensuring residents files are up to date - the Reporting party states the resident facility files do not have Physician Reports and the results of TB tests. Per review of files for Resident #2, Resident #3, Resident #4 and Resident #6, their files contained the required Physician's Reports with the results of the TB test, Based on the file review, there is insufficient evidence to support the allegation that the staff are not ensuring residents files are up to date, therefore the allegation is UNSUBSTANTIATED at this time. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 14, 2024 · control 29-AS-20230929152548

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 21, 2024

Personal Rights of Residents in All Facilities:Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Staff #4 responded back to Resident #1 when they requested their medication by cursing at them and this poses a possible risk to the rights of the residentthe state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: Licensee will provide the Department with evidence of current personal rights training or conduct personal rights training and provide evidence of the training by 11/21/24

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(2) · Plan of correction due date: Nov 21, 2024

87465(c)(2) Incidental and Medical Care: ....Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidenced by: The facility was short staffed and the residents were not being given their medications in a timely manner and this poses an immediate risk to the health of the residents.the state’s words, verbatim · CDSS document, Nov 14, 2024

Plan of correction: Licensee will provide a written plan of action to ensure that the facility always has sufficient staff and medications available to ensure the medications are dispensed in a timely manner by 11/21/24.

Allegation investigated: Neglect/Lack of Care and Supervision: Resident sustained an unstageable pressure injury while in care at the facility as a result of facility neglect

Licensing Program Analyst (LPA), Valeria Conway, conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Administrator, David Aguiniga, and explained the reason for the visit. On 03/11/2024, the Department received a complaint regarding an allegation of Neglect/Lack of Care and Supervision. Resident #1 (R1) sustained an unstageable pressure injury while in care at the facility. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Dennis Seng. Continued on LIC 9099-C Unsubstantiated Continued from LIC 9099 On 03/12/2024, from 9:10 a.m. to 4:15 p.m., LPAs Valeria Conway and Zabel Chochian conducted an unannounced 10-day complaint visit. At 10:00 a.m., the LPAs conducted a physical plant tour of the facility with the Assistant Administrator to ensure there were no health and safety hazards. From 11:05 a.m. to 1:15 p.m., the LPAs conducted records review including but not limited to resident records, facility internal records and obtained copies of pertinent documents relevant to the investigation. On 04/14/2024, from approximately 4:31 p.m. to 5:13 p.m., Investigator Seng conducted interviews with R1’s Resident Representative and Kaiser Permanente Clinical Social Worker; on 05/16/2024, from approximately 8:47 a.m. to 10:58 a.m., with the facility Assistant Administrator, caregivers, and residents; on 06/11/2024, from approximately 4:50 p.m. to 5:54 p.m., with caregiver and an attempted interview with R1 (R1 unable to be interviewed due to mental condition of dementia and non-verbal); and on 06/12/2024, at approximately 2:01 p.m., with Star World Home Health nurse. In addition, the investigator obtained and reviewed medical records from Kaiser Permanente, Astoria Nursing and Rehabilitation Center, Grand Valley Health Care Center, and Star World Home Health, photos of R1’s pressure injury, and facility file documents related to the investigation. According to medical records reviewed, R1 was initially admitted to the Grand Valley Health Care Center (GVHCC) on 12/23/2022 for a left femoral neck fracture (hip fracture). On 01/25/2024, R1 was discharged and admitted to the Glen Park at Valley Village facility. The discharge paperwork from GVHCC did not indicate a pressure injury. However, GVHCC records reviewed indicated that on 01/11/2024, R1’s Patient Care Plan notated R1 had a pressure injury on R1 Sacro coccyx which was listed as a Stage 2. The goal was to ensure the sore was healed within 90 days. The Assistant Administrator stated R1 had no pressure injuries upon admission to the facility, however, it is unknown if a body check was completed. During R1’s file review it was noted R1’s Head to Toe Assessment form was not filled out and left blank, both in the file review and when the investigator requested to view the documents in person. Continued on LIC 9099-C Continued from LIC 9099-C R1’s diagnosis included osteoporosis of knee, myopia, difficulty with walking, diplopia, hypertension, fracture of left femur, history of falling, hyperlipidemia, insomnia, low back pain, lack of coordination, artificial left hip joint, radiculopathy of cervical region, arthritis, senile degeneration of brain, spinal stenosis of lumbar region, spondylolisthesis of lumbar region, type two diabetes, dementia, and glaucoma. A review of the Star World Home Health records revealed R1’s care with home health began on 01/30/2024, the home health nurse reported a Stage 2 pressure injury on R1’s coccyx measuring 0.3x0.2x0.2cm. A Physician’s Order from Dr. David Wong recommended a Skilled Nursing visit one time a week for 3 weeks. Dr. Wong’s order stated the following, “Skilled Nurse to perform/demonstrate and instruct patient/caregiver regarding coccyx pressure ulcer as follows: cleanse with wound cleanser, pat dry, apply triad paste and leave open to air daily. Patient caregiver may perform treatment during non-Skilled Nurse visit days. Coccyx pressure ulcer will be healed with current treatment by 4 weeks. Wound will remain free from signs and symptoms of infection, or complications during the treatment period”. The administrator was made aware of and agreed to the treatment plan. The home health notes indicate by the 02/15/2024 visit, the pressure injury increased in size and progressed in size weekly thereafter. By 03/01/2024, R1 was sent to Kaiser Permanente Emergency Room (ER) for further evaluation and diagnosed with a pressure ulcer of sacrum Stage 3 with full thickness skin loss. Later that same day, R1 was discharged from Kaiser and admitted to Astoria and Nursing Rehabilitation Center to continue with wound care. R1 was diagnosed with a pressure injury of sacral region unstageable. Based on record review and interviews conducted, the Department did not find sufficient evidence to prove that the facility was responsible for the neglect/lack of care and supervision causing R1 to sustain an unstageable pressure injury. Per the staff interviews, it is possible that the Star World Home Health (HH) nurse failed to properly care for R1. The staff interviews reflected that R1 was a “two-person assist;” however, the HH nurse never asked for assistance. Other staff interviews reflected that the HH nurse was only seen twice at the facility and others stated that sometimes the HH nurse would not visit R1 as the HH nurse would only discuss R1’s condition with the Assistant Administrator. The HH nurse did not provide information or documentation to support which caregivers were provided with training on R1’s wound care. Continued on LIC 9099-C Continued from LIC 9099-C The caregivers should not provide wound care given they are not skilled professionals. Based on the evidence received from staff, HH nurse interviews, and the medical records; there was insufficient evidence to prove that the allegation of neglect and lack of care and supervision of the R1’s pressure injury became worse due to staff neglect/lack of supervision. Therefore, the allegation “Neglect/Lack of Care and Supervision: Resident sustained an unstageable pressure injury while in care at the facility as a result of facility neglect” is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued.the state’s words, verbatim · CDSS document, Oct 9, 2024 · control 29-AS-20240311081755

Type of visit: Case Management - Deficiencies

This report has been amended to correct deficiencies from type B to type A. Licensing Program Analysts (LPA), Valeria Conway, conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint control # 29-AS-20240311081755). The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint. Upon arrival LPA met with Administrator, David Aguiniga and explained the reason for the visit. During the Department’s investigation of complaint, the following deficiencies were observed: Resident #1 (R1s) care with Star World Home Health began on 01/30/2024, the home health nurse reported a Stage 2 pressure injury on R1’s coccyx measuring 0.3x0.2x0.2cm. A Physician’s Order from Dr. David Wong recommended a Skilled Nursing visit one time a week for 3 weeks. Dr. Wong’s order stated the following, “Skilled Nurse to perform/demonstrate and instruct patient/caregiver regarding coccyx pressure ulcer as follows: cleanse with wound cleanser, pat dry, apply triad paste and leave open to air daily. Patient caregiver may perform treatment during non-Skilled Nurse visit days. Coccyx pressure ulcer will be healed with current treatment by 4 weeks. Wound will remain free from signs and symptoms of infection, or complications during the treatment period”. The administrator was made aware of and agreed to the treatment plan. The staff were not skilled professionals qualified to perform the treatment. R1’s pressure injury became progressively worse and by 03/01/2024, R1 was diagnosed with an unstageable pressure injury. Continued on LIC 809-C Continued from LIC 809 There were no home health logs or staff notes available at the facility regarding R1’s home health care and treatment plan documenting all aspects of R1’s care. R1’s Physician Report, dated 12/22/2023, indicated that R1 did not have the capacity for any self-care, required continuous bed care, was not able to transfer independently to and from bed, was non-ambulatory, and diagnosed with dementia. The facility did not submit an exception request for the prohibited condition “Resident who depends on others to perform all activities of daily living for them”. Citations issued, exit interview, appeal rights given. On 10/22/2024 At 3:51 p.m., LPA spoke to David Aguiniga to explain the reason for amended report. Copy of report was emailed to daguiniga@glenparkseniorliving.com. LPA requested the report to be sent back with signatures.the state’s words, verbatim · CDSS document, Oct 9, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87609(b)(3) · Plan of correction due date: Oct 23, 2024

87609(b)(3) Allowable Health Conditions and the Use of Home Health Agencies (b) Incidental medical care... (3) The licensee informs the home health agency of any duties the regulations prohibit facility staff from performing...This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff performed wound care treatment to R1’s pressure injury, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 9, 2024

Plan of correction: The licensee will submit planon how facility will ensure staff do not perform treatment which requires an appropriately skilled professional. Submit proof to CCL by POC due date

From the deficiency page — Deficiency type: Type A · Section cited: CCR87631(a)(3)(B) · Plan of correction due date: Oct 23, 2024

87631Healing Wounds(a) Except... the licensee shall be permitted... a resident who has a healing wound...(3) Residents with a stage 1 or 2 pressure injury...an appropriately skilled... (B) All aspects... documented in the resident's file.This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. There were no home health logs or staff notes available for R1 at the facility, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 9, 2024

Plan of correction: The licensee will plan how facility will ensure all aspects of care by home health and staff are documented. Submit proof to CCL by POC due date

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(5) · Plan of correction due date: Oct 23, 2024

87615Prohibited Health Conditions (a) Persons who require health services for or have a health condition...shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform...This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. Facility admitted and retained R1 who had no capacity for self-care, without submitting an exception request for the prohibited health condition, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 9, 2024

Plan of correction: The licensee will submit a plan how facility will ensure that exception requests will be submitted for residents with a prohibited health condition. Submit proof to CCL by POC due date

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA), Valeria Conway, conducted a subsequent Case Management - Incident visit to deliver findings for the above allegation. LPA met with Administrator, David Aguiniga and explained the reason for the visit. On 01/29/2024, the Department received a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) from the facility regarding Resident #1 (R1). The report indicated that Resident #1 (R1) alleged that they were sexually assaulted by facility Resident #2 (R2). The case was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Laarni Santiago. On 01/31/2024, from 12:30 p.m. to 1:45 p.m., LPA Zabel Chochian responded to the facility to conduct a Case Management - Incidient visit in response to the SOC341 submitted by the facility administrator on 01/30/2024. The SOC341 report indicated that Resident #1 (R1) alleged that they were sexually assaulted two-weeks ago by another facility resident, Resident #2 (R2). The SOC 341 form was also submitted by the facility administrator to Adult Protective Services (APS), the local Long Term Care Ombudsman (LTCO) and local law enforcement. The administrator stated she was working on submitting the incident report to Community Care Licensing (CCL). During the visit, the LPA completed a brief physical plant tour, discussed the case with the administrators and obtained copies of R1 and R2’s records. Continued on LIC 809-C Continued from LIC 809-C On 02/16/2024, at approximately 3:00 p.m., Investigator Santiago conducted an interview with the administrator; on 03/13/2024, from approximately 11:30 a.m. to 11:40 a.m., with administrator, assistant administrator, and staff; on 04/25/2024, from approximately 11:04 a.m. to 12:03 p.m., with resident, staff, and R1; and on 04/26/2024, from approximately 9:20 a.m. to 10:50 a.m., with residents, R2, and staff. In addition, facility file documents related to R1 and R2 were reviewed. Law enforcement interviewed and obtained statements from R1 and R2, however the police report and findings have not yet been received by the Department. Information obtained from the Department’s investigation revealed that R1 reported that sometime in mid-January of 2024, R2 offered R1 a cigarette. When R1 moved R1’s wheelchair closer to R2’s wheelchair, R2 pulled R1 closer by wrapping R2’s leg around R1’s. R2 suggested it was the only way R2 could light R1’s cigarette. Subsequently, R2 placed R2’s hand over R1’s vagina and touched it. R1 said that R2 “scooped” (no penetration) R1’s vagina without R1’s consent. R1 repeatedly told R2 to “stop” and when R2 finally did, R2 asked R1 to go with R2 behind the dumpsters because there were “too many cameras.” R1 followed R2 and R2 asked if R1 could orally copulate R2 for money and R1 said “no.” R1 left the backyard patio and went to R1’s room. R1 later reported the incident to law enforcement and the administrator. R1 revealed that this was the first time R2 had ever touched R1 inappropriately. The administrator and staff began to closely supervise R2 and R1 to avoid any future encounter that would put R1’s safety at risk. This was corroborated by R1 when R1 told the investigator that staff had been keeping a close eye on them since the incident, and there had not been any new incidents since then. Furthermore, staff were all aware of keeping close supervision on R2 to ensure that R2 does not sexually or physically assault R1 or other residents. Continued from LIC 809-C Continued on LIC 809-C R2 declined to be interviewed but refuted the claim that R2 touched or sexually assaulted any residents at the facility. Interviews with residents did not express any concerns about staff supervision. There were no witnesses to corroborate the incident between R2 and R1. Additional information gathered during the investigation revealed that there is a surveillance camera in the back patio where the alleged incident happened between R1 and R2. However, per the administrator, there were no footage found of them in the back patio. The Department found insufficient evidence to prove that the staff's neglect/lack of care and supervision led to the alleged incident. Exit interview, copy of report given.the state’s words, verbatim · CDSS document, Oct 9, 2024

Allegation investigated: Staff does not provide safe environment for resident.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to investigate the allegation listed above. The LPA met with Executive Director (ED) David Aguiniga and Assistant Administrator (AA) Virginia Sumulong informed them of the reason for the visit. On 09/04/2024, Licensing Program Analyst (LPA) Sandra Urena conducted an initial 10-day visit to investigate the allegation listed above. The LPA arrived at 1:35 p.m., met Executive Director (ED) David Aguiniga and informed of the reason for the visit. At 1:45 p.m., LPA Urena requested records pertinent to the investigation, and interviewed the ED at 2:30 p.m. The complaint needs further investigation. Continues on LIC 9099C... Unsubstantiated Staff does not provide safe environment for resident. On the allegation that staff do not provide a safe environment for resident, it is the reporting party’s (RP) concern that resident (R1) does not feel safe at the facility. The RP did not elaborate in the complaint report as to why R1 does not feel safe. To investigate the allegation, on 09/03/2024 LPA Urena attempted to interview the RP, but RP did not return phone calls. On 09/03/2024, LPA attempted to interview R1’s acquaintances but was unable to communicate with them and leave a message. On 09/18/2024, the LPA introduced themselves to R1 and attempted to interview them privately, however, R1 refused the interview by saying that they did not want to speak. LPA tried to explain to R1 the reason for the visit and the interview and told R1 that they could stop the interview at any time they did not feel comfortable, but R1 continue to say they did not want to speak to the LPA. On 09/04/2024, the LPA interviewed the ED. The ED stated that R1 was admitted at the end of July 2024, and that R1 has complained since day one that staff do not like them and give R1 attitude with facial expressions, however R1 cannot say specifically to the ED, how staff are abusive. The LPA interviewed staff and the interview revealed that R1 has a tendency to get quickly irritated if they don’t immediately get what they ask for. The staff stated that on 09/01/2024, R1 called law enforcement and EMT because their breakfast was delayed. Based on the information obtained through interviews and record review, there is insufficient evidence to support the allegation that staff do not provide a safe environment for resident in care. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 29-AS-20240903161533

Allegation investigated: Staff are not notifying residents of COVID outbreak.

Licensing Program Analyst (LPA) Sandra Urena conducted an initial 10-day visit to investigate the allegation listed above. The LPA met with Executive Director (ED) David Aguiniga and Assistant Administrator (AA) Virginia Sumulong informed them of the reason for the visit. At 1:45 p.m., LPA Urena requested records pertinent to the investigation, and conducted administrators, staff and residents’ interviews from 2:00 p.m. to 5:30 p.m. Staff are not notifying residents of COVID outbreak. On the allegation that staff are not notifying residents of a COVID outbreak, it is the concern of the reporting party (RP) that staff are not notifying residents of the cases of COVID at the facility or conducting COVID testing. Per the RP, one staff had COVID (although the staff did not know they were COVID positive); however, the staff was in contact with residents. Additionally, the RP stated that they knew that three residents were also COVID positive but did not know the name of two of the residents. To investigate the allegation, LPA Urena interviewed administrators, staff and residents about the allegation. Continues on LIC 9099C... Unsubstantiated The Administrators interviews revealed that there were three residents COVID cases, and one staff case in the past three weeks. The first two cases were during the first week of September, and the third case was confirmed on 09/12/2024. Initial and follow up COVID testing was done for the one resident. The follow up test showed negative for COVID. The resident was isolated during the six-day wait period between the initial and the follow-up COVID testing. Staff was tested by their health provider and were off work during the infectious period. The ED stated that they informed the residents about the COVID cases during the lunch time while residents were in the dining room. Furthermore, the ED stated that residents were told that if they wanted a mask, that the masks were available at the front desk. The ED also stated that they told the residents that facility staff could not force residents to wear the mask, but residents were highly encouraged to wear the mask. The ED stated that they did not inform residents in writing, only verbally, however they did post the quarantine notice on the COVID positive residents’ door as well as the PPE equipment outside the residents’ doors. The Administrator denied telling the RP that “they are not telling anyone or not doing testing”. Residents’ interviews revealed that some residents were in the dining room when the ED told them about the COVID positive cases and about the masks being available at the front office. Other residents stated that they saw the quarantine notices posted on the residents’ doors, and other residents stated that they were tested and came out with negative results for COVID. During the physical plant walk, the LPA observed the PPE COVID equipment still placed outside the last resident who tested COVID positive. Furthermore, the LPA noticed paper notices taped to each one of the residents’ bedrooms doors about a Vaccination Clinic (COVID, Flu, Shingles, Pneumonia, and RSV) being offered at the facility on 09/20/2024. Although the administrative staff did not send written notices to residents about the COVID cases, the administrative staff verbally informed residents and staff about the positive COVID cases and offered to mitigate the spread of COVID by offering PPE equipment. Based on the information obtained through interviews and record review, there is insufficient evidence to support the allegation that staff did not inform residents about the COVID positive cases. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview was conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 29-AS-20240917113114

Allegation investigated: Questionable Death. Staff is abusing residents in care. Staff hide residents’ prohibited health conditions. Staff steal residents’ money. Staff steal resident belongings. Staff threaten residents in care. Staff are unlawfully evicting residents.

This amended report supersedes the report issued on 05/23/2024. Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint visit to deliver the findings for the allegations listed above. LPA Urena met with Executive Director, David Aguiniga and explained the reason for the visit. On 05/09/2023, Licensing Program Analyst (LPA) Angel Ascencio conducted an initial 10-day complaint. LPA Ascencio met with Interim Administrator Rafael Silva at 10:08 a.m. Entrance interview conducted. During the visit, LPA Ascencio reviewed staff files at 11:00 a.m. and obtained pertinent documents. LPA Ascencio advised Interim Administrator Silva that the allegation of Personal Rights has been referred to the Department's Investigation Branch (IB) for further review. Although IB did not conduct any additional investigation. On 04/09/2024, LPA Urena requested additional documents pertinent to the investigation at 11:30 a.m. and interviewed the ED at 11:55 a.m. Continues on LIC 9099C ... Unsubstantiated Pg. 2 On 05/23/2024, LPA Urena conducted a subsequent inspection and met Executive Director (ED) Marylou V. Mendoza and Assistant Administrator (AA) Virginia Sumulong. Staff and resident interviews were conducted and it was determined that further investigation was needed. On 06/19/2024, LPA Urena conducted an additional inspection and interviewed staff and the administrator between 12:45 p.m. to 3:30 p.m. LPA Urena also conducted two telephone interviews with staff on 06/19/2024. Questionable Death On the allegation of questionable death, it is the concern of the reporting party that residents die because staff make medication errors. No additional information was provided about the residents’ questionable death identifiers or the names of the medications. No contact information was provided for the reporting party to obtain additional information about the allegation. To investigate the allegation, the LPA reviewed the Department’s database for Deaths Reports (LIC624 A) for dates from January 2023 through June 2023. The LIC 624A reports received in our office indicate the manner of deaths to be of natural causes due to conditions contributing to death. Three (3) out of the four (4) deaths occurred at the hospital and one (1) death occurred at the facility. The death that occurred at the facility, was listed in the Death Certificate as ‘conditions contributing to death: myocardial infarction’. Residents interviewed stated that they receive their medications from the med techs as prescribed and have not reported any errors. Staff interviewed, stated that when medications arrive the medications are reviewed right away, and documented on the LIC 622. On 04/09/2024, LPA Urena conducted an audit of five randomly selected medications and all medications were found to be correctly recorded in the Centrally Stored Medication and Destruction Record (LIC 622) and administered as prescribed. On 06/19/2024, LPA Urena conducted staff interviews about the allegation that residents have died due to medication error. One staff stated that, “I don't recall anything about a death due to medication error; I don't recall anyone who passed away, the last time I was at this facility, was back in 2019, it has been a long time since I was there”. Another staff stated that they don’t recall the incident since they have moved throughout the different Glen Park facilities “I am all over the place”. A third staff stated that they seemed to recall an incident about a death due to medication error but did not remember the name or date of the incident. Based on the information obtained through record review and interviews; the allegation of a questionable death, is deemed Unsubstantiated at this time. Pg. 3 Staff is abusing residents in care. On the allegation of that staff are abusing residents, it is the reporting’s party concern that residents are being sexually abused and bullied by Staff #1 (S1). To investigate the allegation, LPA Urena conducted residents’ interviews on 04/09/2024. The interviews revealed that the residents did not feel abused in any manner. Sometimes staff may not be friendly, but overall, they are not abusive, nor did residents feel bullied by staff. On 06/19/2024, LPA Urena conducted staff interviews. Staff interviews revealed that they don't recall anyone accusing them of abusing residents or staff either physically or sexually. Staff #1 (S1) “No one has accused me of sexual harassment, not residents or employees”. Other staff stated that they had not experienced any sexual abuse either from other staff or residents. Based on the information received through interviews, residents and staff denied that they were abused or bullied by staff. Therefore, the allegation is deemed Unsubstantiated at this time. Staff hide residents’ prohibited health conditions. It is alleged that staff are hiding prohibited health conditions, and skin tears larger than a stage 4. No additional information was provided by the reporting party about the resident(s) who exhibited prohibited health conditions, or how to the reporting party acquired the information. No contact information was provided for the reporting party to obtain additional information about this allegation. To investigate the allegation, the LPA conducted residents’ interviews on 04/09/2024. The interviews revealed that none of the residents have had prohibited health conditions, nor did they have knowledge of any other resident having such conditions. On 06/19/2024, LPA Urena interviewed staff who were working at the facility at the time the allegation was made. The staff interviewed stated that they were not aware of any residents residing at the facility with prohibited conditions; furthermore, staff stated that any resident who develops a wound or prohibited condition while at the facility are sent to the hospital right away for assessment and care. Any wound care was done by a wound specialist, and we would do a one-to-one meeting to ensure the resident was being assisted. The current facility’s LVN stated that they monitor the assessment of residents’ conditions and any health-related issue they may have. Based on the information received through interviews; the allegation that staff hide residents’ prohibited health conditions, is deemed Unsubstantiated at this time. Pg 4. Staff steal residents’ money. On the allegation that staff steal residents’ money, it is the reporting party’s concern that the facility’s accounting department staff is stealing money from North Los Angeles Regional County Center (NLACRC) program and Assisted Living Waiver (ALW) program. No additional information was provided about the residents’ identifiers. No contact information was provided for the reporting party to obtain additional information about this allegation. The LPA interviewed residents on 04/09/2024 about their funds through the programs listed in the allegation. The residents stated that they work with their case workers/care coordinators and create plans to assist them in qualifying for the programs and do not receive the funds directly. The programs pay the facility. The LPA reviewed the Departments’ data system for complaints related to the allegation that may have been submitted by either the NLACRC or the ALW programs; the data searched was done for the time period between 06/01/2022 to 12/01/2023. The LPA did not find any complaints related to the allegation of the accounting department staff stealing residents’ money. Based on the information obtained though data search done on complaints related to staff stealing residents’ money, the searched revealed that there were no complaints regarding the NLACRC or the ALW programs. Therefore, the allegation that the staff steal residents’ money, is deemed Unsubstantiated at this time. Pg.5 Staff steal resident belongings. On the allegation that staff steals residents’ belongings, it is alleged by the reporting party that the medical technicians (med techs) are stealing residents’ medications. No additional information was provided about the residents’ identifiers. No contact information was provided for the reporting party to obtain additional information about this allegation. To investigate the allegation the LPA interviewed residents about receiving their medication according to their daily doses and if any medications were missing. The residents interviewed stated that they receive their medications from the med techs as prescribed, one resident stated that they take only daily supplements such as vitamins, which they keep in their rooms. LPA Urena conducted an audit of five randomly selected medications and all medications were found to be correctly recorded in the Centrally Stored Medication and Destruction Record (LIC 622). On 06/19/2024, LPA Urena conducted staff interviews. The current facility’s Licensed Vocational Nurse (LVN) stated that they monitor the delivery of medications to the facility: “I review the doctor's orders, I audit the meds (go over the medications)', because different med-techs may receive them, (depending on the time of the delivery from the pharmacy) and cross check with the Centrally Stored and Destruction Record. The meds come in cycles thought out the month.” A former med-tech staff stated: “I have not been involved with medication distribution since 03/15/2022; and no, I have never done anything improper with medications. I never saw staff doing anything improper with the medications, either”. Management staff indicated that they never observed improper handling of medications. Based on interviews, a medication audit and record review, and interviews, the LPA could not find evidence of residents’ medications being stolen. Therefore, the allegation, is deemed Unsubstantiated at this time. Staff threaten residents in care. The reporting party’s concern is that staff threaten residents with bodily harm and financial abuse if they complain to reporting agencies. No additional information was provided about the residents’ identifiers. No contact information was provided for the reporting party to obtain additional information about this allegation. To investigate the allegation the LPA conducted residents’ interviews. The residents interviewed stated that they have not been threaten by staff. Some residents stated that they know how to submit complaints to Licensing Department or to the Ombudsman Office and would so if necessary. On 06/19/2024, LPA Urena conducted staff interviews. The staff interviewed denied any type of abuse towards residents in care or towards staff. Based on the information obtained through residents’ interviews, the residents have not been threatened with bodily harm, or financial abuse. Therefore, the allegation is deemed Unsubstantiated at this time. Pg. 6 Staff are unlawfully evicting residents. On the allegation of unlawful eviction of residents, it is the concern of the reporting party that residents are wrongfully being evicted. No additional information was provided about the residents’ eviction identifiers. To investigate the allegation, LPA Urena collected documents pertinent to the allegation. The LPA reviewed eviction notices issued from January 2023 through June 2023. The LPA identified two (2) residents that received eviction notices for non-payment of rental fees. One resident received four eviction notices dated from 08/2022 through 03/2023, a second resident received one eviction notice. Eviction Notices followed regulations and the facility's protocol based on non-payment of rental fees. The eviction notices had attached Past Due notices which totaled the amount owe for the rent, along with the Admission Agreement page that states that rental fees are due each month, and the grievance procedures a resident may follow to file a complaint. On 06/19/2024, LPA Urena interviewed staff. Staff stated that the residents who were evicted was due to non-payment of the monthly rent, “There was a non-compliant resident who called licensing several times. They were being evicted for not paying the monthly rent”. Based on the information obtained through record review and staff interviews, two out of two evictions were done based on the admission agreement, house rules and through a formal letter. Therefore, the allegation, is deemed Unsubstantiated at this time. No citations were issued. Exit interview was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 4, 2024 · control 29-AS-20230508154924

Allegation investigated: Staff do not prevent a resident from causing harm to other residents while in care Staff did not meet the medical needs of the residents while in care Staff did not properly report incident involving residents

Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. for the above allegation. During today’s visit, LPA met with Executive Director Marilou Mendoza and explained the reason for the visit. On 3/30/2023, the initial complaint visit was conducted by LPA’s Angel Ascencio and Sandra Urena between approximately 09:35 a.m. - 4:15 p.m. During the visit, LPA’s conducted physical plant, interviewed staff, residents, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. On 06/26/2024, LPA Brian Balisi conducted a subsequent visit between approximately 01:00 p.m. – 3:30 p.m. During the visit, LPA conducted physical plant, interviewed staff, residents and reviewed and obtained copies of pertinent documents relevant to the investigation. Today LPA conducted physical plant, interviewed staff and conducted medication audit. Continued on 9099-C Unsubstantiated Continued from 9099 It was reported that “Staff do not prevent a resident from causing harm to other residents while in care”, as it was alleged that that due to lack of staff supervision Resident #1 (R1) and Resident #2(R2) were physically assaulted by Resident #3(R3) on separate occasions. R2 and R3 were roommates during the time of the complaint. On 02/22/2023, at approx 4 p.m. R2 and R3 were reported to have an argument in their shared room, which resulted in R3 striking R2 with a cane on their face. R2 immediately went downstairs to Staff and received first aid then was admitted into a local hospital. It was also reported that R3 kicked R1 on the back of their wheelchair. LPA's interview with R1 revealed they do not recall their wheel chair being kicked by R3 or having any physical altercation with any resident at this time. LPA's interview with six (6) residents in care who resided at the facility at the time of the complaint revealed that all six (6) residents did not express any potential or immediate concerns for being involved in a physical altercation due to lack of staff supervision. Furthermore interviews with all (6) residents stated they have always observed staff intervene when residents were observed to be overly aggressive with other residents. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff do not prevent a resident from causing harm to other residents while in care” is deemed Unsubstantiated at this time. It was reported that “Staff did not meet the medical needs of the residents while in care”, as it was alleged that a med tech was not available to administer medications on 03/13/2023. It was also stated that a med tech not being available has occurred on multiple occasions. Interviews conducted and records review revealed that there is at least one (1) med tech per shift with five (5) med techs on staff along with an LVN. Interviews conducted with six (6) residents in care who resided at the facility at the time of the complaint revealed that four (4) out of the six (6) residents interviewed have never missed a medication dosage due to a med tech not being available. LPA's interview with two (2) out of the (6) residents revealed they have not experienced missing a dosage of medication due to a med tech not being available, however they have experienced a delay in receiving their medications due to a med tech arriving late to work. Those (2) residents continued to state it does not occur often and they recall they did not have to wait more than 30 mins from their typical time of administration. LPA's records review of six (6) resident Medication Administrator Records (MARS) dated 03/13/2023 revealed that all (6) residents received their medications as prescribed.. Continued from 9099-C On 08/22/2024, LPA conducted a medication review for five (5) randomly selected residents in care. Medication review revealed that medications are centrally stored in the med room next to the front desk. All medications reviewed were observed to be administered as prescribed at this time. Additionally, LPA’s interview with the Executive Director revealed there are (5) med techs on the schedule along with the receptionist, the activity director and the Assistant Administrator who are each certified for medication pass. If there is a call out or a delay in one of the staff’s arrivals, any one of the trained staff would take over for medication pass. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not meet the medical needs of the residents while in care” is deemed Unsubstantiated at this time. It was reported that “staff did not properly report incident involving residents”, as it was alleged that staff do not contact the proper emergency personnel when situations arise. Interviews conducted with six (6) residents in care who resided at the facility at the time of the complaint revealed that all six (6) residents did not express any potential or immediate concerns for staff not contacting the proper emergency personnel if emergency situations were to arise. Furthermore all (6) residents have always observed staff address resident concerns or emergency situations in a timely manner. In addition, LPA's interview with five (5) staff revealed that when any staff observes a medical emergency or other emergency situations the med tech is informed right away. Med techs then assess the situation and contact proper authorities. All (5) staff also stated they have always observed staff to address any emergency situations in a timely manner. LPA’s records review of Incident reports (LIC 624) from July 1st 2024 to August 2024 revealed either 911 or a Non-Emergency medical transport was called approx. seventeen (17) times for various resident related emergencies or needs. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not properly report incident involving residents” is deemed Unsubstantiated at this time. Exit interview conducted and copy of report issuedthe state’s words, verbatim · CDSS document, Aug 22, 2024 · control 29-AS-20230321141523

Allegation investigated: Facility has bed bugs Facility is not safeguarding residents’ belongings

Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to deliver investigation finding. Upon arrival LPA met with current Administrator Marilou Mendoza, and Virgina Gigi Sumulong the Assistant Administrator. Reason for the visit was explained. Entrance interview conducted. On 08/14/2023, Community Care Licensing Division received the above complaint allegations. Investigation into the allegations consist of facility physical plant tour, interview with staff and residents on 08/16/2023. Following is a summary of the allegations and investigation finding: Allegations) Facility has bed bugs and Facility is not safeguarding residents’ belongings – It was reported that the facility is not taking appropriate action to eradicate the bed bug issue. Furthermore, it was reported that the previous administrator Marhlyn Sapugay, put all the residents' clothes and personal belongings outside in the facility parking lot allowing public access to residents’ belongings. (Continue to LIC 9099c). Substantiated To investigate this allegation on 08/16/2023 random resident rooms (#5, 6, 22, 23, 37) were toured. In addition, staff and random residents were interviewed. Staff reported that bed bugs are an ongoing issue at the facility due to residents bringing it in and refusing to shower or maintain room cleanliness. Staff reported that they do regular room checks and if any bed bug activity is noticed or reported by any resident the resident is moved to another room and the room is treated. Six out of six residents interviewed reported having bed bug activity in their room. It was confirmed through interviews with staff and previous administrator that resident rooms identified with bed bug activity were cleared and clients’ belongings were taken out and left in the open parking lot. Ms. Sapugay stated this action was taken to mitigate the bed bug issue identified in specific client rooms. Discussion was held with Ms. Sapugay regarding allegations, and Ms. Sapugay acknowledged that the action taken to eradicate the facility bed bug issue was not handled appropriate at the time. Based on the information gathered allegations “Facility has bed bugs and Facility is not safeguarding residents’ belongings’” is deemed SUBSTANTIATED. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview and report reviewed with the Administrator. A copy of the report and appeal rights were issued. Clients reported that staff assist with medication, showers and clean their room when needed. No issues were reported. One client expressed that they are responsible for self and do not need staff to assist with care needs. Client expressed that if needed staff assist with daily activities. Client expressed they do not like to be bothered therefore refuse at times to be showered and have room cleaned. Client reported that staff do come by and offer to assist with shower and clean room however most of the time client refuses. Staff interviewed reported that most of the clients cooperate with care services being provided. According to staff if client refuses any services, it is document. Regarding client #1 staff reported that it is a great challenge getting client #1 to shower and having room cleaned. Staff reported that client #1 is very combative therefore staff are afraid to approach client #1. According to staff they have identified that client #1 will only allow specific staff to assist with care needs and cleaning. Therefore client #1 did recently agree to shower and have room clean. During initial visit LPA observed staff interact with client #1 and client agreed to have room cleaned. Based on the above information gathered although the allegation may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegation “Facility is not meeting client’s needs” is deemed unsubstantiated at this time. Exit interview held. Copy of report provided.the state’s words, verbatim · CDSS document, May 22, 2024 · control 29-AS-20230814151148

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1 · Plan of correction due date: May 28, 2024

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews and observation, the facility did not provide residents a safe, healthful and comfortable accommodations, as bed bugs were observed and interviews confirmed bed bugs. This posed a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: Current Administrator stated that they have the pest control company assess the facility and all resident rooms for pest control. Ongoing service is provided. Administrator will provide invoice copies from 8/2023 to present. Also submit what steps have been taken to rectify the facility pest issues and what actions will be taken to ensure facility is maintained free of pests.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: May 28, 2024

Safeguards for Resident Cash, Personal Property, and Valuables Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above as it related to former administrator storing/leaving resident's belongings outside in the parking lot to get rid of bed bugs. This posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: The current Administrator has agreed to do the following: 1. Submit a Plan of Action, detailing how the facility will ensure that resident personal property is safeguarded. Submit plan to CCLD by 05/24/2024.

Allegation investigated: Staff steal resident's medications. Staff falsify residents' medication records.

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit. LPA met with administrator Marilou Mendoza and explained the reason for the visit. On 7/6/2023, LPA Angel Ascencio conducted an initial complaint investigation visit. During that visit LPA Ascencio interviewed three staff and conducted a medication audit of seven randomly chosen residents. LPA Ascencio found one resident’s medications had not yet been logged on the centrally stored medication and destruction record (CSMDR). The resident had a medication change mid-cycle and staff had not yet logged the medications on the CSMDR, however it appeared the resident was receiving their medications as prescribed. This error was addressed that day in a Case Management - Deficiencies visit. Otherwise, all the other medications were logged and appeared to be given as prescribed. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) During LPA Camara’s visit on 5/15/2024, LPA interviewed staff at 1:10 p.m., 1:25 p.m., 1:30 p.m. and 1:44 p.m. LPA reviewed records at 1:37 p.m. for former resident 1 (R1). LPA Camara discovered the facility did not maintain all records for R1; medication records were missing. In addition, personnel records for former staff 1 (S1) and staff 2 (S2) were also missing. These missing records were addressed on a Case Management - Deficiencies visit on 5/15/2024. Based on interviews, a medication audit and record review, LPAs could not find evidence of residents’ medications being stolen nor was there any indication staff falsify medication records. Therefore, these allegations are deemed Unsubstantiated at this time. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, May 15, 2024 · control 29-AS-20230630155629

Allegation investigated: Facility staff did not notice resident’s absence

Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint visit to deliver findings on the above noted allegation. LPA met with administrator Marilou Mendoza and explained the reason for the visit. On 02/7/2023, LPA Angel Asencio conducted an initial complaint investigation visit. LPA Ascencio interviewed staff and obtained pertinent documents regarding resident 1 (R1). LPA Ascencio also interviewed the nurse case manager for R1 on 2/7/2023. R1’s physician’s report indicated R1 was able to leave the facility unsupervised. LPA Ascencio obtained copies of the “Resident Sign In & Out” sheets for 1/10/2023, 1/11/2023, and 1/17/2023. R1 signed out on 1/10/2023 at 11:40 a.m. and signed back in at 10:30 p.m. R1 signed out on 1/11/2023 at 1:20 p.m. and (continued on LIC 9099-C) Substantiated (continued from LIC9099) signed back in at 3:07 p.m. R1 signed out on 1/17/2023 at 4:16 p.m. and never signed back in. The facility’s house rules indicate on rule number four that all residents must sign out and sign in upon return to the facility. A nurse came to the facility to meet with R1 on 2/2/2023, but R1 was not there. The receptionist told the nurse R1 had left that morning and she did not know when R1 would be returning. The nurse asked R1’s roommate about R1’s whereabouts and the roommate informed the nurse R1 had not returned to the facility for weeks. On 2/3/2023, the nurse conducted a medical eligibility search for R1 and discovered R1 had been reported deceased. The nurse then called the facility, spoke with the receptionist and asked to speak with R1. The receptionist told the nurse R1 was visiting their family member and did not know when R1 would return to the facility. The nurse then informed the receptionist that R1 had been reported deceased. The receptionist called the nurse back later and stated that R1 had signed out on 1/17/2023 and did not return to the facility. R1’s family stated R1 passed away on 1/19/2023 at a friend’s house. The receptionist explained that they had mistaken another resident for R1 when they told the nurse they had seen R1 on 2/2/2023. The nurse contacted R1’s family who informed the nurse R1 was deceased. R1 had gone to visit a friend on 1/17/2023 and passed away at the friend’s house on 1/19/2023. The facility had been unaware of R1’s whereabouts from 1/17/2023 until they received notification of R1’s death on 2/3/2023. The administrator at that time, Tillman Pink, submitted a death report on 2/7/2023 stating they were informed of R1’s 1/19/2023 death by R1’s family on 2/3/2023. Based on the information gathered from interviews and record review, the facility staff did not know the whereabouts of R1 for nearly three weeks. They did not review the sign-in/out sheet to follow-up on anyone who had not signed back in. Therefore, the allegation facility staff did not notice resident’s absence is deemed Substantiated at this time. The following deficiencies were observed (see LIC9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted with administrator. A copy of this report with appeal rights provided to administrator.the state’s words, verbatim · CDSS document, May 15, 2024 · control 29-AS-20230207083249

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: May 22, 2024

§1569.312(a)Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as the licensee failed to provide adequate supervision to R1 who signed out of the facility and never returned, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: Licensee will submit a Plan of Action, documenting how the facility will follow-up with residents who do not sign back in after an outing to ensure residents are provided appropriate care and supervision. Submit plan to CCL on or before 5/22/2024.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Teresa Camara conducted a Case Management - Deficiencies visit to the above facility. LPA met with administrator Marilou Mendoza and explained the reason for this visit. During today's visit, 5/15/2024, LPA requested medication records for resident 1 (R1) who no longer resides at the facility. R1 moved out on 8/4/2023. Assistant Administrator Gigi Sumulong located R1's records but there were no medication records. These records must be maintained at the facility a minimum of one year. LPA requested personnel records for two former employees, staff 1 (S1) and staff 2 (S2), who were reportedly terminated in 2023. The Assistant Administrator attempted to locate the personnel records for these two employees. She looked through records in storage but could not locate them. These records must be maintained at the facility for a minimum of three years following termination of employment. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. A copy of this report and appeal rights were provided to the Administrator.the state’s words, verbatim · CDSS document, May 15, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: May 22, 2024

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as the licensee failed to keep medication records for R1, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: Licensee will submit a Plan of Action, documenting how the facility will maintain medication records. Submit plan to CCL on or before 5/22/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(h) · Plan of correction due date: May 22, 2024

87412 Personnel Records (h) All personnel records shall be retained for at least three (3) years following termination of employment. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as the licensee failed to keep personnel records for S1 and S2, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 15, 2024

Plan of correction: Licensee will submit a Plan of Action, documenting how the facility will maintain personnel records of ex-employees. Submit plan to CCL on or before 5/22/2024.

Allegation investigated: Facility staff are violating resident’s personal rights.

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent visit to investigate the allegation listed above. The LPA met with the Executive Director (ED), Marilou Mendoza and explained the reason for the visit. On 04/17/2024, Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced 10-day visit to investigate the allegations listed above. The LPA met with the Executive Director (ED), Marilou Mendoza and explained the reason for the visit. At 10:35 a.m. The LPA interviewed the ED and requested documents pertinent to the investigation. At 11:34 a.m. the LPA interviewed the resident (R1). Continues on LIC 9099C... Substantiated Facility staff are violating resident’s personal rights. On the allegation that the facility staff violated the personal rights of the resident (R1), the reporting party’s concern is that the facility staff searched R1’s dresser and night stand drawers without R1’ permission. The LPA interviewed R1 who stated that staff had searched the night stand and dresser by opening drawers without R1’s permission. The LPA interviewed the facility’s staff about the search of R1’s night stand drawers and dresser drawers; and the staff stated that they conducted a search of the dresser drawers due to a preceding incident that took place in the R1’s room, which prompted the search for safety reasons. However, the staff stated that they had not asked for permission from R1 for the search of the drawers. Based on the information gathered through interviews, the staff searched the personal accommodations of R1 without permission. Therefore, the allegation of violation of personal rights, is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiency is cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted. A copy of the report and appeal rights were issued. Facility staff retaliated against resident. On the allegation that the facility staff retaliated against the resident, it is the concern of the reporting party that staff retaliated against the resident by taking away their personal hygiene items. The LPA interviewed R1 who stated that at some point during the search of a dresser drawer in their room being conducted by staff, the R1 witnessed the staff remove personal hygiene items from a dresser drawer, however the R1 added that they left the room at the point of the search. When the R1 returned to their room, R1 observed all the personal hygiene items neatly placed back inside the dresser drawer. The LPA interviewed the staff, who stated that they conducted a search of the dresser drawers due to a preceding incident that took place in the R1’s room, which prompted the search for safety reasons. The staff stated that they indeed had taken out the hygiene items out of the drawer, which they placed on top of the dresser. Once the search was completed, the staff placed back the hygiene items in the drawer, and never removed the items from the room. Based on the information obtained from interviews, the interviews revealed that the items were not removed or taken away from R1’s room as a form of retaliation. Therefore, the allegation that the facility staff retaliated against resident, is deemed Unsubstantiated at this time. No citations were issued. Exit interview was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 14, 2024 · control 29-AS-20240416111628

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2 · Plan of correction due date: May 31, 2024

Additional Personal Rights of Residents in Privately Operated Facilities. (a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations …This requirement is not met as evidence by: Based on information obtained through interviews, the administrator searched R1’s dresser and nightstand drawers without prior permission, which poses a potential health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, May 14, 2024

Plan of correction: The ED will review the regulations on Residents’ Rights and will email the CCL department a statement of understanding and review of the regulation 87468.2- Additional Personal Rights of Residents in Privately Operated Facilities.

Allegation investigated: Illegal Eviction

Licensing Program Analyst (LPA) Valeria Conway conducted a subsequent complaint visit to the above noted facility. The purpose of the visit is to conclude an investigation initiated by LPA Peraldi on 03/27/2024. LPA met with Marilou Mendoza and explained the reason for the visit. It was alleged that Resident #1 (R1) was issued an illegal eviction. During the initial visit, LPA Peraldi conducted an interview with the Administrator at 11:19 a.m. At 11:26 a.m., the LPA requested copies of pertinent documents. At 11:48 a.m., the LPA, along with the Administrator conducted a brief physical plant tour. On 04/15/2024 LPA Conway reviewed the eviction letter submitted to R1 on 03/13/2024. Continued on LIC9099-C Substantiated Continued from LIC 9099 Information gathered during the course of the investigation reflected that R1 was issued a 30-Day eviction notice on 03/13/2024, due to resident breaking house rules and being abusive towards staff and residents. LPAs review of the eviction notice reflected that the eviction notice was not in compliance with Title 22 due to the eviction not containing specific facts to permit determination of the date, place, witnesses, and circumstances concerning the reasons for the eviction. On 04/16/2024, LPA contacted facility administrator and notified that the eviction letter should be rescinded and re-issued with the required components. Based on the information gathered, the above allegation “illegal eviction” is deemed SUBSTANTIATED at this time. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Apr 26, 2024 · control 29-AS-20240319110021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d) · Plan of correction due date: May 3, 2024

Eviction Procedures. (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement is not met as evidenced by: Based on interviews, and record review, licensee did not meet with the section above by not including date, place, witnesses, and circumstances surrounding the concerns of the eviction, which causes a potential personal rights violation to residents in care.the state’s words, verbatim · CDSS document, Apr 26, 2024

Plan of correction: Administrator agreed to do the following: 1.Rescind the eviction notice within the next 24 hours. This must be done in writing. Submit proof to CCL by 05/03/2024 2.Create a valid eviction notice for R1 and submit the eviction notice to CCL for prior approval.

Allegation investigated: Staff do not meet the minimum qualifications required.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint unannounced visit to investigate the allegation(s) listed above. LPA Urena met with Executive Director (ED) Marylou V. Mendoza and Assistant Administrator (AA) Virginia Sumulong, and explained the reason for the visit. On 05/09/2023, Licensing Program Analyst (LPA) Angel Ascencio conducted an initial 10-day complaint. LPA Ascencio met with Interim Administrator Rafael Silva at 10:08 a.m. Entrance interview conducted. During the visit, LPA Ascencio reviewed staff files at 11:00 a.m. and obtained pertinent documents. LPA Ascencio advised Interim Administrator Silva that the allegation of Personal Rights has been referred to the Department's Investigation Branch (IB) for further review. On 04/09/2024, LPA Urena requested additional pertinent documents at 11:30 a.m. and interviewed the ED at 11:55 a.m. Continues on LIC9099C... Unsubstantiated Staff do not meet the minimum qualifications required. On the allegation that staff do not meet the minimum qualifications required, the reporting parties concern is that staff#1 (S1) has no education and is not qualified to run a facility. To investigate the allegation, the LPA reviewed documents collected during the initial 10-day visit. The records indicate that S1 meets the minimum requirements by the department. The records include State Certification, background check and training required. Based on the documents review, the allegation that staff do not meet the minimum qualifications required, is deemed Unsubstantiated at this time. Exit interview was conducted, and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 9, 2024 · control 29-AS-20230508154924

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 refuse to let residents leave the facility. Staff tie/lock up resident doors. Residents in care are denied food.

Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent complaint unannounced visit to investigate the allegations listed above. LPA Urena met with Executive Director (ED) Marylou V. Mendoza and Assistant Administrator (AA) Virginia Sumulong, and explained the reason for the visit. On 05/09/2023, Licensing Program Analyst (LPA) Angel Ascencio conducted an initial 10-day complaint. LPA Ascencio met with Interim Administrator Rafael Silva at 10:08 a.m. Entrance interview conducted. During the visit, LPA Ascencio reviewed staff files at 11:00 a.m. and obtained pertinent documents. LPA Ascencio advised Interim Administrator Silva that the allegation of Personal Rights has been referred to the Department's Investigation Branch (IB) for further review. On 04/03/2024, at 11:05 a.m. LPA Urena requested additional records pertinent to the investigation, and at 11:20 a.m. the LPA interviewed the ED and the AA. At 12:15 p.m., the LPA observed lunch in the dining room and conducted residents’ interviews and staff interviews from 12:21 p.m to 2:30 p.m. Unsubstantiated Page 2. Staff tie/lock up resident doors. It is the concern of the Reporting Party(s) (RP) that staff are tying the doors up, so they cannot be opened by residents. LPA Urena interviewed staff and residents about front doors being tied up or locked. The ED and AA interviews revealed that the front doors are never locked/tied from the inside. However, the front doors are locked from the outside. Visitors must be buzzed in, and residents have the code to the front doors to gain access into the building. If the resident does not have the code, they get buzzed in. Five out of six residents’ interviews revealed that they have not experienced, nor have witnessed the front doors being tied up. One resident stated that they have experienced in the past, the front door being locked, but when they asked the front desk staff to unlock it, the door was unlocked. The resident added that they understood why it was locked at that time. The resident went on to explain that there are residents who may experience dementia and try to leave the building, and given the busy street and the traffic outdoors, the door was locked for their safety. Based on the information obtained through interviews, the allegation that staff tie/lock the residents’ doors is deemed Unsubstantiated at this time. Staff refuse to let residents leave the facility. It is the concern of the Reporting Party(s) (RP) that staff refuse to let residents leave the building by illegally locking facility doors at night, so residents are trapped in the facility. The ED and AA interviews revealed that the front doors are never locked from the inside. However, the front doors are locked from the outside. Six out of six residents’ interviews revealed that they have not experienced, nor have witnessed the front doors being locked at night. One resident stated that sometimes they hear commotion, when transients are pounding on the front doors trying to get in the building. The resident stated that they are glad the doors are locked from the outside for the safety of the residents. Based on the information obtained through interviews, the allegation that staff refuse to let residents leave the facility is deemed Unsubstantiated at this time. Continues on pg. 3 Page 3. Residents in care are denied food. On the allegation that residents are denied food, the RP(s) only stated that residents are being denied food. To investigate the allegation, the LPA observed lunch time at approximately 12:15 p.m. The LPA observed approximately fifteen (15) residents in the dining room, either eating on their own or residents were being fed by staff. Per the staff interviews, some of the residents were in an outing and took lunch bags; additionally four (4) residents receive their meals served in their room due to being bed bound. The interview with the ED, and the AA revealed that the residents either eat in the dining room or in their room. Some may eat in their room due to being ill and not able to go to the dining room, or due to being bed bound. Six out of six residents interviewed revealed that they have not been denied food, however one resident reported that when they ask for additional liquids/different meal, staff may say ‘wait, wait’. One resident stated that residents are given the menu on a monthly basis, and that if residents wish to make a specific meal request, the resident must write it down on a request slip prior to meal being served, preferably the day before, and give the request slip to the front desk staff, who then gives it to the to the chef assistant. The special meal request is then prepared and provided to the residents. The AA provided a copy of the menu for the month of April to the LPA. The LPA was able to review, compare and confirm the menu meal, as it was served during today’s lunch time. Based on the information received through interviews, and observation, the residents are being provided with meals that are reflected in the monthly menu. Therefore, the allegation that Residents in care are denied food, is deemed Unsubstantiated at this time. Exit interview was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 3, 2024 · control 29-AS-20230508154924

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

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Valeria Conway and Zabel Chochian conducted an unannounced Case management deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #29-AS-20240311081755. During the complaint investigation LPAs conducted a physical plan tour of the facility with Assistant Administrator from 10:00 a.m. to 11:15 a.m. to ensure there are no health and safety hazards and the following deficiencies were observed. During the physical plan tour LPAs met with Resident #1 (R1). R1 expressed concerns about wheelchair provided not having enough support and causing resident discomfort. Based on interview with R1, record review and interview with Assistant Administrator it was revealed that two (2) prescriptions for a new wheelchair from primary physician were issued since December 2023. As of today, R1 has not received a new wheelchair prescribed by physician. At approximately 10:25 a.m. LPAs observed Laundry room in second floor was unlocked and cabinets in the laundry room containing detergents, and chemical supplies were unlocked, unsupervised and accessible to residents. Also during the tour at approximately 11:02 a.m. LPAs observed Resident's 2 (R2) Room #11 door was wide open, nobody in the room at the time. LPAs observed resident's hygiene products/items such us body lotion and hand cream on a table along side the wall. Also, on top the night stand next to resident's bed LPAs discovered a container with scissors accessible to other residents. Although R1 is able to store personal hygiene items and not at risk, based on random records reviewed and interview with Administrators other residents are. Based on records review and the information obtained, the following deficiencies were observed. Pursuant to Title 22 of the CA Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 809-D) Exit interview conducted with Administrators. Today's reports, and appeal rights were discussed, and copy was provided.the state’s words, verbatim · CDSS document, Mar 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 13, 2024

Storage Space: Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observations, licensee did not comply with section above by not ensuring detergents, cleaning solutions and scissors are kept inaccessible to residents. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: Administrators agreed to provide in service training to staff and discuss with residents the importance of keeping personal items, which pose a dangerous to clients when accessible before POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR80072(a)(2) · Plan of correction due date: Mar 29, 2024

Personal Rights: Except for children’s..., each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations...and equipment to meet his/her needs.This requirement is not met as evidenced by: Based on record review and interviews, licensee did not comply with section above. R1's prescription order dated on 12/14/2023 and _____ for new wheelchair was not processed in a timely manner. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Mar 12, 2024

Plan of correction: Administrators agreed to follow up with medical supply company by upcoming Friday and have proof of outcome or resolution to R1 needs before POC due date

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Zabel Chochian responded to the facility to conduct a case management visit in response to the SOC341 submitted by the facility Administrator on 01/30/24. Upon arrival LPA met with Administrator Marilou Mendoza and Assistant Administrator Virgina Sumulong. Reason for visit was explained. The SOC341 indicated that Resident #1 (R1) alleged that they were sexually assaulted two-weeks ago by another facility resident (R2). An SOC 341 was also submitted by facility Administrator to Adult Protective Services (APS), Local Long Term Care Ombudsman (LTCO) and local law enforcement. Facility Administrator stated that she is currently working on submitting the incident report to Community Care Licensing (CCL). Administrator stated that Law Enforcement will be visiting facility today and once she gathers additional information she will submit the incident report to CCL. During today's visit, the LPA completed a brief physical plant tour, discussed case with Administrators and obtained copies of R1 and R2’s records. The Administrator was notified that this incident was referred to Community Care Licensing Investigation's Branch (IB) and assigned to Special Investigator Laarni Santiago and that further investigation is required. Exit Interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Jan 31, 2024

Type of visit: Required - 1 Year

On 01/27/2024, Licensing Program Analyst (LPA) Sandra Urena arrived unannounced to conduct a required annual inspection. The LPA met with staff, and explained the reason for the visit. Administrators are on call on the weekend. The administrator Virginia Sumulong arrived shortly thereafter. LPA Urena toured the physical plant areas inside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN/DINING ROOM: At 8:43 a.m., the LPA toured the kitchen area along with the facility's chef. The facility has a sufficient supply of non-perishable and perishable food items. Appliances appeared to be in operable condition. The menu was posted. The kitchen and dining room area was observed to be clean and in good condition. The fire extinguisher in the kitchen was served on 12/06/2023. The refrigerator and freezer were observed to be within the required temperatures of 40 degrees and 0 to below 0 degrees. Overall dining room temperature was kept at 71 degrees. This is part-one of the annual inspection. Due to time constraints, a continuation annual inspection visit will be conducted in the near future. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 27, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to deficiency observed during a visit to the facility today. LPA Yee met with Virginia Sumulong, Assistant Administrator. Rafael Silva, Administrator was also at the facility during the visit. Per review of the staff roster, staff file at 2:14pm, Guardian document provided during today's visit, Virginia Sumulong, who is also known as Virginia De Los Reyes was hired on 9/18/23 and has been present and working at the facility from September 18, 2023 through October 5, 2023 without being associated to the facility. The Administrator was made aware that Virginia Sumulong was not listed on the Personnel Report printed on 10/2/23 and he indicated that he would have to go on to Guardian to determine what happened. A report was provided to LPA Yee by the Administrator that indicated that Virginia De Los Reyes was previously associated to the facility on 5/4/2011 and disassociated on 4/3/23. Per verification with Licensing personnel, the association for Virginia De Los Reyes was completed today (10/5/23). The facility failed to ensure that Virginia was cleared and associated to the facility prior to being present at the facility from 9/18/23-10/5/23. Deficiency cited under California Code of Regulations, Title 22, Division 6, Chapter 8. CIVIL PENALTIES were assessed. Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was given.the state’s words, verbatim · CDSS document, Oct 5, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Oct 6, 2023

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or Per record review, Virginia Sumulong, aslo known as Virginia De Los Reyes, hired on 9/18/23, has been employed and present at the facility and has not been associated to the facility until it was brought to the Admnistrator's attention today-10/5/23. CIVIL PENALTIES of $500 were assessedthe state’s words, verbatim · CDSS document, Oct 5, 2023

Plan of correction: The Licensee will ensure that all staff, volunteers or individuals who are subject to a criminal record clearance have received a criminal record clearance and are associated to the facility prior to being present at the facility at all times. Virginia Sumulong was associated to the facility under the name of Virginia De Los Reyes through Guardian during the visit today. ***corrected at the time of the visit****

Allegation investigated: Licensee falsified residents' cash resource records. Resident cash resources were commingled with the facility funds.

This is an amended report to correct the dates of the initial 10-day visit by LPA Basili, and the complainant's interview. Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced subsequent visit to deliver the findings for the allegations above. The LPA arrived at 10:00 a.m., met with Molly Ayala, LVN, the facility representative, and explained the reason for the visit. On 03/15/2021, Licensing Program Analyst (LPA) Brian Balisi initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation visit was conducted telephonically at 11:00am with Elizabeth Flores, the facility Assistant Administrator. Between 12:30pm – 1:00pm, LPA Basili conducted telephone interviews with the administrator and a video call which consisted of a review of the physical plant. LPA also requested copies of census, staff schedule, admission agreement and resident documentation relevant to the investigation to be emailed to the LPA by end of business day. On 03/12/2021, LPA Basili interviewed the complainant at 11:15 a.m. Continues on LIC 9099C... Unsubstantiated Page 2. Licensee falsified residents' cash resource records. On the allegation that the licensee falsified residents’ cash resource records; it is the reporting party’s concern that some residents had their Personal and Incidental Needs allowance (P&I) records falsified by staff. It was alleged that staff would write down that the residents received more money than what was given to them. A financial audit was conducted, and a final audit report was completed on 08/29/2023. The audit review revealed that the documentation submitted by the facility and reviewed by the auditor, disclosed that the facility provided “petty cash” receipts to the residents. However, the facility’s cash handling policy and procedures described that, residents are to sign for their deposits and withdrawal on ledgers (LIC 405). Additionally, residents’ signature/initials were not found on the ledgers, only the accounting personnel typed initials were observed on the ledgers. This system does not allow for the resident to acknowledge their balance, which include deposits and withdrawal amounts. Residents should be able to see their ledger amounts to ensure they are free of error and deposits are entered in a timely manner. Residents were asked to sign the individual “petty cash slips” which do not allow the residents to be aware of the total amount they have and how much is credited/debited each month. Although the facility’s cash resource records were not documented appropriately, there is insufficient evidence to prove that the records were falsified. Based on the information obtained and reviewed, and although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed Unsubstantiated at this time. Resident cash resources were commingled with the facility funds. On the allegation that cash resources were commingled with the facility funds; it is the reporting party’s concern that the facility is mixing residents' Personal and Incidental Needs allowance (P&I) with staff’s payroll. The complaint was referred to the Community Care Licensing Audit Department. A financial audit was conducted, and an audit report was completed on 08/29/2023. The audit review revealed that all the checks for P&I were from the residents’ trust account. Continues on LIC9099 C- page 3... Page 3. Glen Park has a Trust Account to save and manage the personal and incidental cash the residents receive from various sources, the most common source being from family members or Social Security benefits, especially for those individuals needing assistance in managing their finances. Each facility has two Trust Accounts: one account for Regional Center residents and a second account for Social Security beneficiaries. Though the licensee kept the residents’ cash in the two trust accounts, their actual practice of having residents sign the “petty cash slip” made this process look like they were commingling residents’ funds with facility’s petty cash. After further investigation, it was noted that the facility has kept an inaccurate receipt for cash. However, no commingling of cash resources was noted. Therefore, the allegation is deemed Unsubstantiated at this time. An exit interview was conducted with facility representative. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 29, 2023 · control 29-AS-20210310091929

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case Management-Deficiencies visit due to deficiencies observed during the course of the audit investigation for C#29-AS-20210310091929. LPA Urena and Jessica Chen, General Auditor III (joined via Microsoft Teams) met with facility representative Molly Aayala, and explained the reason for the visit. During the course of the audit investigation for complaint C#29-AS-20220826155207, the Department’s Audit Section concluded the following three deficiencies: Deficiency #1: Safeguards for Resident Cash, Personal Property, and Valuables The audit review revealed the following -The facility’s cash handling policy and procedures describe that residents sign for their deposits and withdrawal on the ledgers (LIC 405). However, residents’ signature/initials were not found on the ledgers, only the accounting personnel typed initials were recorded on the ledgers. Residents are given a “petty cash slip” to sign when the residents receive cash. The “petty cash slip” is the only place a signature from the resident is obtained, which includes the business manager/staff initials/signature on the slip as facility representative. This system does not allow for the resident to acknowledge their balance including deposits and withdrawal amounts. Residents should be able to see their ledger amounts to ensure they are free of error and deposits are entered in a timely manner. Residents were asked to sign the individual “petty cash slips” which would not allow for the resident to be aware of the total amount they have and how much is credited each month. A LIC 405 ledger was maintained for each resident the facility handles cash for, however, the LIC 405 forms submitted for audit review appear to be entered by the accounting personnel at the corporate office, with accounting personnel initials typed in, and not at the facility.No residents’ signatures were observed on the LIC 405 ledgers, which is inconsistent with their policies and procedures. Continues on LIC 809C-page 2. Page 2. The licensee failed to maintain adequate safeguards and accurate records of cash resources and valuables entrusted to their care, including, but not limited to the following: (1) Records of residents' cash resources maintained as a drawing account shall include a ledger accounting (columns for income, disbursements, and balance) for each resident, and supporting receipts filed in chronological order. Deficiency #2: Surety Bond – Insufficient Coverage The audit review revealed the following -The auditor requested the surety bond from the licensee. The review of the surety bond revealed that the current coverage is for $11,000 thousand. No expiration date was shown on the certificate. Auditor made inquiry to the bond issuer if the bond was still valid and for the expiration date. The bond issuer responded that the surety bond is still valid until it’s next renewal date of 12/4/2023. However, audit review of the residents’ trust accounts noted that the facility normally safeguards between $44,000 to $53,000 per month. The amount of the surety bond shall be according to the following schedule: Amount safeguarded per month $1,501 to $2,500, bond required $3,000. Every further increment of $1,000 or fraction thereof shall be required to have an additional $1,000 on the bond.” The facility failed to maintain sufficient surety bond coverage to safeguard the residents’ resources. The current $11,000 surety bond coverage is not sufficient and needs to be increased for the amount that is being safeguarded. Deficiency #3: Some residents’ P&I were mishandled, due to lack of supporting documents for cash withdrawals, purchases, other deductions, and rent miscalculation. The audit review revealed the following- Based on documentation and information reviewed by the auditor, the facility handles cash resources for 16 residents, including 3 residents that the facility is the SSI representative payee. Admission Agreements, LIC 602 (Physician Report), financial ledger LIC 405 forms, “petty cash slips” and purchase invoices were requested and reviewed for the residents. Some cash withdrawals and purchases were not accepted for audit due to lack of supporting documentation. Instances noted, “petty cash slip” had no residents’ signature; invoiced amount disagrees with the recorded purchased amount; the “petty cash slip” were from dates out of the audit period. Continues on LIC 809C-page 3. Page 3. During the audit, the residents’ LIC 602 were reviewed, and it revealed that some residents are not able to leave the facility unassisted; are not even able to transfer to and from bed or have dementia. Although these residents do not leave the facility, there were frequent, and material amounts of cash withdrawals recorded on their ledgers and the petty cash slips. The auditor provided the facility the draft of audit working papers, listing questionable transactions, by resident. Auditor made inquiry regarding where, how, when, and who accompanied these residents to spend the cash. The facility did not provide an explanation or supporting documents. The withdrawals are not supported, and the facility is to refund the residents accordingly. The documentation submitted and reviewed disclosed that the facility mishandled some of the residents’ funds. The following amounts show the refund amount determined for each resident: R1-$424; R2-$60; R3-$270; R4-$253; R5-$1,055; R6-$290; R7-$502; R8-$20; R9-$0; R10-$910; R11-$438; R12-$760; R13-$130; R14-$1,678; R15-$1,584; R16-$664. TOTAL Refund for 16 residents: $9,038.00. Based on records review and the information obtained, the following deficiencies were observed. Pursuant to Title 22 of the CA Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 809-D) Citations were issued. Exit interview conducted with facility's representative. Today's reports, and appeal rights were reviewed, and issued.the state’s words, verbatim · CDSS document, Sep 29, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(g)(1) · Plan of correction due date: Oct 16, 2023

87217 (g)(1) Safeguards for Resident Cash, Personal Property, and Valuables. Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care, including, but not limited to the following...the resident's signature or mark, or responsible party's full signature...This requirement was not met. Based on record review, no residents’ signatures were observed on the LIC 405 ledgers, which is inconsistent with the facility's policies and procedures. The licensee failed to maintain adequate safeguards and accurate records of cash resources and valuables entrusted to their care, which poses a potential health and safety danger to persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Effective immeadiatly as 09/29/2023: Licensee must maintain a current and accurate account of resident's cash resource by using a ledger (LIC405) for each resident with income, disbursement, and balance with date of transaction, description and signature of the resident and the office representative involved with the transaction. The “petty cash” slips used need to be replaced with a “cash receipt”.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87216(1) · Plan of correction due date: Oct 16, 2023

Section 87216 (1) Bonding- Each licensee, other..., shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. The amount of the bond shall be in accordance with the …schedule. This reuirement was not met. Based on record review, the facility failed to maintain sufficient surety bond coverage to safeguard the residents’ resources. The current $11,000 surety bond coverage is not sufficient and needs to be increased for the amount that is being safeguarded. which poses a potential health and safety danger to persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee will submit proof of the amount increase of surety bond per the set schedule to CCLD office by 10/16/2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 387217(c)(1) · Plan of correction due date: Oct 16, 2023

387217 (c) (1) Safeguards for Resident Cash, Personal Property, and Valuables-Every facility shall account for any cash resources entrusted to the care or control of the licensee or facility staff, (1) Cash resources include … and personal and incidental need allowances from funding sources such as SSI/SSP. This requirement was not met. Based on record review, the withdrawals are not supported, and the facility is to refund the residents accordingly. The documentation submitted and reviewed disclosed that the facility mishandled some of the residents’ funds.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee is to refund the residents’ accounts for the amount as listed for each of the sixteen (16) residents. Proof of the refund (copies of cashed checks by residents) must be submitted to the CCLD office by 10/16/2023.