Golden Manor Retirement Center

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Administrator Maria Jacobo and explained the reason for the visit. The purpose of the visit is to complete the required inspection. LPA Trueman toured the facility along with Staff Robert Blanco today 04/13/2026 at 10:30 AM and the following was observed: Facility contains 80 Bedrooms and 80 Bathrooms for residents, dining room, 2 TV rooms , and outdoor patio area.. LPA inspected 10 Rooms which included on the 1st Floor # 3, 16, 20, 26 and 31 and on the 2nd Floor # 47, 51, 61, 63 and 70. Hot water temperature measured between 105 F. and 120 F. meeting Title 22 Regulations. Room 3 (111.3), Room 16 (111.9), Room 20 (110.4), Room 26 (113.5) and Room 31 (115.5). Room 47 (105.5), Room 51 (107.0), Room 61 (112.8), Room 63 (112.8) and Room 70 (114.0), Required Annual inspection included Infection Control Practices, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/ Staff Training, Resident Records/ Incident Reports, Resident Rights/ Information, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. LPA observed sufficient supply of 2 day perishables and 7 day non perishables. All staff were cleared and associated. Visitation signage was posted along with signage for hand washing and proper sanitizing. Staff responsible for providing care and supervision received training in First Aid. Licensee maintained an individual admission agreement for each client. Fire Clearance has been maintained. Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature. Program site was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors. Medication was reviewed for 7 Resident's. 7 Resident Files and 7 Staff Files were reviewed. No deficiencies. Exit interview conducted and copy provided.the state’s words, verbatim · CDSS document, Apr 13, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced case management visit in response to Special Incident Report (SIR) that describes the incident of Resident R1 that occurred on 01/17/2026. LPA met with Administrator Maria Jacobo and explained the purpose of the visit. LPA Interviewed Administrator Maria Jacobo during the visit and reviewed Resident R1's file. Facility submitted R1's Identification and Emergency Information, Physician's Report dated 10/2/2025, Appraisal Needs and Services Plan dated 2/15/25, Medication Log for January 2026, and Admission Agreement. SIR stated that there was a loud noise and 2 staff ran outside and observed a police car had crashed into the street light in front of the facility and on the floor was Resident R1. Resident did not respond when staff called out R1's name. 911 was called and ambulance came within seconds. R1 was taken to L.A. USC County Hospital and is currently still there. Administrator Maria Jacobo confirmed that R1 was hit by the police car just steps in front of the facility. Also stated that R1 was still in the hospital and is receiving updates from family member of R1 and will also notify Licensing of R1's status going forward. Physician's Report dated 10/2/2025 is checked off Yes for being able to leave the facility unassisted. No deficiencies. Exit interview conducted and copy provided. .the state’s words, verbatim · CDSS document, Jan 22, 2026

Allegation investigated: Staff did not report resident's incident to appropriate parties Staff failed to take action on change of condition

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Staff S1 and explained the reason for the visit. Today's visit is a subsequent visit to conduct additional Interviews in regards to the above allegations. Shortly thereafter Administrator Maria Jacobo arrived. The initial visit was conducted on 05/23/25 and included the following: Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Administrator Maria Jacobo and explained the reason for the visit. On 05/23/2025 Administrator Maria Jacobo was interviewed. Staff S1 was interviewed. Resident and Staff Roster submitted. File was reviewed for Resident R 1 and VA Medication List, MAR Log for May 2025, Physician's Report , Special Incident Report (SIR) and ID page submitted. At today's visit 12/18/25 interviews were conducted with Client's C2-C9. Unsubstantiated Interviews were conducted with the Administrator and Staff S1 and Staff S2. In regards to the allegation Staff did not report resident's incident to appropriate parties, based on interviews conducted and information gathered LPA did receive Special Incident Report (SIR) dated 05/12/25 which states that at 9:15PM 05/11/25 Client C1 left the facility to go to a friends house and would return later. Following day 05/12/25 C1 had not returned back to the facility. Report was made to Law Enforcement on 05/12/25 at 3:30PM Case #25-2841 and Case Manager from VA and Conservator for Client C1 were informed. Staff interviewed all stated that Special Incident Report (SIR) was sent on 05/12/25 to Licensing and that Case Manager from VA was notified. 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. In regards to the allegation Staff failed to take action on change of condition, based on interviews conducted and information gathered it was revealed upon observation of Medication Log from the VA dated 04/23/2025 that there was no physician's order for Clonozepam and therefore was not on the Medication list. MAR's Log also for the month of 05/25 did not have Clonozepam on the list of medications. Client's C2-C6 all are with the VA and stated the staff does a great job assisting them on VA appointments and transportation and that they have received all doses of their medication and it has always gone smoothly. Client's C7- C9 said they are assisted with all their medications and it has always gone smoothly. Stated staff are great and also assist with food service and any other needs they may have. Staff all stated that Client C1 was admitted on 03/19/25 and had never been prescribed Clonozepam. All said that Client C1 had not refused taking any medication. Physician's Report under listed medications does not have Clonozepam listed, All staff stated that Client C1 never had a change in condition. It should be noted that Client C1 no longer resides at the facility as of 05/11/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Exit interview with Administrator Maria Jacobo conducted and copies of the report provided..the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 28-AS-20250516113955

Allegation investigated: Staff abandoned resident Illegal eviction

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced subsequent visit to the facility and was greeted by Administrator Maria Jacobo and explained the reason for the visit. The purpose of the visit is to conduct additional interviews and gather additional information in regards to the above allegations. At today's visit interviews were conducted with the Administrator,and Staff S1-S3. The initial visit was conducted on 10/27/2025 and included the following: Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Staff Carmen Virrueta and explained the reason for the visit. The purpose of the visit is to conduct a 10 day complaint visit in regards to the above allegations. At today's visit the following was done: On 10/27/2025 Staff Carmen Virrueta was interviewed. Staff S1 and Staff S2 were interviewed. Resident and Staff Roster submitted. Unsubstantiated Resident's R2-R8 were interviewed. Interview conducted with family member of Resident R1. File was reviewed for Resident R 1 and VA Medication , Physician's Report , Special Incident Report (SIR) and ID page were submitted. In regards to the allegation Staff abandoned resident, based on interviews conducted and information gathered it was revealed by the family member of Resident R1 who stated that the facility did nothing wrong and that they are nice people. Stated R1 makes false accusations and was physically aggressive at the facility. Said R1 walked to the donut shop up the street and they called 911. He ended up at Whittier Hospital and family member said it was him who took R1 to the VA and it's not true that R1 was abandoned. Case Manager at the VA for R1 stated that it definitely wasn't abandonment in regards to R1. R1 was very aggressive and a danger to staff and residents. Said R1 wanted to go to the hospital saying was sick. Has had multiple ER visits. Spoke with staff who stated that the family member of R1 had taken him to the VA and thus it is not true about being abandoned. Family member told them it's too much with his behaviors so he would take to the VA Hospital. Resident's R2-R8 all stated that staff are really good. Said they are treated well. Said staff aren't inappropriate that it is resident's inappropriate toward staff. Resident R6 and R8 stated that R1 was screaming that he hates it here, throwing tables, chairs, library books and scaring alot of resident's. Stated that staff did a good job of calming down R1. 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. In regards to the allegation Illegal eviction based on interviews conducted and information gathered it was revealed by the family member of Resident R1 who stated that the facility did nothing wrong and that they are nice people. Stated that R1 makes false accusation's saying they stole his wallet, but the hospital called saying they had it. Told him they stole his boots and then they were found. Said R1 has memory problems and also was physically aggressive to staff and resident's. Said it is not true that it was an eviction. Case Manager at the VA for R1 stated that it definitely wasn't an eviction in regards to R1. Stated it was R1 who didn't want to return and was a danger to himself and others at the facility. R1 was very aggressive and a danger to staff and residents. Said R1 wanted to go to the hospital saying was sick. Has had multiple ER visits. Spoke with staff who stated that the family member of R1 had taken him to the VA . Family member told them it's too much with his behaviors so he would take to the VA Hospital. Stated R1 wanted to go back to the Ridgecrest area and kept screaming I hate it here. Resident's R2-R8 all stated that staff are really good. Said they are treated well. Said staff aren't inappropriate that it is resident's inappropriate toward staff. Resident R6 and R8 stated that R1 was screaming that he hates it here, throwing tables, chairs, library books and scaring alot of resident's. Stated that staff did a good job of calming down R1 and never did staff threaten R1 with eviction. It should be noted that the findings will remain Unsubstantiated after additional interviews were conducted and information gathered. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Nov 20, 2025 · control 28-AS-20251022084029

Allegation investigated: Staff abandoned resident Illegal eviction

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Staff Carmen Virrueta and explained the reason for the visit. The purpose of the visit is to conduct a 10 day complaint visit in regards to the above allegations. At today's visit the following was done: On 10/27/2025 Staff Carmen Virrueta was interviewed. Staff S1 and Staff S2 were interviewed. Resident and Staff Roster submitted. Resident's R2-R8 were interviewed. Interview conducted with family member of Resident R1. File was reviewed for Rsident R 1 and VA Medication , Physician's Report , Special Incident Report (SIR) and ID page were submitted. In regards to the allegation Staff abandoned resident, based on interviews conducted and information gathered it was revealed by the family member of Resident R1 who stated that the facility did nothing wrong and that they are nice people. Unsubstantiated Stated R1 makes false accusations and was physically aggressive at the facility. Said R1 walked to the donut shop up the street and they called 911. He ended up at Whittier Hospital and family member said it was him who took R1 to the VA and it's not true that R1 was abandoned. Case Manager at the VA for R1 stated that it definitely wasn't abandonment in regards to R1. R1 was very aggressive and a danger to staff and residents. Said R1 wanted to go to the hospital saying was sick. Has had multiple ER visits. Spoke with staff who stated that the family member of R1 had taken him to the VA and thus it is not true about being abandoned. Family member told them it's too much with his behaviors so he would take to the VA Hospital. Resident's R2-R8 all stated that staff are really good. Said they are treated well. Said staff aren't inappropriate that it is resident's inappropriate toward staff. Resident R6 and R8 stated that R1 was screaming that he hates it here, throwing tables, chairs, library books and scaring alot of resident's. Stated that staff did a good job of calming down R1. 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. In regards to the allegation Illegal eviction based on interviews conducted and information gathered it was revealed by the family member of Resident R1 who stated that the facility did nothing wrong and that they are nice people. Stated that R1 makes false accusation's saying they stole his wallet, but the hospital called saying they had it. Told him they stole his boots and then they were found. Said R1 has memory problems and also was physically aggressive to staff and resident's. Said it is not true that it was an eviction. Case Manager at the VA for R1 stated that it definitely wasn't an eviction in regards to R1. Stated it was R1 who didn't want to return and was a danger to himself and others at the facility. R1 was very aggressive and a danger to staff and residents. Said R1 wanted to go to the hospital saying was sick. Has had multiple ER visits. Spoke with staff who stated that the family member of R1 had taken him to the VA . Family member told them it's too much with his behaviors so he would take to the VA Hospital. Stated R1 wanted to go back to the Ridgecrest area and kept screaming I hate it here. Resident's R2-R8 all stated that staff are really good. Said they are treated well. Said staff aren't inappropriate that it is resident's inappropriate toward staff. Resident R6 and R8 stated that R1 was screaming that he hates it here, throwing tables, chairs, library books and scaring alot of resident's. Stated that staff did a good job of calming down R1 and never did staff threaten R1 with eviction. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.the state’s words, verbatim · CDSS document, Oct 27, 2025 · control 28-AS-20251022084029

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Staff Carmen Virrueta and explained the reason for the visit. The purpose of the visit is to complete the required inspection. Shortly thereafter Administrator Maria Jacobo arrived. LPA Trueman toured the facility along with Staff Robert Blanco today 05/23/2025 at 9:00AM and the following was observed: Facility contains 80 Bedrooms and 80 Bathrooms for residents, dining room, 2 TV rooms , and outdoor patio area.. LPA inspected 11 Rooms which included on the 1st Floor # 8, 16, 23, 32, and 70. On the 2nd Floor #35, 45, 46, 66, 72, and 77. Hot water temperature measured between 105 F. and 120 F. meeting Title 22 Regulations. Room 8 (107.9), Room 16 (112.4), Room 23 (113.5), Room 32 (114.2) and Room 70 (112.8). Room 35 (106.2), 45 (109.2), Room 46 (110.4), Room 66 (107.2), Room 72 (112.2) and Room 77 (105.0) Required Annual inspection included Infection Control Practices, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/ Staff Training, Resident Records/ Incident Reports, Resident Rights/ Information, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. LPA observed sufficient supply of 2 day perishables and 7 day non perishables. All staff were cleared and associated. Visitation signage was posted along with signage for hand washing and proper sanitizing. Staff responsible for providing care and supervision received training in First Aid. Licensee maintained an individual admission agreement for each client. Fire Clearance has been maintained. (cont. on 809 c ) Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature. Program site was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors. Medication was reviewed for 7 Resident's. 7 Resident Files and 5 Staff Files were reviewed. Interviews were conducted with 5 Resident's and 3 Staff. During tour of the facility it was observed in Resident Room 35 Screen in the sliding door and Room 45 that there is a tear in the window screen. In Room 77 the Resident's mattress had a very large tear in the middle of the mattress. Deficiencies to be cited on a new 809 Case Management - Deficiencies which contains the specific citations which are not located in the Care Tools. Exit interview conducted.the state’s words, verbatim · CDSS document, May 23, 2025

Type of visit: Case Management - Deficiencies

The purpose of this report is to issue deficiencies that were observed during the 2025 Annual Inspection. The specific deficiencies to be cited are not located in the Care Tools. During tour of the facility the following was observed. In Resident Room 35 sliding door screen has a tear and Room 45 there is a tear in the window screen. In Room 77 the Resident's mattress had a very large tear in the middle of the mattress. Deficiencies cited on the 809 D.the state’s words, verbatim · CDSS document, May 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(c) · Plan of correction due date: Jun 6, 2025

Maintenance and Operation All window screens shall be clean and maintained in good repair. This requirement was not met as evidenced by: Facility failed to have window screens in good repair in resident room 35 sliding door screen and Room 45 window screen which posed a potential Health and Safety Risk to residents care.the state’s words, verbatim · CDSS document, May 23, 2025

Plan of correction: Facility to submit proof of repair of window screens by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: May 30, 2025

Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Facility failed to have the resident's mattress in good repair in Room 77 which posed a potential Health and Safety Risk to residents care.the state’s words, verbatim · CDSS document, May 23, 2025

Plan of correction: Facility to submit proof of repair of resident's mattress by POC due date.

Allegation investigated: Staff at facility failed to properly store medication

Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit to the facility and was greeted by Staff Robert Blanco and explained the reason for the visit. The purpose of the visit is to conduct a 10 day complaint visit in regards to the above allegation. At today's visit the following was done: On 10/03/2024 Resident and Staff Roster submitted. Interviews were conducted with the Administrator and Staff S1 and Resident's R2, R3, R5 and R6.. Resident R1 and R4 were unable to be interviewed because of being hospitalized. File for Resident R1 was reviewed and Admissions Agreement and Physician's Report were submitted. LPA conducted a tour along with Staff S1 which included Rooms 3, 12, 13, 14, 17 and 27. LPA reviewed doctor's orders for Resident R2- R6. In regards to the allegation Staff at facility failed to properly store medication, based on interviews conducted and information gathered it was revealed by the Administrator and Staff S1 that they were informed during a tour of Resident R1's room by a Veteran Affairs (VA) Representative that there was an inhaler in the room of Substantiated Resident R1..Both staff confirmed that the inhaler was in Resident R1's room and that a doctor's order was needed and Resident R1 did not have a doctor's order. Interview with VA Representative stated that inhaler was found in Resident R1's room and that there was not a doctor's order allowing it to be in the room. Physician's Report for Resident R1 dated 08/19/24 listed under Medication Management, ls able to administer own Prescription Medications it states no. Also listed for Resident R1 under able to administer own PRN medications it states no. Interviews were conducted with Resident's R2, R3, and R6 who all stated taht they use the inhaler and they take on their own and have had no issues. All 3 had a doctor's note for the inhaler to be in their room. Resident R5 also had a doctor's note for Tylenol and stated it has gone smoothly. Resident R1 and R4 are both hospitalized. There was a doctor's order for Resident R4 to have an inhaler in their bedroom. Based on LPAs observations and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 is being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Oct 3, 2024 · control 28-AS-20240926144908

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Oct 3, 2024

Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Licensee failed to ensure that medication was kept in a safe and locked space with inhaler observed in R1's room which posed an Immediate Health and Safety concern.the state’s words, verbatim · CDSS document, Oct 3, 2024

Plan of correction: Facility to submit by POC due date training regarding medication management and submit signed log of who had attended. Administrator at visit submitted a Training Log pertaining to medication management that was conducted on 10/02/24. Deficiency cleared.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Maria Jacobo, administrator for the facility, and was granted entrance. There are seventy-six (76) total residents residing in the facility, six (6) of which are non-ambulatory and seventy (70) of which are ambulatory. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control practices and Personal Protective Equipment (PPEs) were observed. · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a two-story building located in a residential neighborhood. It is licensed for a capacity of sixty-four (64) non-ambulatory residents and ninety-six (96) ambulatory residents, and the second floor of the facility is approved only for ambulatory residents. The facility consists of a kitchen, a dining room, an activity room, a television room, eighty resident bedrooms, a public resident restroom, and two outdoor patio areas that contain a shaded area. LPA checked seven (7) resident bedrooms and found that they had all the required furnishings and fixtures, and LPA also measured the hot water temperature in the public bathroom, along with the bathrooms of resident rooms #10, 11, 23, 27, 37, 55, 58, 61, 63, and 70, all of which fell within the required range of 105 – 120 Degrees Fahrenheit. The facility was observed to be in good repair. ·The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has multiple fully charged fire extinguisher located throughout the facility. · Water temperature readings were within the required range of 105 - 120 degrees Fahrenheit. Operational Requirements: · The Program Design was reviewed. · Fire clearance was approved by LA County Fire Department for a capacity of sixty-four (64) non-ambulatory residents and ninety-six (96) ambulatory residents, and the second floor of the facility is approved only for ambulatory residents. · Care and supervision to meet the clients’ needs was observed. Staffing: · Twenty-one (21) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Seven (7) staff files were reviewed for criminal background clearance and training. · Seven (7) staff records reviewed have health/TB screenings. · The administrator’s certificate expires on 11/2/2025. Resident Rights/Information: · Physician orders were reviewed for seven (7) resident files. · Medications were also reviewed for seven (7) residents. Resident Records/Incident Reports: · Seven (7) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. · Staff training was on file. Disaster Preparedness: · Emergency and Disaster Plan was publicly posted and found within the facility. · The last emergency and disaster drill was conducted on 2/14/2024, which is not within the requirement that the drill be conducted quarterly. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs: · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 18, 2024

Allegation investigated: Staff did not maintain a safe environment for residents. Facility is not in good repair. Facility has bedbugs. Facility does not provide meals and snacks for diabetic diet. Facility does not provide adequate food service. Resident is not receiving mail. Resident did not get 60-day notice of rent increase. Facility does not provide activities.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint investigation for the allegations listed above. LPA met with Administrator, Maria Jacobo, and explained the purpose of the visit. On 7/8/21, LPA Glenn Trueman conducted the initial visit and interviewed the administrator and a resident. On 10/30/23, LPA Chan toured the facility and randomly selected 8 rooms (rooms #4, #11, #23, #26, #36, #44, #51, and #68) to inspect. Interviews were held with the administrator, 5 Staff, and 8 Residents. LPA also reviewed 5 resident files. The investigation revealed the following: 1. Allegation - Staff did not maintain a safe environment for residents. It was alleged that the staff allow people to smoke inside their rooms, allow to sell marijuana, and have registered sex offenders at the facility. LPA interviewed administrator, staff, and residents. Unsubstantiated The administrator stated the residents could smoke outside in the patios or outdoors but not in their rooms. She had not heard of any residents selling marijuana in the facility nor do they hire staff or admit residents who are registered sex offenders. Staff stated they do not allow residents to smoke in their rooms. They have not witnessed any residents selling marijuana or other drugs either. 7 out of the 8 residents interviewed stated the residents do not smoke in their rooms. They go outside to the patio where it is allowed. They have not seen or heard of any residents selling marijuana at the facility. They stated they feel safe residing here. 2. Allegation - Facility is not in good repair. It was alleged that the air conditioner was not working for almost 2 years, the elevators are frequently breaking down, and the ceiling had leaks. Per the administrator and staff, when things are not working properly, the maintenance personnel will try to fix it immediately. She stated the facility is an older building and they are maintaining the physical plant as best as they could. When the elevator is in disrepair, she contacts the outside elevator technician and they come right away to repair it. During the tour today, LPA observed the elevator and air conditioners working properly. The rooms inspected did not have any water leaks from ceiling. 3 out of 8 residents stated the elevator breaks down at time but they will fix it right away. One reported the elevator has been down for 10 months. The rest did not have any issues with things in disrepair. 3. Allegation - Facility has bedbugs. Administrator and staff stated they have not seen or received any reports of bedbugs from residents. LPA obtained the pest control report which was last serviced on 6/6/23. Per administrator, the maintenance staff has been performing the pest inspections and spraying the facility. Staff stated the maintenance person conducts random room checks every week to observe for pests. 7 out of the 8 residents interviewed had not seen any bedbugs in their rooms. During the visit today, LPA inspected 8 rooms and found a dead bed bug with blood stain in room #36. Although a bed bug was discovered, the facility does not have an infestation of pests nor has not been neglectful. The maintenance staff has been inspecting rooms weekly to ensure there are no bugs. 4. Allegation - Facility does not provide meals and snacks for diabetic diet. Administrator and staff stated their meal plans are created and meets the dietary needs of the residents. The foods are cooked with minimal salt and offer sugar-free desserts. LPA also interviewed the dietitian via telephone, who stated a visit is conducted monthly to ensure there is adequate food supplies, cleanliness of the kitchen, and the menu is appropriate for residents’ diets. At the visit today, LPA observed serving of foods that meet the different food groups. They had rice, chicken, soup, vegetables, and jello. 7 out of 8 residents stated the facility serves foods that are appropriate for those who are diabetics or have dietary restrictions. One stated he/she cooks own food and does not eat the food served at the facility. 5. Allegation - Facility does not provide adequate food service. It was alleged the facility rarely serve the foods reflected on the menu. Per administrator, the cook will replace an item in the menu if it is not available that day and stated it does not occur often. The cook stated the menu is generated ahead of time and they will ensure there is sufficient items. Cook will also follow the menu and cook with less salt/sugar. They also have alternatives if residents do not want the main course. 6 out of the 8 residents interviewed stated the facility serve the foods according to the menu. 6. Allegation - Resident is not receiving mail. Administrator stated mails are received usually in the mornings and are distributed to the residents while they are having lunch or are brought to the resident rooms. Staff stated they are sometimes asked to deliver their mails and do not open their mails. LPA interviewed 8 residents, and all stated they receive their mails unopened. 7. Allegation - Resident did not get 60-day notice of rent increase. The administrator stated the rent increases as the Social Security office increases the SSI amount. A notice is provided to the person who pays the rent, which is either the resident or family member. The letter is given ahead of time and when the facility receives notification of increase for SSI recipients only. LPA reviewed 5 resident files and observed they have signed admission agreement acknowledging the increased rates. One resident refused to accept the rent increase and did not sign form. 3 of the 8 residents interviewed stated they will receive notification before the rent increases, while one indicated the facility did not provide notice. The rest of the residents either have not had an increase of rent at the moment or someone else pays their rent. 8. Allegation - Facility does not provide activities. LPA toured the facility and observed an activity calendar. There are board games and books available for residents to use. The ping pong table is available when requested. Administrator and staff stated they provide activities to residents daily. The residents interviewed stated there are some types of activities provided daily, but some do not wish to participate. They also have board games, coloring, and books available. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with administrator Jacobo. A copy of this report along with the appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 30, 2023 · control 28-AS-20210629134833