Golden Care Living III

Type of visit: Case Management - Other

On 1/8/2026, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD), Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit and met with Caregiver, Carmelita Bonifacio. The purpose of the visit was explained, and the LPA was allowed entry to the facility. LPA reviewed Personnel Report dated 01/01/2026. No citations were provided. An exit interview was conducted, and a copy of this report was provided to the Caregiver, Carmelita Bonifacio.the state’s words, verbatim · CDSS document, Jan 8, 2026

Type of visit: Case Management - Other

This report supersedes the LIC809 Case Management – Other dated 10/27/2025. On 10/27/2025, Licensing Program Analyst (LPA) Socorro Leandro made an error by creating an LIC809-D page. LPA Leandro did not provide a citation to the facility. On 10/27/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit and met with the Administrator, Angelique Gradney. The purpose of the visit was explained, and the LPA was allowed entry to the facility. LPA reviewed 6 residents physicians reports, appraisal and needs services plans, appraisals and re-appraisals. An exit interview was conducted, and a copy of this report was provided to the Administrator, Angelique Gradney.the state’s words, verbatim · CDSS document, Nov 14, 2025

Type of visit: Case Management - Other

On 10/27/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit and met with the Caregiver, Carmelita Duenas Bonifacio. The purpose of the visit was explained, and the LPA was allowed entry to the facility. LPA received copies of residents physicians reports, Personnel Report, and Register of Facility Residents. No citations were provided. An exit interview was conducted, and a copy of this report was provided to the Caregiver, Carmelita Duenas Bonifacio.the state’s words, verbatim · CDSS document, Nov 14, 2025

Type of visit: Case Management - Other

On 10/27/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit and met with the Administrator, Angelique Gradney. The purpose of the visit was explained, and the LPA was allowed entry to the facility. LPA reviewed 6 residents physicians reports, appraisal and needs services plans, appraisals and re-appraisals. An exit interview was conducted and a copy of this report was provided to the Administrator, Angelique Gradney.the state’s words, verbatim · CDSS document, Oct 27, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 28, 2025

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requierment wasthe state’s words, verbatim · CDSS document, Oct 27, 2025

Type of visit: Case Management - Other

On 05/07/2025 at 9:45 A.M., LPA Pamela Bunker conducted an unannounced Case Management visit. LPA Bunker met with Assistant Administrator Rodolfo Lozada and spoke to Licensee Angelique S. Gradney via telephone, and the purpose of the visit was explained. LPA was granted entry to the facility. On 05/07/2025, the department investigated a Complaint Report, dated 01/31/2024, Control #11-AS-20240131103123, regarding the allegation that Resident #1 (R1) went to the hospital with serious wound issues: Stage 3, Stage 4, and unstageable wounds. On 05/07/2025, Staff members reported that R1 was referred to Golden Care Living III from a facility that was closing. R1 was admitted to the facility on 10/14/2023 and was already receiving wound care treatment for pressure wounds at the time of admission from Legend Home Health, from 02/17/2023 - 01/25/2024, prior to being admitted to Golden Care Living Ill. Upon admission, the resident presented with a pre-existing decubitus ulcer in the buttocks and groin area. The nurse and primary care physician remained in constant communication throughout the resident's entire stay at the facility. Licensee Angelique S. Gradney and Assistant Administrator Rodolfo Lozada confirmed that R1 was admitted with Stage 1 and Stage 2 wounds. On 01/25/2024, R1 was hospitalized at Torrance Memorial Medical Center under the care of Legend Home Health Care, Inc., due to worsening wound conditions, including Stage 3, Stage 4, and unstageable wounds. Although R1 was receiving Home Health Services, R1 was not in hospice at the time of admission. See continued LIC809-C page 3 Continued LIC809-C page 2 According to the California Code of Regulations, Title 22, Division 6, Chapter 8. LPA observed the following deficiencies: The facility is being cited on the attached LIC809-D. An exit interview was conducted, and appeal rights were issued and covered with the facility Assistant Administrator, Rodolfo Lozada.the state’s words, verbatim · CDSS document, Aug 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87615(a)(1) · Plan of correction due date: Aug 5, 2025

87615 (a) Prohibited Health Conditions: Persons who require health services for or have a health condition including, Stage 3 and 4 pressure injuries shall not be admitted or retained in a residential care facility for the elderly. Resident 1 (R1) was receiving treatment from Legend Home Health Services for stage 3 and 4 unstageable pressure injuries. R1 was not on hospice at the time of admission. The violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: The Licensee will review and train staff on Prohibited Health Condition and comply, and ensure that the facility will not admit or retain any residents with a health condition of Stage 3 or 4 pressure injuries. The deficiency was corrected prior to today's visit.

Type of visit: Office

On 07/17/25 at 09:16AM, Community Care Licensing Division (CCLD) held a Noncompliance Conference at El Segundo Regional office. During this office visit, the following individuals were present: Regional Manager, Benita Yates, and Licensing Program Manager, Ulysses Coronel and Licensing Program Analysts Socorro Leandro and Mario Leon along with Licensees Angelique Gradney and Stephen Gradney. During the meeting, Regional Manager Benita Yates provided an overview of the deficiencies and citations, and a plan of action to address the noncompliance issues. An exit interview was conducted with Licensees Angelique Gradney and Stephen Gradney and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 17, 2025

Type of visit: Case Management - Annual Continuation

On 07/16/2024, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced continuation Required – 1 Year Inspection to the above-named facility and met with Licensee/Administrator, Angelique Gradney. Licensing Program Analyst (LPA) Socorro Leandro explained the purpose of the visit and was granted entry to the facility. The Annual Licensing Fees are current. Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there were no security bars or weapons on the premises. One outside wooden side door is in disrepair due to termites eating the wood. Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. There is a fire extinguisher in the kitchen area, and it was last serviced on 02/13/2025. The kitchen window does not have a screen. Great Room: There is a landline telephone and videoconferencing device on the desk in the kitchen area. There are games/activities and books in the dining room area and living room area. Resident Bedrooms: 5 out of 5 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Bathrooms: Toilets, showers, and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. Medications: were inaccessible to residents in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. 4 out of 5 Medication Administration Records (MARs) were reviewed. 1 out 4 residents did not receive medication as prescribed. Garage: The garage area has a laundry area. The garage is used as storage for the facility. Miscellaneous: Documents are posted as mandated. Last fire earthquake drill was conducted on 07/01/2025. Smoke and carbon monoxide detectors were in compliance and operational. A technical violation is being provided regarding facility remaining free of odors and using the facility garage (facility storage room) for resident supplies and facility supplies only not for the storage of staff personal items. Deficiencies are being cited based on observation and record review in accordance with the California Code of Regulations, Title 22 see LIC809D. A violation regarding facility being in good repair and providing residents with medications as prescribed. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Licensee/Administrator, Angelique Gradney.the state’s words, verbatim · CDSS document, Jul 16, 2025

Type of visit: Required - 1 Year

On 07/11/2024, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Licensee/Administrator, Angelique Gradney. Licensing Program Analyst (LPA) Socorro Leandro explained the purpose of the visit and was granted entry to the facility. This facility is licensed to serve 6 non-ambulatory adults ages 55 and above, of which 2 may be bedridden. A total of 5 residents are currently residing in this facility. The facility is a one-story house located in a residential street. The home consists of 5 resident bedrooms, 1 staff room, 3 bathrooms, 1 great room which includes the living/dining/office/kitchen area, 1 attached garage, and 1 backyard patio area with shaded seating. Facility records were reviewed. 5 staff records were reviewed, 5 out of 5 staff records had required documentation. 5 resident records were reviewed. No deficiencies were cited. The department was unable to complete this Annual Inspection due to time constraints. An Annual Inspection Continuation visit is required. An exit interview was conducted, and a copy of this report was left with the Licensee/Administrator, Angelique Gradney.the state’s words, verbatim · CDSS document, Jul 11, 2025

Allegation investigated: Illegal Eviction

On 7/2/25 Licensing Program Analyst(LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to the Assistant Administrator, Rodolfo Lozada and the purpose of the visit was discussed. LPA was granted access to the facility. The investigation consisted of the following: On 7/2/25 LPA requested and reviewed copies of the following records: Residents file, Resident Roster, Staff roster, 30-day Eviction Notice dated, 4/11/25, Id and Emergency Contact form, Physicians Report, Admission Agreement, House Rules and Special Incident Report regarding R1. LPA Shirley interviewed Staff 1 – Staff 4 and Resident 1 and Resident 2, R3, R4 and R5 were not available for interview. Con'd on 9099-C Unsubstantiated The investigation revealed the following: Allegation: Illegal Eviction On 7/2/25, LPA Felisa Shirley reviewed R1’s Admission Agreement dated and signed, 2/20/25. LPA Shirley observed that R1 signed House Rules, 2/20/25. LPA Shirley reviewed all Unusual Incident reports for the month of March 2025 and observed that there were 4 incidents involving violence with staff, 1 incident involving violence with a resident and 2 incidents involving violence with his visitor. LPA Shirley reviewed 30-day Eviction Notice dated, 4/11/25 and consulted with CCLD Management and was told the notice was in compliance and within Title 22 Regulations and was accepted. LPA interviewed staff, staff 1 – staff 4 (S-1 – S-4). LPA asked the staff, if there was a resident being illegally evicted. Of those interviewed 4 out of 4 answered no. LPA interviewed Resident 1 and Resident 2 (R-1 and R-2), R3, R4 and R5 were not available for interview. LPA asked the residents, were they being illegally evicted. Of those interviewed, 1 answered yes and the other answered no. Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. No deficiency was cited for this allegation. An exit interview was conducted and a copy of this report was provided to the Assistant Administrator, Rodolfo Lozada.the state’s words, verbatim · CDSS document, Jul 2, 2025 · control 11-AS-20250626102911

Allegation investigated: Resident #1 went to hospital with serious wound issues:Stage 3, Stage 4 and unstageable wounds

On 05/07/2025 at 10:00 A.M., the Department conducted a subsequent visit to gather information regarding the above allegation. The Department met with Caregiver/Staff Jeremy Nebres, and spoke to Licensee Angelique S. Gradney via and the purpose of the visit was explained. LPA was granted entry to the facility. The investigation consisted of the following: On 05/07/2025, interviews were conducted with staff members #1-2 (S1-S2) and residents #2-6 (R2-R6). Resident #1 (R1) no longer resides at the facility. Staff Jeremy and LPA Bunker toured the entire facility, buildings, and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visit. LPA requested and reviewed the resident's records and asked for copies of the following documents: Personnel report (Dated 05/07/2025), Resident Roster (Dated 05/07/2025), Admission Agreement (Dated 10/14/2023), Identification and Emergency Information (Dated 10/14/2023), Physician's Report (Dated 10/19/2023), Medical Assessment (12/21/2022), Medication Administration Records (MARs), (Dated 10/14/2023 -01/25/2024). See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Appraisal Need and Services Plan (Dated 10/12/2023), Safeguards for Cash Resources, (Dated 10/14/2023) Preplacement Appraisal Information (Dated 10/14/2023), Safeguards for Property Valuables (Dated 10/14/2023), Personal Rights (Dated 10/14/2023), Consent Forms (Dated 10/23/2023), Progress Notes (10/14/2023 - 01/25/2024), and Legend Home Health Medical Records (Dated 02-18-2023 - 01/25/2024) Investigation Reveals the following: It was reported that the resident #1 (R1) arrived at Torrance Memorial Medical Center's Emergency Room on January 25, 2024, with serious wound issues, including stage 3, stage 4, and unstageable pressure ulcers on the heel, leg, and lower back. Staff members #1 and #2 (S1-S2), interviewed, confirmed the allegation. S1 and S2 stated that R1 had been receiving wound care treatment prior to admission and was referred from a facility that was closing. Upon admission to Golden Care Living III, the resident presented with a pre-existing decubitus ulcer in the buttocks and groin area. R1 was referred to Legend Home Health, Inc., for ongoing wound care treatment. The nurse and primary care physician remained in constant communication throughout the resident's entire stay at the facility. Allegation: Resident #1 went to the hospital with serious wound issues: Stage 3, Stage 4, and unstageable wounds. On 05/07/2025, the Department interviewed two staff members #1 and #2 (S1-S2), regarding the alleged allegation that resident #1 (R1) was admitted to the hospital due to serious wound issues: Stage 3, Stage 4, and unstageable wounds. 2 out of 2 staff stated it is true resident #1 (R1) was admitted to the hospital with serious wound complications. S1-S2 stated that R1 was admitted to the facility on 10/14/2023 and was already receiving treatment for pressure wounds at the time of admission from Home Health, from 02/17/2023 - 01/25/2024, before the resident was admitted to Golden Care Living III. S1 and S2 states, R1 was hospitalized on 01/25/2024 while under the care of Legend Home Health Care, Inc., due to worsening wound conditions, including Stage 3, Stage 4, and unstageable wounds. See continued LIC9099-C page 3 Continued LIC9099-C page 3 On 05/05/2025, the Department interviewed five residents. Residents #2 through #6 (R2-R6), regarding the alleged allegation that resident #1 (R1) was admitted to the hospital due to serious wound issues: Stage 3, Stage 4, and unstageable wounds. The Department was unable to interview Resident #1 due to R1 no longer residing at the facility as of 01/25/2024. R2-R6 stated that they had no knowledge of the complaint allegation. 5 out of 6 residents interviewed denied the allegation and stated that they did not witness any residents with serious wounds. R2-R6 stated they had no concerns or problems and were happy with the care and supervision provided. R2-R6 stated that the staff are doing an excellent job of maintaining their living conditions at the facility. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. There were no deficiencies cited. LPA Bunker provided Caregiver/Staff Jeremy Nebres with copies of the Complaint Investigation Reports LIC-9099 and LIC-9099Cs. An exit interview was conducted.the state’s words, verbatim · CDSS document, May 7, 2025 · control 11-AS-20240131103123

Allegation investigated: Illegal eviction

NOTE: This report supersedes the previous report and does not change the findings. On 04/23/2025, the California Department of Social Services (CDSS) Community Care Community Care Licensing (CCL) Licensing Program Analyst (LPA) Socorro Leandro re-delivered findings. LPA met with Caregiver, Jeremy Nebres was granted entry to the facility. The investigation consisted of the following: On 03/27/2025, a facility tour was conducted which consisted of a health and safety check for residents in care. On 04/18/2025, Records were reviewed which consisted of emails from Administrator, Angelique Gradney (Administrator, Gradney) and Resident 1’s (R1) records. R1 records consisted of 30-day Eviction Notices, Unusual Incident Reports for the year 2025, Physicians Report dated 03/26/2024, Appraisal and Needs Services Plan dated 03/27/2025, Preplacement dated 02/26/2025, Admission Agreement dated 02/20/2025 and other pertinent documents. Unsubstantiated The investigation revealed the following: Allegation: “Illegal eviction”, it is being alleged that R1 is getting illegally evicted. Records reviewed revealed the following: On 03/18/2025, R1 received a 30-day Eviction Notice. On 3/18/2025 around 2:38 PM, the department received a 30-day Eviction Notice dated 03/18/2025 for R1 via email from Administrator, Gradney. On 03/25/2025, the department had a conversation with Administrator, Gradney informing them of the changes they need to make to the 30-day Eviction Notice for the notice to be in compliance with California Code of Regulations (CCR) Title 22. On 04/08/2025, Administrator, Gradney emailed the department an updated 30-day Eviction Notice. On 04/10/2025, the department informed Administrator, Gradney of the updates the 30-day Eviction Notice requires to be in compliance with CCR Title 22 regulations. On 04/10/2025 around 11:59 PM, Administrator, Gradney emailed the updated 30-day Eviction Notice. On 04/14/2025, the department informed the Administrator, Gradney that the 30-day Eviction Notice appears to be in compliance with CCR Title 22 regulations. Moreover, R1’s unusual incident reports and eviction notices demonstrate a pattern of aggression toward residents, staff, and the general public. Furthermore, the licensee followed CCR Title 22 regulations by sending a written report of eviction notices within five days. Based on conversations the department has had with Administrator, Gradney and records reviewed this allegation is unsubstantiated. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left with Caregiver, Jeremy Nebres.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 11-AS-20250321105226

Allegation investigated: Illegal eviction

On 04/18/2025, the California Department of Social Services (CDSS) Community Care Community Care Licensing (CCL) Licensing Program Analyst (LPA) Socorro Leandro a LPA Jose Anguiano conducted a continuation unannounced complaint visit. LPAs met with Caregiver Dominador Bonifacio and were granted entry to the facility. The investigation consisted of the following: On 03/27/2025, a facility tour was conducted which consisted of a health and safety check for residents in care. On 04/18/2025, Records were reviewed which consisted of emails from Administrator Angelique Gradney and Resident 1’s (R1) records. R1 records consisted of 30-Day Eviction Notices, Unusual Incident Reports for the year 2025, Physicians Report dated 03/26/2024, Appraisal and Needs Services Plan dated 03/27/2025, Preplacement 02/26/2025, Admission Agreement dated 02/20/2025 and other pertinent documents. Unsubstantiated The investigation revealed the following: Allegation: “Illegal eviction”, it is being alleged that R1 is getting illegally evicted. Records reviewed revealed the following: On 03/18/2025, R1 received a 30-day Eviction Notice. On 3/18/2025 around 2:38 PM, the department received a 30-day Eviction Notice dated 03/18/2025 for R1 via email from Administrator, Gradney. On 3/25/2025, the department had a conversation with Administrator, Gradney informing them of the changes they need to make to the 30-day Eviction Notice for the notice to be in compliance with California Code of Regulations (CCR) Title 22 regulations. On 04/08/2025, the Administrator, Gradney emailed the department an updated 30-day Eviction Notice. On 04/10/2025, the department informed the Administrator, Gradney of the updates the 30-day Eviction Notice requires to be in compliance with CCR Title 22 regulations. On 04/10/2025 around 11:59 PM, the Administrator, Gradney emailed the updated 30-day Eviction Notice. On 04/14/2025, the department informed the Administrator, Gradney that the 30-day Eviction Notice appears to be in compliance with CCR Title 22 regulations. Moreover, R1’s unusual incident reports demonstrate a pattern of aggression toward residents, staff, and the general public. Furthermore, the licensee followed CCR Title 22 by sending a written report of eviction notices within five days. Based on conversations with the Administrator, Gradney and records reviewed this allegation is unsubstantiated. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was left with thethe state’s words, verbatim · CDSS document, Apr 18, 2025 · control 11-AS-20250321105226

Allegation investigated: Staff did not prevent a resident from being exposed to sexual activity.

On 04/18/2025, the California Department of Social Services (CDSS) Community Care Community Care Licensing (CCL) Licensing Program Analyst (LPA) Socorro Leandro and LPA Jose Anguiano conducted an initial unannounced complaint visit. LPAs met with Caregiver Dominador Bonifacio and were granted entry to the facility. The investigation consisted of the following: On 04/18/2025, records were reviewed, interviews of staff, residents, and witnesses were conducted. Interviews conducted consisted of 5 staff interviews [Staff 1 (S1) to Staff 5 (S5) were interviewed], 3 resident interviews [Resident 2 (R2) to Resident 4 (R4) were interviewed], and 1 witness interview [Witness 1 (W1) was interviewed]. Records reviewed consisted of Resident 1’s (R1) unusual incident reports. Unsubstantiated The investigation revealed the following: Allegation: “Staff did not prevent a resident from being exposed to sexual activity”, it is being alleged that R1 engaged in sexual activity in public (within the facility property, not R1’s bedroom) and staff are not preventing residents from seeing the sexual activities that R1 is engaging in. Interviews conducted with R2 to R4 revealed the following: 3 out 3 residents have not witnessed R1 engaging in sexual activities. Interviews conducted with S1 to S5 revealed the following: 2 out of 5 staff have witnessed R1 engaging in sexual activities in public spaces (e.g. living room and driveway); the two staff indicated that they have also informed R1 that they cannot engage in sexual activities in public spaces but due to the aggression of R1 the two staff have stopped engaging with R1. 1 out 5 staff is aware that R1 has engaged in sexual activities in public spaces but has not witnessed R1 engaging in sexual activities. 3 out 5 staff are unaware if residents in care have witnessed R1 engaging in sexual activities in public spaces. 2 out of 5 staff have not seen or heard about complaints regarding R1 engaging in sexual activities in public spaces. Interviews conducted with W1 revealed the following: W1 observed R1 engaging in sexual activities in facility driveway and observed someone come out of the facility home and walk pass R1 and the individual just kept on walking. R1’s records reviewed revealed the following: The department did not find unusual incident reports indicating that R1 has engaged in sexual activities in public spaces. Based on interviews and records this allegation is unsubstantiated because according to interviews and records residents in care have not witnessed R1 engaging in sexual activities. Unsubstantiated: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was left with the Caregiver.the state’s words, verbatim · CDSS document, Apr 18, 2025 · control 11-AS-20250416103546

Allegation investigated: Staff did not prevent resident from engaging in a physical altercation Staff did not prevent resident from having access to pepper spray

This report supersedes report dated 03/19/25. On 4/3/25 Licensing program analyst (LPA) Villegas conducted a subsequent unannounced complaint visit regarding the allegations above. LPA met with caregiver Jaremy Nebres as the purpose of the visit was explained. The investigation consisted of the following: On 03/12/25 LPA Villegas obtained copies of the following; staff and resident rosters, and the following documents for residents #1 (R1); admission agreement dated 02/20/25, physicians report dated 03/26/24, resident personal property and valuables: dated 02/24/25, Appraisal/Needs and service plan dated: 02/20/2025, Preplacement appraisal: Dated: 02/20/25, Resident appraisal: Dated 02/20/25, and copies of unusual incident reports dated 02/23/25 and 03/05/25. On 03/12/25 between 10am-11 am LPA conducted interviews with residents #1-3 (R1-R3), and between 11am-11:40am LPA conducted interviews with staff #1-2 (S1-S2). On 3/12/25 LPA conducted a facility tour. On 03/19/25 LPA conducted a telephone interview with witness #1 (W1). On 03/19/25 at 11:am LPA conducted interview with staff #3 (S3). On 4/3/25 LPA conducted a review of police report dated 3/1/25 and conducted telephone interview with Administrator (A1). Unsubstantiated The investigation revealed the following: Allegation: Staff did not prevent resident from engaging in a physical altercation It is being alleged that facility did not come out of the facility while a resident in care was in a physical altercation out in the facility yard. On 03/12/25 between 10 am-11 am LPA conducted interviews with R1-R3 regarding the allegation above, 2 of 3 residents interviewed denied the allegation above, and reported being aware that the police were called to the facility but are unaware of the reason the police were called. 1 of 3 residents interviewed denied the allegation above, however 1 of 3 residents interviewed reported being involved in an altercation outside of the facility. On 03/12/25 LPA was unable to interview resident 4 (R4) due to communication barrier. On 03/12/25 and 03/19/25 between 11 am-11:40 am LPA conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above, however 3 of 3 staff interviewed reported the police arrived at the facility due to an altercation between a resident and visitor that occurred outside of the facility. Per 3 of 3 staff interviewed there are procedures in place for when there is an altercation inside the facility which include informing the Administrator. On 3/18/25 LPA conducted review of R1’s physicians report dated 03/26/24 which indicates R1 does not require constant supervision, and R1 is able to leave the facility unattended. On 03/19/25 LPA conducted telephone interview with W1 regarding the allegation above, W1 denied the allegation above and reported there are no health and safety concerns regarding facility staff. On 4/3/25 LPA conducted a file review and observed that the facility sent an unusual incident report to the department on 3/5/25. On 4/3/25 LPA conducted a review of police report dated 3/1/25. Per police report, an incident occurred on 3/1/25 between R1 and another party which resulted in the other party to be arrested, not another action taken by police. In addition, the Police report states that the facility staff was not interviewed regarding the situation outside the facility. On 4/3/25 LPA conducted telephone interview with A1 regarding the allegation above, A1 denied the allegation above and reported that staff on shift will call A1 and inform A1 of the situation. A1 continued to state that staff were unaware of the incident that occurred on 3/1/25 as it occurred off facility property after midnight. Allegation: Staff did not prevent resident from having access to pepper spray. It is reported that a resident in care has possession of pepper spray. On 03/12/25 between 10 am-11 am LPA conducted interviews with R1-R3 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. 1 of 3 residents interviewed reported hearing a resident in care looking for pepper spray but did not observe any physical pepper spray at the facility. On 03/12/25 LPA was unable to interview resident 4 (R4) due to communication barrier. On 03/12/25 and 03/19/25 between 11 am-11:40 am LPA conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. On 3/12/25 LPA conducted a facility tour, there were no health and safety concerns observed. On 03/18/25 LPA conducted a review of R1's personal property and valuables dated 02/24/25, LPA did not observe any documentation regarding pepper spray. On 03/19/25 LPA conducted telephone interview with W1 regarding the allegation above, W1 denied the allegation above and reported there are no health and safety concerns regarding facility staff. On 4/3/25 LPA conducted telephone interview with A1 regarding the allegation above, A1 denied the allegation above and report all belongings are documented upon admission to the facility. A1 continued to state that staff check bedrooms while cleaning and will remove anything that is found that is not allowed in the facility, per A1 pepper spray has not been found inside the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 11-AS-20250303094055

Allegation investigated: Staff did not prevent resident from engaging in a physical altercation Staff did not prevent resident from having access to pepper spray

This report supersedes report dated 03/19/25. On 4/3/25 Licensing program analyst (LPA) Villegas conducted a subsequent unannounced complaint visit regarding the allegations above. LPA met with caregiver Jaremy Nebres as the purpose of the visit was explained. The investigation consisted of the following: On 03/12/25 LPA Villegas obtained copies of the following; staff and resident rosters, and the following documents for residents #1 (R1); admission agreement dated 02/20/25, physicians report dated 03/26/24, resident personal property and valuables: dated 02/24/25, Appraisal/Needs and service plan dated: 02/20/2025, Preplacement appraisal: Dated: 02/20/25, Resident appraisal: Dated 02/20/25, and copies of unusual incident reports dated 02/23/25 and 03/05/25. On 03/12/25 between 10am-11 am LPA conducted interviews with residents #1-3 (R1-R3), and between 11am-11:40am LPA conducted interviews with staff #1-2 (S1-S2). On 3/12/25 LPA conducted a facility tour. On 03/19/25 LPA conducted a telephone interview with witness #1 (W1). On 03/19/25 at 11:am LPA conducted interview with staff #3 (S3). On 4/3/25 LPA conducted a review of police report dated 3/1/25 and conducted telephone interview with Administrator (A1). Unsubstantiated The investigation revealed the following: Allegation: Staff did not prevent resident from engaging in a physical altercation It is being alleged that facility did not come out of the facility while a resident in care was in a physical altercation out in the facility yard. On 03/12/25 between 10 am-11 am LPA conducted interviews with R1-R3 regarding the allegation above, 2 of 3 residents interviewed denied the allegation above, and reported being aware that the police were called to the facility but are unaware of the reason the police were called. 1 of 3 residents interviewed denied the allegation above, however 1 of 3 residents interviewed reported being involved in an altercation outside of the facility. On 03/12/25 LPA was unable to interview resident 4 (R4) due to communication barrier. On 03/12/25 and 03/19/25 between 11 am-11:40 am LPA conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above, however 3 of 3 staff interviewed reported the police arrived at the facility due to an altercation between a resident and visitor that occurred outside of the facility. Per 3 of 3 staff interviewed there are procedures in place for when there is an altercation inside the facility which include informing the Administrator. On 3/18/25 LPA conducted review of R1’s physicians report dated 03/26/24 which indicates R1 does not require constant supervision, and R1 is able to leave the facility unattended. On 03/19/25 LPA conducted telephone interview with W1 regarding the allegation above, W1 denied the allegation above and reported there are no health and safety concerns regarding facility staff. On 4/3/25 LPA conducted a file review and observed that the facility sent an unusual incident report to the department on 3/5/25. On 4/3/25 LPA conducted a review of police report dated 3/1/25. Per police report, an incident occurred on 3/1/25 between R1 and another party which resulted in the other party to be arrested, not another action taken by police. In addition, the Police report states that the facility staff was not interviewed regarding the situation outside the facility. On 4/3/25 LPA conducted telephone interview with A1 regarding the allegation above, A1 denied the allegation above and reported that staff on shift will call A1 and inform A1 of the situation. A1 continued to state that staff were unaware of the incident that occurred on 3/1/25 as it occurred off facility property after midnight. Allegation: Staff did not prevent resident from having access to pepper spray. It is reported that a resident in care has possession of pepper spray. On 03/12/25 between 10 am-11 am LPA conducted interviews with R1-R3 regarding the allegation above, 3 of 3 residents interviewed denied the allegation above. 1 of 3 residents interviewed reported hearing a resident in care looking for pepper spray but did not observe any physical pepper spray at the facility. On 03/12/25 LPA was unable to interview resident 4 (R4) due to communication barrier. On 03/12/25 and 03/19/25 between 11 am-11:40 am LPA conducted interviews with S1-S3 regarding the allegation above, 3 of 3 staff interviewed denied the allegation above. On 3/12/25 LPA conducted a facility tour, there were no health and safety concerns observed. On 03/18/25 LPA conducted a review of R1's personal property and valuables dated 02/24/25, LPA did not observe any documentation regarding pepper spray. On 03/19/25 LPA conducted telephone interview with W1 regarding the allegation above, W1 denied the allegation above and reported there are no health and safety concerns regarding facility staff. On 4/3/25 LPA conducted telephone interview with A1 regarding the allegation above, A1 denied the allegation above and report all belongings are documented upon admission to the facility. A1 continued to state that staff check bedrooms while cleaning and will remove anything that is found that is not allowed in the facility, per A1 pepper spray has not been found inside the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 3, 2025 · control 11-AS-20250303094055

Allegation investigated: Resident developed a Stage 3 pressure injury while in care.

On 01/23/2025, the Department of Social Services (DSS) - Community Care Licensing Division (CCLD) staff conducted an unannounced subsequent complaint visit at this facility. CCLD staff met with Administrator, Angelique Gradney. CCLD staff explained the purpose of this visit. The investigation consisted of the following: On 10/14/2024, CCLD staff initiated the complaint investigation and requested: Personnel Report LIC 500, residents service records which included: Physicians Reports, Identification and Emergency Information’s, Admission Agreements, Resident Appraisals, and Medication Administration Records and a tour of the facility was conducted. On 10/17/2024 to 12/20/2024, CCLD staff: interviewed facility residents, facility staff, witnesses (Home Health staff, Physicians, Social Workers, Registered Nurses, etc.); and requested R1’s records from several agencies which included medical records. On 01/08/2024, CCLD staff submitted an Investigation Care Report of interviews conducted and records reviewed. Substantiated The investigation revealed the following: Regarding the allegation “Resident developed a Stage 3 pressure injury while in care”, it is being alleged that staff do not reposition Resident 1 (R1) as instructed by medical professionals which resulted to R1 developing prohibited health conditions. Records reviewed revealed the following: On 4/29/2024, R1’s Physicians Report does not mention pressure injuries or states “No” under “History of Skin or Breakdown.” On 05/01/2024, R1 was admitted to the facility; R1’s Preplacement Appraisal does not mention pressure injuries or history of skin breakdown; R1 was admitted to Home Health and was assessed by a Home Health Registered Nurse and noted no wounds and skin intact. On 05/03/2024, Home Health Record noted a sore on R1’s buttocks the Home Health nurse “instructed caregivers to reposition every 2 hours” and facility staff verbalized understanding; R1 was placed on an “individualized emergency plan.” Home Health Records indicate that Home Health nurses consistently advised facility staff to turn and reposition R1 every two hours, maintain skin clean and dry at all times, and advised them on the importance of movement and mobility for circulation, reduce prolonged exposure to pressure and facility staff (S1, S2, S3, and S4) “verbalized understanding or teachings and instructions.” between 05/03/2024 to 10/05/2024. Home Health Records indicated that on 06/25/2024, R1 developed stage 2 pressure injury to the buttock region and nurse provided staff with education on prevention with pressure wounds. Facility Records indicated that care was not being provided to residents between 8:00 PM to 7:00 AM seven days a week during the months of September 2024 and October 2024. On 09/04/2024, Home Health Records reveal that R1 acquired new wounds on inner leg, right foot heel, bruises to buttocks, and arms are swollen; Home Health Records describe R1 as having seven wounds. Hospital Medical Records indicated that on 10/08/2024, R1 was diagnosed with stage 3 pressure injury on left heel measuring 1.4cm and an unstageable pressure injury on his right heel, measuring 2x1.5x0.1cm. Interviews conducted revealed the following: On 10/17/2024, Four residents indicated that facility staff does not check in on them from 2:00 AM to 6:00 AM. One resident explains that staff tells them to request their needs before 7 PM because after 7 PM they will not assist. Staff 1 indicated that Home Health “Nurses advised them to reposition R1 every two hours.” Staff 2 indicated that “no one would reposition R1 overnight. S2 explained that “at that time, we don’t have a night shift.” Interviews with facility staff revealed that care is not being provided to residents between 8:00 PM to 7:00 AM seven days a week upon their hire dates in 2023 up until 10/14/2024. Interviews with Home Health staff indicated that facility caregivers were “instructed…to keep R1 clean and dry and to reposition R1 every two hours, “around the clock” and added that, “the pressure injury never fully resolved because R1 was not consistently repositioned or kept clean and dry.” On 10/09/2024, Registered Nurse-Wound Care Nurse saw R1 at the hospital and they explained “that incontinence causes MASD (Moisture-Associated Skin Damage) wounds and that not being turned/repositioned would contribute to pressure injuries.” Regarding the allegation “Resident developed a Stage 3 pressure injury while in care”, the preponderance of the evidence standard has been met therefore the allegation is substantiated. Deficiencies cited based on records reviewed and interviews conducted in accordance with the California Code of Regulations, Title 22, please see LIC9099D. An immediate $500 Civil Penalty assessed, please see LIC421. Enhanced Civil Penalty: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.” An exit interview was conducted, and a plan of correction was developed. A copy of this report and appeal rights were provided to the Administrator, Angelique Gradney.the state’s words, verbatim · CDSS document, Jan 23, 2025 · control 11-AS-20241011142515

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Feb 11, 2025

Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided...facility require such additional staff for the provision of adequate services. This has not been met as evidenced by: Based on interviews and record review, the licensee did not have staff working between 8PM and 7AM to provide R1 with their care needs, which resulted in R1 developing a stage 3 pressure injury while in care.the state’s words, verbatim · CDSS document, Jan 23, 2025

Plan of correction: On 10/15/2024, Licensee provided facility with overnight staff. The Administrator has agreed to create a plan to follow CCR 87411 Personnel Requirements regarding services necessary to meet the needs of residents who require rotation every 2 hours and to follow Home Health instructions for residents in care. Email plan to Socorro.Leandro@dss.ca.gov

Allegation investigated: Staff did not check on resident every 2 hours for incontinence care Staff did not answer residents calls for assistance

On 10/30/2024, the Department of Social Services (DSS) - Community Care Licensing Division (CCLD) staff conducted an unannounced subsequent complaint visit at this facility. CCLD staff was greeted by Caregiver Daniel Aliony. CCLD staff explained the purpose of this visit. The investigation consisted of the following: On 10/17/2024, The department interviewed 4 out 6 residents and 3 staff. The department gathered facility timesheets for the month of October 2024 and resident records. On 10/30/2024, The department interviewed 1 out 6 residents. The department attempted to interview 1 out 6 residents but resident was sleeping. The department conducted a tour of the facility. Substantiated The investigation revealed the following: Regarding the allegation “Staff did not check on resident every 2 hours for incontinence care”, it is being alleged that Resident 1 (R1) was not assisted with incontinence care on 10/15/2024 from 2:00 AM to 6:00 AM. Interviews conducted revealed the following: 5 out 5 residents indicated that staff does not check on them or assist them from 2:00 AM to 6:00 AM. 4 out 5 residents indicated that there is no night staff. R1 indicated that she was not assisted with incontinence care at night. 3 out of 3 staff indicated that they do not work from 2:00 AM to 6:00 AM. 3 out of 3 staff indicated that their “Daily Time Sheet” is correct. Records reviewed of Daily Time Sheets revealed the following: “Daily Time Sheet Caregiver 1” “Covered Dated Oct. 1-15, 2024” demonstrates that Caregiver 1 works from 7:00 AM to 7:00 PM; according to the time sheet Caregiver 1 worked on 10/15/2024 from 7:00 AM to 7:00 PM. “Daily Time Sheet Caregiver 2” “Covered Date” Oct. “1-15, 2024” demonstrates that Caregiver 2 works from 8:00 AM to 8:00 PM; according to the time sheet Caregiver 2 worked on 10/15/2024 from 8:00 AM to 8:00 PM. “Daily Time Sheet” for Caregiver 3 “Covered Date Oct. 1-15, 2024” demonstrates that Caregiver 3 works from 8:00 AM to 8:00 PM; according to the time sheet Caregiver 3 did not work on 10/15/2024. Resident 1’s records revealed the following: “Physician’s Report for Residential Care Facilities for the Elderly” indicated that R1 needs incontinence assistance; “Resident Appraisal for Residential Care Facilities for the Elderly” states “Services Needed” with incontinence care; “Appraisal/Needs And Services Plan” states “Physical/Health: Incontinent, Provide Assistance on their Toileting Needs, Time Frame: Length of stay, Method of Evaluating Progress: Daily Observation and Monitoring”; “Admission Agreements for Residential Care Facilities for the Elderly” states that R1 will be receiving assistance with “toileting” and “other personal care needs.” Regarding the allegation “Staff did not check on resident every 2 hours for incontinence care”, the preponderance of the evidence standard has been met therefore the allegation is substantiated. Regarding the allegation “Staff did not answer residents calls for assistance”, it is being alleged that R1 called for help on 10/15/2024 from 2:00 AM to 6:00 AM and staff did not assist R1 with R1's incontinence care needs. Interviews conducted revealed the following: 5 out 5 residents indicated that staff does not check on them or assist them from 2:00 AM to 6:00 AM. 4 out 5 residents indicated that there is no night staff. R1 indicated that she called for assistance at night time and staff did not assist them. 3 out of 3 staff indicated that they do not work from 2:00 AM to 6:00 AM. 3 out of 3 staff indicated that their “Daily Time Sheet” was correct. Records reviewed of Daily Time Sheets revealed the following: “Daily Time Sheet Caregiver 1” “Covered Dated Oct. 1-15, 2024” demonstrates that Caregiver 1 works from 7:00 AM to 7:00 PM; according to the time sheet Caregiver 1 worked on 10/15/2024 from 7:00 AM to 7:00 PM. “Daily Time Sheet Caregiver 2” “Covered Date” Oct. “1-15, 2024” demonstrates that Caregiver 2 works from 8:00 AM to 8:00 PM; according to the time sheet Caregiver 2 worked on 10/15/2024 from 8:00 AM to 8:00 PM. “Daily Time Sheet” for Caregiver 3 “Covered Date Oct. 1-15, 2024” demonstrates that Caregiver 3 works from 8:00 AM to 8:00 PM; according to the time sheet Caregiver 3 did not work on 10/15/2024. Resident 1’s records revealed the following: R1 requires assistance with Activities of Daily Living (ADLs) and incontinence care, and the facility agreed to “Provide Assistance on R1’s Toileting Needs” and “Provide Assistance on R1’s Activities of Daily Living” throughout R1’s “Length of Stay” through staff “Daily Observation and Monitoring.” “Regarding the allegation “Staff did not answer residents calls for assistance”, the preponderance of the evidence standard has been met therefore the allegation is substantiated. Deficiencies cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, and a copy of this report was left with the Caregiver Daniel Aliony along with their appeal rights.the state’s words, verbatim · CDSS document, Oct 30, 2024 · control 11-AS-20241016091424

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 19, 2024

Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided...facility require such additional staff for the provision of adequate services. This has not been met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not having night staff to assist R1 with their care needs, which poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: Staff have agreed to create a plan to follow CCR 87411 Personnel Requirements and email plan to Socorro.Leandro@dss.ca.gov. Staff have agreed to hire an overnight staff in order to attend to Resident 1’s incontinence care needs. Staff have agreed to email an updated LIC500 to Socorro.Leandro@dss.ca.gov.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2) · Plan of correction due date: Nov 19, 2024

Managed Incontinence (b) In addition... the licensee shall be responsible for the following: (1) Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This has not been met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by not ensuring that R1’s incontinent care needs were checked at night time, which poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: Staff have agreed to create a plan to follow CCR 87625 Managed Incontinence for residents in care and email plan to Socorro.Leandro@dss.ca.gov. Staff have agreed to re-train all staff on Incontinence Care Needs for Residents in Care and email training log to Socorro.Leandro@dss.ca.gov.

Allegation investigated: Facility staff pushed resident.

On 10/30/2024, the Department of Social Services (DSS) - Community Care Licensing Division (CCLD) staff conducted an unannounced subsequent complaint visit at this facility. CCLD staff was greeted by Caregiver Daniel Aliony. CCLD staff explained the purpose of this visit. The investigation consisted of the following: On 10/14/2024, The department gathered facility records. On 10/17/2024, The department interviewed 4 out 6 residents and 3 staff. On 10/30/2024, The department interviewed 1 out 6 residents and conducted a tour of the facility. The department attempted to interview 1 out 6 residents but the resident was sleeping. Unsubstantiated The investigation revealed the following: Regarding the allegation “Facility staff pushed resident”, it is being alleged that a staff member pushed a resident multiple times to the floor. Interviews conducted revealed the following: 5 out 5 residents denied the allegation. 3 out 3 staff denied the allegation. Records reviewed revealed the following: The department requested Unusual Incident Reports (UIRs) but did not receive UIRs indicating that allegation occurred. Regarding the allegation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. No citations were issued. An exit interview was conducted, and a copy of this report was left with the Caregiver Daniel Alionye.the state’s words, verbatim · CDSS document, Oct 30, 2024 · control 11-AS-20241011142515

Type of visit: Case Management - Health Checks

On 10/14/24, Licensing Program Analyst (LPAs) Ernand Dabuet and Socorro Leandro conducted a Case Management visit at this facility. LPA met with assistant administrator Catherine Espino and allowed entry inside this facility. LPA informed Espino the purpose of the visit is to conduct a health and safety check in association with complaint #11-AS-20241011142515. LPAs conducted an audit of resident #2 -#5 (R2-R5) service records (4) out of (4) are unable to self-care require assistance with toileting, and are incontinent. Two (2) out of four (4) are on home health care services. According to staff #2 (S2), (R2-R5) depend on assistance with diaper changes. Espinso verified that the facility Personnel Report LIC 500 (dated: 09/12/24) that three (3) care staff provide care for residents at this facility Monday through Sunday between 7 am - 7 pm. As a result of the LPAs reviewing (R2-R5’s) service records, home health records, and staff statements, it revealed the facility did not have sufficient personnel staff at all times to provide the service necessary to meet resident needs. The facility does not have a night staff on schedule between 7 pm - 7 am to assist with incontinent services to residents (R2-R5). According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 809-D). An exit interview conducted with Katherine Espino and a copy of report and appeal rights provided. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *the state’s words, verbatim · CDSS document, Oct 14, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Oct 28, 2024

Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This has not been met as evidenced by: Based on record review/interview (R2-R5) are incontinent and requires assistance with diaper changes. Facility did not have a night staff to meet (R2-R5) needs after 7pm. This violation which poses a potential health and safety to residents in care.the state’s words, verbatim · CDSS document, Oct 14, 2024

Plan of correction: Licensee/Administrator have agreed to hire an overnight staff in order to attend to residents' needs while in care. Administrator will send an updated LIC500 to LPA Dabuet, via email, at Ernand.Dabuet@dss.ca.gov

Type of visit: Required - 1 Year

On 08/09/2024 at around 8:00 AM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with the Caregiver Jeremy Jade Ebilane Nebres. LPA explained the purpose of the visit and was accompanied by Caregiver inside and outside the facility during this inspection. This facility is licensed to serve 6 non-ambulatory adults ages 55 and above, of which 2 may be bedridden. A total of 5 residents are currently residing in this facility. The Annual Licensing Fees are current. The facility is a one-story house located in a residential street. The home consists of 5 resident bedrooms, 1 staff room, 3 bathrooms, 1 living/dining/office/kitchen area, 1 attached garage, and 1 backyard patio area with shaded seating. Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet. LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Fire drill was conducted on 06/15/2024. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. There is a fire extinguisher in the kitchen area and it was last serviced on 02/19/2024. The facility does not have a videoconferencing device dedicated for resident use. LPA observed liability insurance expired on 06/23/2023. LPA observed: mold in bathroom 1, bedroom 2’s drawer in disrepair, kitchen cabinet in disrepair, no shower head in bathroom 3. 4 out of 4 resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb. 5 staff records were reviewed, 5 out of 5 staff records had required documentation. 5 resident records were reviewed and, 5 out of 5 resident records had required documentation. Deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds. Violations regarding: facility in good repair; videoconferencing device dedicated for client use; liability insurance; Resident 5 medication assistance. An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Caregiver.the state’s words, verbatim · CDSS document, Aug 9, 2024

Allegation investigated: Staff left residents in soiled diapers for an extended time Staff are not meeting residents needs

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, July 02, 2024, upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with staff member Jeremy Nebres. During the visit, Administrator Katerine Espino arrived to assist with the visit. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: LPA Bunker conducted interviews with staff 1-3 (S1-S3) and residents 1-2 (R1-R2). Resident 3 (R3) was unable to communicate effectively due to a stroke, Resident 4 (R4) was non-verbal, and Resident 5 (R5) was not available for an interview as she was out with her family. LPA Bunker asked questions relevant to the nature of the complaint. S1-S3 agreed and stated it was true that the resident was left in soiled diapers for an extended time because one of the staff did not report to work and was a no-show. On that day, the facility was understaffed, with only one staff member on duty to provide care and supervision for five residents. Staff could only assist one resident at a time. See LIC9099-C page 2 Substantiated Continued LIC9099-C page 2 S1-S3 stated that meeting the residents' needs requires two staff members, but on Sunday, June 23, 2024, there was only one staff member available to manage the care of all five residents. Staff Jeremy and LPA Bunker toured the entire facility buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visit. LPA Bunker requested and reviewed staff and residents' records. LPA Bunker requested pertinent documentation regarding the above allegation. (Identification and Emergency Information, Physician's Report, Medical Administration Record, Admission Agreement, Appraisal/Needs and Services Plan, Functional Capability Assessment, Personnel Report, Resident's Roster, Special Incident Report, Corrective Action Memo, and Ongoing In-Service Training) Allegation #1: Staff left residents in soiled diapers for an extended time S1-S3 stated that it is true the facility was not fully staffed on Sunday, June 23, 2024, with only one staff member on duty to care for five incontinent non-ambulatory residents. S1-S3 and R1-R2 stated that residents were left in soiled diapers for hours before staff could provide assistance. Allegation #2 Staff are not meeting residents' needs S1-S3 and R1-R2 stated on Sunday, June 23, 2024, staff did not meet the care needs of the residents for one day. S1-S3 and R1-R2 stated staff normally meet residents' care needs. R1-R2 stated they are generally happy with the care they receive, but on June 23, 2024, there were not enough staff on duty to assist residents as required. R1 mentioned that everything had been exceptional until the incident on that one day. S1-S3 and R1-R2 stated the staff addressed and resolved the issue. Investigation revealed the following: S1-S3 and R1-R2 stated that residents were left in soiled diapers for hours before staff could provide assistance. S1-S3 and R1-R2 stated on Sunday, June 23, 2024 staff did not meet the care needs of the residents for one day. S1-S3 and R1-R2 stated the staff addressed and resolved the issue. See continued LIC9099-C page 3 Continued LIC9099-C page 3 S1-S3 ensured that incontinent residents were kept clean and dry, the facility remained free of odors, and incontinent residents were checked regularly during known periods of incontinence. S1-S3 ensures sufficient and competent staff are available to provide the necessary services needed to meet residents' needs. Based on LPA’s observations, interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D. Appeal Rights were discussed, and copies of the Complaint Investigation Report LIC9099, LIC9099-C, and LIC9099-D were provided to staff. Appeal rights have been issued and discussed. Exit interview conductedthe state’s words, verbatim · CDSS document, Jul 2, 2024 · control 11-AS-20240624162458

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(2)(3) · Plan of correction due date: Jul 2, 2024

87625 (b) (2) (3) Managed Incontinence: The licensee shall be responsible for ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence odors from incontinence. On Sunday, June 23, 2024 residents 1 and 2 were left in soiled diapers for an extended period because one of the staff did not report to work and was a no-show The violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2024

Plan of correction: The deficiency was corrected prior to today's visit. The staff ensured that incontinent residents were kept clean and dry, the facility remained free of odors, and incontinent residents were checked regularly during known periods of incontinence.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.2(c) · Plan of correction due date: Jul 2, 2024

1569.2 (c) Health and Safety Code: The facility staff is responsible for providing care and supervision to meet residents’ needs, including assistance with daily living activities such as personal care, dressing, bathing, and managing incontinence of bowel and/or bladder. The staff failed to meet the resident’s daily personal care needs. The violation poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 2, 2024

Plan of correction: The deficiency was corrected prior to today's visit. The facility ensures sufficient and competent staff are available to provide the necessary services needed to meet residents' needs.

Allegation investigated: Staff refused to allow resident’s hospice agency to provide care to resident as ordered by a physician

On 1/6/2024, Licensing Program Analyst (LPAs) Alfonso Iniguez conducted a subsequent complaint visit at this facility to deliver the complaint investigation findings. LPA met with the Jeremy Nebres/Caregiver, who assisted with the visit. The purpose of the visit was explained. The investigation consisted of the following: On 1/9/2023, LPA Montoya conducted a tour of the facility. LPA interviewed staff and witnesses. LPA’s attempt to interview all five residents was unsuccessful. LPA obtained copies of Staff Roster (LIC 500), Register of Facility Clients/Residents (LIC 9020) and resident’s (R1) Admission Agreement, Physician’s Report, Preplacement Appraisal, and Needs and Services Plan. During this visit, LPA did not observe R1’s Medication Administration Records and hospice referral order. Report continued in LIC 9099C Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff refused to allow resident’s hospice agency to provide care to resident as ordered by a physician Based on records review, Admission Agreement indicates Resident #1 (R1) was admitted to the facility on 12/29/2022. A hospice referral for R1 from SCAN Health Plan with Healing Care Hospice was dated 12/30/2022. It was alleged that staff refused to allow resident’s hospice agency to provide care to resident as ordered by a physician. On 1/9/2023 from 11:00 am – 1:55 pm, LPA Lourdes Montoya conducted interviews with four out of four staff (S1-S4). LPA attempted to interview five out of five residents (R2-R6). Two out of five residents were sleeping, two out of five residents refused the interview, and one out of five residents was unable to maintain a conversation. R1 was transferred to another facility and LPA was unable to obtain statements from R1 during the visit. Interviews with six witnesses (W1-W6) disclosed that Healing Care Hospice agency was the selected and preferred hospice agency to provide hospice care services to R1. Two out of six witnesses revealed the visiting nurse from Healing Care Hospice agency attempted to visit and assess R1 on 12/30/2022 around 6:00 pm, but facility staff denied the nurse an entry to the facility. W5 revealed R1 was transferred to another facility on 1/5/2023 due to the facility’s refusal to use R1’s preferred and contracted hospice agency. Based on interviews conducted, two out of four staff (S3-S4) claimed they were confused about who is supposed to provide hospice care to R1. Both staff stated Global Hospice delivered a hospital bed, comfort kit, oxygen tank, and bedside table to the facility for R1 but another hospice agency (Healing Care Hospice agency) attempted to assess R1 on 12/30/2022 and the hospice nurse was denied entry. Two out of four staff (S1-S2) claimed there was no doctor’s referral for Healing Hospice Care agency to provide hospice care to R1. They also claimed Healing Care Hospice Nurse was not denied entry on 12/30/22 instead the visit was only placed on hold due to a confusion which hospice agency, between Global Hospice and Healing Care Hospice, was selected by R1’s family. Report continued in LIC 9099C Based on LPA’s observation on 1/9/2023, a hospice comfort kit stored in the medication cabinet with R1’s name of the label was provided by Global Hospice Agency but there was no doctor’s referral for Global Hospice Agency. LPA also observed a hospital bed in the front patio. Per interview with a staff (S3), the hospital bed in the front patio was provided by Global Hospice for R1’s use. Based on information gathered, there is sufficient evidence to prove that staff refused to allow resident’s hospice agency to provide care to resident as ordered by a physician. Based on the department’s observations, records review and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 is cited on the attached LIC 9099D. Exit interview was conducted and Appeal Rights was discussed with Jeremy Nabres/ Caregiver. A hard copy of the report and Appeal Rights were provided. INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility staff refused to refund resident's unused rent payment Based on records review, Admission Agreement indicates Resident #1 (R1) was admitted to the facility on 12/29/2022. R1 moved out and transferred to another facility on 12/5/2023. It was alleged that facility staff refused to refund resident's unused rent payment. On 1/9/2023 from 11:00 am – 1:55 pm, LPA Lourdes Montoya conducted interviews with four out of four staff (S1-S4). LPA attempted to interview five out of five residents (R2-R6). Two out of five residents were sleeping, two out of five residents refused the interview, and one out of five residents was unable to maintain a conversation. R1 was transferred to another facility and LPA was unable to obtain statements from R1 during the visit. The department reviewed Resident’s (R1) service records. Based on records review, the Admission Agreement indicates “Resident is required to pay a full amount of Non-refundable Board and Care fee upon admission”, and “A thirty days written notice of intent to vacate is required or will be charged a full month pay on the following month or until all belongings are removed from the facility”. Based on interviews conducted, S1 stated the facility is willing to refund a prorated amount based on the days R1 resided in the facility. Based on LPA’s follow-up telephone interview with S1 on 1/10/22, S1 stated a refund letter for R1 was generated and a copy will be provided to the department. LPA received and reviewed the refund letter which indicates the facility has refunded R1 a prorated amount of $4600.00 of which $1400.00 was charged for her seven days of stay at the facility. Based on the information gathered, there is insufficient evidence to corroborate the above allegation. Based on the department’s observations, interviews and records review, the preponderance of evidence standard has not been met therefore the above allegation, “Facility staff refused to refund resident's unused rent payment” is found to be UNSUBSTANTIATED. Exit interview conducted. A copy of this report was provided to Jeremy Nabres/Caregiverthe state’s words, verbatim · CDSS document, Jan 6, 2024 · control 11-AS-20230106110553

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Jan 22, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services. This was not met as evidenced by: Based on interviews with six witnesses (W1-W6), it was revealed that Healing Care Hospice agency was the selected and preferred hospice agency to provide hospice care services to R1. Two out of six witnesses revealed the visiting nurse from Healing Care Hospice agency attempted to visit and assess R1 on 12/30/2022 around 6:00 pm, but facility staff denied the nurse an entry to the facility. W5 revealed R1 was transferred to another facility on 1/5/2023 due to the facility’s refusal to use R1’s preferred and contracted hospice agency. This poses an immediate risk to health, safety and/or personal rights to residents in care.the state’s words, verbatim · CDSS document, Jan 6, 2024

Plan of correction: The administrator shall review Section 87468.1 of Title 22 and shall self-certify understanding of this provision. Administrator shall conduct in-service training to staff about resident’s personal rights indicated in this section of Title 22. Administrator shall submit proof of corrections to CCLD by faxing to 424-544-1016 by the POC due date.