Glen Terra Assisted Living

Allegation investigated: Staff did not prevent resident from being physically harmed by another resident

On 04/14/26, at 8:40am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Executive Director, Carlos Lara. LPA explained the purpose of this visit was to gather information and deliver findings for this complaint. On 04/14/26, LPA Saucedo asked for the census, staff, and resident rosters. On 04/14/26, at 8:50am, LPA Saucedo conducted a physical tour. During the pre-investigation, on 04/09/26 and 04/10/26, LPA conducted resident and staff interviews. LIC 9099C-continued Unfounded Regarding the allegation: Staff did not prevent resident from being physically harmed by another resident. It is being alleged that Resident #1 (R1) was physically and verbally abused as they were being transported in the van back to the assisted living facility where R1 lives by Resident #2 (R2). During LPA’s interview with R1, R1 stated, “R2 told them to shut up then R2 hit them on the arm and facial area with a newspaper and their glasses fell.” LPA asked in what van did this happen and R1 stated, “it was in the day program van.” During LPA’s interview with R2, R2 stated, “they don’t remember hitting R1.” Furthermore, LPA interviewed Staff #1 (S1) whom stated, “that R2 hit R1 during the transport back to the facility.” LPA asked if the transportation van belonged to the facility and S1 stated, “no, it was from PACE WElBEHEALTH van.” Let it be noted, R2 did hit R1 but it did not happen at the assisted living facility, and it did not happen in the assisted living facility van. Therefore, based on the interviews conducted the allegation is UNFOUNDED at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and a copy of this report issued to the Executive Director.the state’s words, verbatim · CDSS document, Apr 14, 2026 · control 31-AS-20260408144111

Allegation investigated: Staff do not provide snacks to residents in care

Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver finding of the above noted allegation. LPA met with ED and explained the reason for this visit. During this visit at approximately 10:00a.m., LPA and ED conducted a physical plan tour and observed no health and safety issues. It was alleged that facility does not provide any free snacks to residents in between meals or at bedtime. Resident #1 (R1’s) caregiver phoned the daytime receptionist to request snacks because R1 was hungry. To investigate the allegation, during initial visit on 01/09/26 at approximately 10:00a.m., LPA requests and received copies of the facility resident and staff rosters. Between 10:45a.m. – 2:30p.m., LPA interviewed ED, Chef, Staff #1- 2 (S1-S2) and nine (9) out of ninety-three (93) residents. Interviews with residents revealed that snacks are not routinely provided between meals. If they feel hungry Cont. on LIC 9099-C Substantiated Cont. from LIC9099 outside of scheduled mealtimes, they must buy a snack from the vending machine or go to the market. Staff interviews reveal that snacks are not consistently offered to residents and are not part of the facility’s regular daily meal schedule. Administrator indicated that in the past there was a resident that would take all the snacks and since then snacks have not been readily available or accessible to residents. During the visit on 01/09/26, LPA conducted a tour of the facility kitchen and Coffee Room and did not observe any snacks readily available or accessible to residents between scheduled meals times in the Coffee Room. At the time of the visit the Coffee Room only had a vending machine selling snacks, there was no designated snack area or other common areas where residents could get snacks. There was no written documentation/notification posted in prominent areas indicating that snacks are regularly offered or available to residents. During inspection, LPA observed a schedule of mealtimes as follows; Breakfast time- 7:45am - 10:00am, Lunch time 11:30am – 1:00pm, Dinner time 4:30pm - 6:00pm. Snacks and refreshments (no time frame) are provided in Coffee Room. A review of the facility’s posted menu did not reflect the provision of snacks between meals. Based on observation, interviews, and records reviewed, the facility failed to ensure that snacks are available and offered to residents between meals. Therefore, the allegation is SUBSTANTIATED at this time. Exit interview conducted/Citations issued on 9099-D/Appeal rights/Copy of report given.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 31-AS-20260102091923

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(3) · Plan of correction due date: Apr 8, 2026

87555(b)(3) General Food Service Requirements(b) The following food service requirements shall apply: (3) Between meals nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician. This requirement is not met as evidenced by. On 01/09/26 and before licensee failed to ensure that snacks are available or accessible to residents between meals.the state’s words, verbatim · CDSS document, Mar 18, 2026

Plan of correction: By POC due date, the licensee wil submit a written plan describing how snacks will be consistently available between meals. The facility menu will be updated to include snacks times and options, and a current weekly menu with snack information will be submitted to CCLD.

Allegation investigated: Facility staff did not prevent a resident from threatening another resident

Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver finding of the above noted allegation. LPA met with ED and explained the reason for this visit. During this visit at approximately 10:00a.m., LPA and ED conducted a physical plan tour and observed no health and safety issues. It was alleged that on 10/30/25, the resident #1 (R1) was threatened by another facility resident #2 (R2) to "beat them up" and wanted to "go outside" to fight. R2 also used "explicative language". About a month ago, there was a disagreement in the dining room over seating involving R1 and R2. To investigate the allegation, during initial visit on 11/04/25 at approximately 10:15a.m., LPA requests and receives copies of the facility resident and staff rosters, copies of R1 & R2 Physician Report, Identification Emergency Information, Appraisal/Needs & Services Plan and other pertinent documentation. Between Cont. on LIC 9099 -C Unsubstantiated Cont. from LIC 9099 11:30a.m. – 3:45p.m., LPA interviewed ED, other staff and four (04) out of one hundred one (101) residents including R1, R2 and other residents that have knowledge of the incident. ED and other staff revealed that staff did not witness any incident of verb altercation between R1 and R2. R2 came and reported to staff that while R2 and three (3) other residents were sitting outside having a conversation, R1 walked towards them and accused R2 of talking about R1. R2 denied the accusation and told R1 to leave them alone and continue talking with R3. R1 walked away. Staff never received any complaints from R1 regarding the incident. R1 did not want to talk to staff about it. During interviews R1 revealed inconsistent statements regarding the incident. R2 and other residents present during incident verified the information received from staff. A review of residents’ records and other internal documents did not reveal any pertinent information to verify the allegation. Overall investigation revealed that although there was an incident involving R1 and R2, there is no sufficient information and/or evidence to verify that R2 threatened R1. Therefore, based on interviews and record review, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard noted during this visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 31-AS-20251030144748

Allegation investigated: Staff do not prevent resident from physically assaulting another resident

At 7:15a.m., Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver finding of the above noted allegation. LPA met with Housekeeper, Maintenance and granted entry to the facility. LPA explained the reason for this visit. At 7:35a.m., LPA and Maintenance conducted a physical plan tour and observed no health no safety issues. It was alleged that on or around 10/28/2025, resident #1 (R1) was physically assaulted by Resident#2 (R2) and staff only spoke with R2 and did not further address the matter. To investigate the allegation, during initial visit on 11/04/25 at approximately 10:15a.m., LPA requests and receives copies of the facility resident and staff rosters, copies of R1 & R2 Physician Report, Identification Emergency Information, Appraisal/Needs & Services Plan and other pertinent documentation. Between 11:30a.m. – 3:45p.m., LPA interviewed ED, DCR and four (04) out of one hundred one (101) residents including R1, R2 and other residents that have knowledge of the incident. Involving R1 and R2. Cont. on LIC 9099-C Unsubstantiated Cont. from LIC 9099-C ED and other staff revealed that they had knowledge of the incident. However, there was no physical altercation between R1 and R2. According to staff, even though R2 has health condition that reflect their physical and mental condition, R2 is not combative towards others. R2 likes to walk around and at times walks to close to other residents. On 10/25/25, R2 walked towards R1 and asked for candy. R1 refused and R2 threw water on R1. Staff immediately intervened and redirected R2. Police was called by R1 and no report was filed, due to absence of verifiable information. During interviews with R1 revealed inconsistent statements regarding the incident. R1 was unable to clearly describe the events. LPA attempted to speak with R2 and she was unable to respond to LPAs questions. A review of residents’ records and incident reports verified the information revealed from staff. Overall investigation revealed that although there was an incident involving R1 and R2, there is no sufficient information and/or evidence to verify that there was physical altercation between residents. Therefore, based on interviews and record review, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard noted during this visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 31-AS-20251029102336

Allegation investigated: Facility staff hit client with an object, resulting in bruising

At 7:15a.m., Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver finding of the above noted allegation. LPA met with Housekeeper, Maintenance and granted entry to the facility. LPA explained the reason for this visit. At 7:35a.m., LPA and Maintenance conducted a physical plan tour and observed no health no safety issues. At about 9:00a.m. Executive Director (ED) joined us. During initial visit on 07/16/25 at approximately 9:15a.m., LPA requests and receives copies of the facility resident and staff rosters, copies of the staff schedule, staff contact information and other pertinent documents. At 9:30a.m., ED and LPA conducted a physical plant walk-through. Between 11:30a.m. – 1:15p.m., LPA interviewed ED, four (04) out of one hundred one (101) residents and about 3:35pm., LPA interviewed two (02) staff. LPA asked questions relevant to the investigation. LPA request copies of resident #1 (R1) Physician Report, Identification & Emergency Information, and other pertinent documentation. Cont. on LIC 9099-C Unsubstantiated Cont. from LIC 9099 During subsequent visits on 11/04/25 between 11:30a.m. – 3:45p.m., LPA interviewed additional three (03) out of one hundred one (101) residents and on 01/06/26 LPA interviewed three (03) additional residents via -phone. Prior to this visit on 12/20/25 LPA Alvizar-Ettima reviewed records and other documentation obtained during the initial visit. Facility staff hit client with an object, resulting in bruising It was alleged that during nighttime hours, a staff member became upset because Resident #1 (R1) was out of bed. R1 reported that staff folded R1's walker and began swinging toward R1. R1 states they blocked the walker with the back of their hand, resulting in bruising to the back of both hands. During interviews with R1 revealed inconsistent statements regarding the incident. R1 appeared confused and was unable to clearly describe the events. R1 later stated they may have hurt themselves but could not provide specific details. Staff #1 (S1) and Staff #2 (S2) denied hitting R1. Both staff reported R1 was confused, attempting to leave the facility at night, throwing personal belongings, yelling, and exhibiting agitated behavior. Staff reported attempts to redirect R1 back to bed. S2 reported hearing R1 state, “Oh, I hurt myself,” but did not witness an injury occur. The Executive Director reported R1 has a history of nighttime confusion and behavioral episodes and denied staff misconduct. During interviews with residents, ten (10) out of one hundred one (101) residents reveal staff has not hit them and did not observed staff hitting R1. Resident #2 (R2) reported R1 is outspoken and has a history of agitation but R2 did not witness the incident. During facility visits, LPA observed staff present in resident areas, engaged in resident care activities, and responsive to resident needs. No inappropriate staff conduct was observed. Facility records indicated R1 has mild cognitive impairment and is not permitted to leave the facility unassisted. Based on interviews, observation and review records, there is insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazard noted during this visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 31-AS-20250714163010

Allegation investigated: Insufficient staffing to meet resident needs

At 7:15a.m., Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced subsequent visit to deliver finding of the above noted allegation. LPA met with Housekeeper, Maintenance and granted entry to the facility. LPA explained the reason for this visit. At 7:35a.m., LPA and Maintenance conducted a physical plan tour and observed no health no safety issues. At about 9:00a.m. Executive Director (ED) joined us. During initial visit on 07/16/25 at approximately 9:15a.m., LPA requests and receives copies of the facility resident and staff rosters, copies of the staff schedule, staff contact information and other pertinent documents. At 9:30a.m., Between 11:30a.m. – 1:15p.m., LPA interviewed ED, four (04) out of one hundred one (101) residents and about 3:35pm, LPA interviewed two (02) Night shift staff. LPA asked questions relevant to the investigation. Information received revealed that within the months of June and July 2025 two (02) out of three (03) night shift staff were not available for work for different reasons. Cont. on LIC 9099-C Unsubstantiated Cont. from LIC 9099-C Therefore, to verify if facility had appropriate coverage for staff shortages during night shift, LPA requested a revised staff schedule for the month of June and July 2025 to determine appropriate staff coverage. On 11/04/25 between 11:30a.m. – 3:45p.m., LPA interviewed additional three (03) residents and on 01/06/26 LPA interviewed three (03) more residents via -phone. Prior to this visit on 12/20/25, LPA Alvizar-Ettima reviewed the documentation previously obtained from the facility Insufficient staffing to meet resident needs It was alleged that there are insufficient staff members to provide for care and supervision for all residents residing in the facility. There are only two (02) night shift caregivers for the entire facility. During mealtime in the dining room, residents’ food is served by the caregivers instead of kitchen staff. Interview with Executive Director revealed that for night shift there are always no less than two (02) staff and no more than three (03) staff working. Plus, five (05) evening shift staff may work double shifts to cover shortage of night shift staff. Executive Director also stated that caregivers are trained in Dining Room procedures and permitted to assist with meal service as part of their job duties. Four (04) facility staff (S1-S4) interviewed during investigation, confirmed the information provided by Executive Director. Staff confirmed that evening shift staff work double shifts to assist night shift if needed. As a part of their job duties, caregivers also assist residents in the dining room. Meal service duties are not compromising resident supervision or care. Residents did not address any concerns regarding staff shortages. During facility visits, residents were observed to be appropriately supervised, and staff were present and engaged in resident care activities. LPA observed caregivers present in resident areas, responsive to resident requests, and assisting them as needed. A review of documents provided by Executive Director verified the information revealed from staff interviews. No information or evidence was obtained to corroborate with the allegation. Based on observation, interviews and records review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 31-AS-20250708134009

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced One (1) year Required visit at this facility. LPA met with Executive Director Carlos Lara and explained the reason for the visit. At 9:23 AM, with the assistance of the Executive Director, LPA toured the facility inside and out and the following was observed: The facility is a four (4) storey building fire cleared for 155 non-ambulatory residents, four (4) of which may be bedridden and has hospice waiver for twenty (20) residents. The facility had submitted and approved Mitigation and Infection Control plan. The facility's smoke alarms are hard wired and interconnected. Last testing, which includes the sprinklers, fire door, alarms and exit light was completed on 12/12/24. Fire/earthquake and emergency evacuation drill is conducted on monthly basis for different shift and the last one was conducted ton 08/13/25. The fire extinguishers throughout the facility hallways are on all four (4) floors, all extinguishers were last serviced on 05/20/25. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility and properly stored. Residents do not have access to the kitchen. Listing for residents that require a special diet is posted on the kitchen wall. There were no pesticides or poisons observed near any food areas. Kitchen/food service staff observed with gloves and proper hair cover. Bedrooms: Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings and grab bars and nonskid surfaces in the bathrooms. Emergency push button was tested for proper function. Bathrooms: Resident bathrooms were properly supplied and had functional fixtures. Hot water temperature in random resident bathrooms on all floors were checked and measured at a range of 113.0°F to 117.5°F. Common Areas: Common areas, including the lobby, activity rooms, dining rooms, and reading room appeared clean and were properly furnished. There is a coffee/hot beverage station at the reading room. Salon was closed and locked during the day of the visit. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor/patio areas are located at the front and beside the dining room. There is no body of water in the facility Laundry: Each floor has it's own designated laundry area for personal clothing of residents. The main laundry area is located on the 1st floor beside the employees' lounge. All the laundry areas were locked during the day of the visit. Staff Office/Work Station: Administrator's office is located on the first floor, by the entrance. Medication room and nurses' office on the second floor. Resident Files: LPA conducted a file review of resident records. Residents records observed to be complete and updated. Staff Files: LPA also conducted a file review of staff records. Staff records observed to be complete and updated. Medications: There are medication carts stationed at the medication/nurses' room. There is a refrigerator, with lock, in the medication room to store medicine that requires cooler temperature. Medication room is also locked at all times. Medication documentation and implementation appeared to be complete. There is a First aid kit on each medication cart and another by the reception area. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of this Report Issued.the state’s words, verbatim · CDSS document, Sep 21, 2025

Allegation investigated: Due to lack of supervision, resident had multiple falls with injury.

At 10:00 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced subsequent complaint visit. LPA met with the Executive Director Carlos Lara and explained the reason for the visit. To investigate the allegation above LPA Rahimi, conducted an initial visit on 03/20/2025. During course of the investigation, interviews and record review were made. At 10:10 AM, LPA requested client and staff roster. At 10:15 AM, LPA requested copies of pertinent information which include, but not limited to Physician’s Report, Admission Agreement, Appraisal Needs and Services Plan, etc., relevant to the investigation. At approximately 10:25 AM, LPA conducted a physical plant tour. Between 10:40 AM – 3:40 PM, LPA conducted an interview with the Executive Director (ED), a MedTech, a Licensed Vocational Nurse (LVN), two (2) staff, a Housekeeper, and eight (8) residents. During today’s visit, between 10:30 AM to 11:45 AM, LPA conducted additional interviews with five (5) residents. Continue on LIC 9099C Substantiated Due to lack of supervision, resident had multiple falls with injury. It was alleged that due to lack of supervision, Resident #1 (R1) had multiple falls with bruises and not enough assistance was provided based on R1’s need. To investigate this allegation on 03/20/2025, LPA conducted interviews with the Executive Director, Wellness Director/LVN, and two MedTechs, and it was revealed that R1 only had one known fall on 03/11/2025 and proper assistance was being provided by assessing R1 for injuries and pain. Additionally, on 03/12/2025, R1 was offered to be taken to the hospital; however, R1’s family refused to let the facility take R1 to the hospital and instead took R1 to the hospital themselves. Furthermore, LPA reviewed R1’s medical records and observed that on 03/13/2025, R1 was provided wound care consult at the hospital. During the wound care consult, it was revealed that due to the falls R1 had bilateral arms bruising and abrasions, redness to left breast, bilateral groin and perineal areas, right foot bruising on dorsal and planar area, and left knee/leg abrasion. Moreover, during the initial visit, LPA conducted a file review of R1 and observed that last Physician report was dated 05/23/2023, and R1 was diagnosed with Mild Cognitive Impairment and Fibromyalgia (impaired balance and muscle weakness). LPA also did not observe that the facility either notified R1's Physician nor updated the Appraisal Needs and Services Plan to meet and address R1’s needs appropriately. Lastly, during the initial visit on 03/20/2025, LPA interviewed eight (8) out of nine (9) residents, who confirmed that not enough assistance is being provided to meet their needs. During today’s visit, LPA interviewed five (5) additional residents and one (1) out of five (5) residents interviewed stated that their care needs are not being met. Therefore, based on interviews, medical records review, and R1's facility file review this allegation is Substantiated. Deficiency issued and appeal rights explained. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Sep 18, 2025 · control 31-AS-20250314081909

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 25, 2025

87468.1 Personal Rights of Residents in All Facilities- (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful..... . This requirement is not met as evidenced by: Based on the interviews, medical record review and R1's facility file review the facility did not ensure to provide proper/enough care to R1 to prevent multiple falls which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: The Executive Director agreed to provide staff training on Personal Rights of Residents and will provide copy of the training materials to RO/LPA by the POC due date, which is 09/25/2025.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control #31-AS-20250314081909. LPA met with Carlos Lara, Executive Director and explained reason for the visit. During the visit, LPA conducted file review of R1 and observed that R1 is diagnosed with Mild Cognitive Impairment and Fibromyalgia (impaired balance and muscle weakness) as of 05/23/2023; however, no new Physician report was obtained or updated for any changes of Cognitive Impairment or Fibromyalgia. Furthermore, the facility did not notify R1's Physician nor updated the Appraisal Needs and Service Plan for R1 to meet their needs. LPA observed that the Appraisal Needs and Services Plan was last updated on 10/14/2020. Moreover, LPA was informed that R1 was transported to hospital for Acute UTI, Intertrigo, and multiple falls on 03/11/2025; however, no incident report was submitted to the Community Care Licensing Department (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Executive Director admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. LPA informed the Executive Director to submit an incident report that occurred on: 03/11/2025 (one incident) Deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Sep 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Sep 25, 2025

87463-Reappraisals- (a)The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first,......This requirement is not met as evidenced by: Based on record review and interviews the licensee did not comply with the section cited above by not updating R1's Appraisal Needs and Services upon observing change in condition which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: Executive Director agreed to complete and update Appraisal Needs and Services Plan for all the residents and provide training to all staff to meet all residents needs accordingly. The proof of completion should be communicated with LPA via e-mail by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)A,B&D · Plan of correction due date: Sep 25, 2025

Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's hospitalization on 03/11/2025, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 18, 2025

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's incident report shall be submitted to LPA by POC date.

Allegation investigated: Staff did not ensure the facility was free from pests.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegation. LPA met with Executive Director, Carlos Lara, and explained the reason for the visit. ---Staff did not ensure the facility was free from pests. It was alleged that there was a cockroach seen on the wall of the third-floor hallway and that an unidentified resident confirmed facility has cockroaches. LPA conducted a physical plant tour at around 1:15p.m., requested pertinent documents at around 2:15 PM, interviewed three (03) staff from 2:45 PM to 3:45 PM and interviewed ten (10) residents from 4:00p.m. to 5:30p.m. During the physical plant tour, LPA did not observe any cockroaches in the facility. (CONT. on LIC9099-C) Unsubstantiated A review of the facility’s maintenance records show that facility’s most recent fumigation was 04/01/2025. During interviews with staff, Staff #1 (S1) stated they have had cockroaches in the past and every now and then a water bug might find its way in, but facility gets regular pest control and have not had any issues lately. S1 added that nothing has been reported in recent days. All other staff stated they have not witnessed cockroaches on the third floor or anywhere in the facility. During interviews with residents, one (01) out of ten (10) residents stated they saw cockroaches in the facility recently. All other residents stated they did not observe cockroaches in the facility. Based on observations, record review and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Apr 25, 2025 · control 31-AS-20250423144330

Allegation investigated: Staff did not prevent resident from developing a pressure injury Staff does not ensure resident receives adequate incontinence care Staff allowed resident to sleep in a wheelchair overnight

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegations. LPA met with Administrator Carlos Lara and explained the reason for the visit. It was reported that staff did not prevent resident from developing a pressure injury. To investigate the allegation on 8/20/2024 between 10:30am and 11:30am, staff interviews were initiated. Interviews revealed that Resident #1 (R1) does not have a pressure injury. R1 has a fungal infection on their buttocks that is being treated by home heatth care. Between 11:30am and 12pm, LPA reviewed facility records. Records confirmed what staff told LPA. Based on interviews and records review there is not sufficient information to support this allegation. Thus, ths allegation is UNSUBSTANTIATED att this time. Continue on 9099-C Unsubstantiated It was alleged that staff does not ensure resident receives adequate incontinence care. It was reported that R1 was left in a wet diaper for an extended period of time. To investigate this allegation on 08/20/2024 between 10:30am and 11:30am, staff interviews were initiated. Interviews revealed that staff change residents diapers every two hours or as often as needed. R1 is checked on more often by staff since they have a history of skin breakdown and due to their diagnosis of diaper dermatitis. Between 11:30am and 12pm, LPA reviewed facility records. Records confirmed what staff told LPA. LPA attempted to interview R1, but they were not able to answer any questions. Based on interviews and records review there is not sufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. It was reported that staff allowed resident to sleep in a wheelchair overnight. To investigate this allegation between 10:30am and 11:30am, staff interviews were initiated. Interviews revealed that night staff constantly check on residents throughout the night and do not allow residents to sleep in their wheelchairs. In addition, staff indicated that R1 has a history of making up stories in order to get attention. Based on interviews there is not sufficient information to support the allegation. Thus, the allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 20, 2024 · control 31-AS-20240815143315

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced annual inspection visit. LPA met with Administrator Carlos Lara. The purpose of the visit was explained. Facility is licensed to served 155 non - ambulatory residents, of which 4 may be bedridden and has a hospice waiver for 20 residents. Facility is a 4 story building, with a lobby, dining room, 2 activity rooms, a kitchen, a small outdoor shaded patio, medication room is on the second floor, and a salon in the third floor. Fire alarm sprinkle system was observed throughout the facility. There are no large bodies of water on the premises. LPA Valenzuela conducted a walk through with the Administrator and observed the following: Facility is clean and free of odors in common areas. Elevators are in working condition. All bedrooms have the proper bedding, and furniture. The facility maintains a comfortable temperature at 78 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There are carbon monoxide detectors in the facility. Fire extinguishers are located throughout the facility and were last serviced in May of 2024. The bathrooms were checked for cleanliness and proper operation. LPAs observed the appropriate grab bars in the showers and toilets. The hot water temperature was measured at 115.6 degrees. LPA observed seven days worth of perishable and non-perishable food. There are three complete first aid kits. Exit interview conducted. A copy of this report was issued and signature obtained. No deficiencies were issued at this time.the state’s words, verbatim · CDSS document, Aug 19, 2024

Allegation investigated: Staff are not meeting residents diapering needs Staff are not responding to residents call buttons in a timely manner

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegations. LPA met with Executive Director Carlos Lara and explained the reason for the visit. LPA conducted physical plant tour at 9:30 AM, requested copies of facility documents relevant to the investigation at 10:33 AM, reviewed documents from 10:45 AM to 11:40 AM and interviewed staff and residents between 12:00 PM to 2:00 PM. Regarding the allegations that staff are not meeting residents diapering needs, it was alleged that Resident #1 (R1) has been left in soiled diapers for about 1-2 hours. LPA's interview with R1 today at 1:20 PM revealed that revealed that staff are changing R1's diaper regularly and on time for at least 3-4 times a day including nights and denied being soiled for one (1) to two (2) hours. Further interview also revealed that staff are checking on R1 regularly. LPA's interview with six (6) incontinent residents today between 12:00 PM to 2:00 PM revealed that staff changed their diaper regularly 3-4 times a day. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) Regarding the allegation that Staff are not responding to residents’ call buttons in a timely manner, it was alleged that R1 waited for 45 minutes to an hour before someone respond to R1's call. LPA's interview with R1 today revealed that whenever R1 pushed own call button, staff respond within ten (10) minutes at most. LPA's interview with three (3) residents on 03/27/24 at 12:00 PM to 1:30 PM and eight (8) residents today between 12:00 PM to 2:00 with a total of eleven (11) total residents interviewed, six (6) of which are incontinent, revealed that ten (10) out of eleven (11) residents stated that staff respond to call button within reasonable time or within three (3) minutes to a maximum of fifteen (15) minutes. One (1) out of eleven (11) resident interviewed did not use the call button while living at the facility. Based on the information gathered during this and prior visit, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jul 12, 2024 · control 31-AS-20240319091602

Allegation investigated: Staff did not ensure the facility was free from pests

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit to this facility to investigate the above allegation. LPA met with Executive Director Carlos Lara and explained the reason for the visit. LPA conducted a physical plant tour at 9:12 AM, requested copies of facility documents relevant to the investigation at 10:01 AM, reviewed records between 10:30 AM to 12:00 PM and interviewed residents between 12:00 PM to 1:30 PM. Regarding the allegation that the staff did not ensure was free from pests, it was alleged that Reporting party (RP) heard staff complaining that there are roaches in the kitchen and that RP saw roaches in the kitchen cabinet and bathrooms. During this visit, LPA toured the kitchen, random residents' room and common bathroom at 9:12 AM and did not observe any roach or pests on any of the areas visited. LPA's interview with four (4) kitchen staff today between 12:00 PM to 1:30 PM also revealed that all four (4) of them did not see any roach or any pests inside the kitchen and that they always clean the kitchen at every end of the shift. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 90990 Further, LPA’s interview with the Kitchen supervisor and the Executive director today between 12:00 PM to 1:30 PM also revealed that kitchen is being fumigated/treated by their contracted pest control once a month or more during summer to avoid any infestation in the kitchen. LPA's record review confirmed that the facility has a contracted pest control company that visits the facility once a month to treat/fumigate reported rooms, common areas and random rooms to avoid any kind of infestation. LPA's interview with nine (9) residents or 10% of the current census between 12:00 PM to 1:30 PM revealed that nine (9) out of nine (9) residents did not see any roaches in their room or any common areas of the facility. Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Mar 27, 2024 · control 31-AS-20240319091602

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 are not providing basic care to resident

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegation. LPA met with Administrator Carlos Lara and explained the reason for the visit. It was reported that staff are not providing basic care to resident. To investigate this allegation on 02/20/2024 between 1:10pm and 2:00pm, staff interviews were initiated. Interviews revealed that Resident #1 (R1) is being well taken care of and is also receiving Hospice services. From 2/05-2/10, R1 had been experiencing diarrhea. Both the facility and their responsible party were aware of the situation. Facility informed responsible party that R1 probably required antibiotics to treat the diarrhea. R1's responsible party did not want them to take antibiotics. Moreover, responsible party wanted R1 to take a natural remedy. Facility told responsible that the facility could not administrator any medication without a medical order. R1's responsible party became upset with facility staff, but then agreed to R1 taking antibiotics. Between 2:00pm and 2:45pm, LPA reviewed facility records. Records confirmed that R1 is receiving Hospice services and that R1 was treated for diarrhea and is now stable. Between 3:50pm and 4:00pm, LPA saw R1 in the front lobby. Unsubstantiated LPA observed R1 to be clean, well nourished, and in good spirits. Based on interviews, records review, and observation, there is not sufficient information to support this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. No health and safety issues noted at the time of this visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Feb 20, 2024 · control 31-AS-20240212090733

Allegation investigated: Staff do not ensure infection control plans are followed for residents in care Staff do not ensure residents personal property is adequately disinfected

Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced complaint investigation for the above noted allegations. LPA met with Exexcutive Director Carlos Lara and explained the reason for vist. It was alleged that staff do not ensure infection control plans are followed for residents in care. It was reported that two residents have scabies. To investigate this allegation on 11/27/2023, between 1:00pm and 2:00pm, staff interviews were initiated. Interviews revealed that Resident #1 (R1) and Resident #2 (R2) have been itchy and scratching their skin, but that neither of the two residents have been diagnosed by a medical doctor for scabies. They have both been given medicated creams to help alleviate the itchy skin. Both residents are doing better and scratching less often. Between 2:00pm and 2:30pm, LPA reviewed facility records. Records did not reveal that either R1 or R2 have scabies or have been diagnosed with scabies. Continue on 9099-C Unsubstantiated Based on interviews and record review there is not sufficient information to verify this allegation. Therefore, this allegation is UNSUBSTANTIATED at this time. It was alleged that staff do not ensure residents personal property is adequately disinfected. It was reported that the all the residents clothes are washed together and not separated from those that have scabies. To investigate this allegation between 1:00pm and 2:00pm, staff interviews were initiated. Interviews revealed that residents clothes are washed separately, but the linens and towels are not. The washing machines and dryers are pre-set to hot temperatures to make sure everything gets disinfected. In addition, if the towels or linens are white, bleach is also added to the wash. There are six washing machines and there is a schedule that each resident has as to when their clothes gets washed. Currently, the facility does not have any residents with an active case of scabies. Between 3:15pm and 3:30pm, LPA went to inspect one of the laundry rooms. LPA observed more that one washing machine and staff washing residents clothes separately. Based on interviews and observation, there is not sufficient information to support this allegation. Thus, this allegation is UNSUBSTANTIATED at this time. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Nov 27, 2023 · control 31-AS-20231120120707