Grace Retirement Village

Type of visit: Case Management - Health Checks

On today's date, Licensing Program Analysts (LPAs) Sean Haddad and Edward Kim made an unannounced case management inspection for the purpose of conducting health checks. LPAs were greeted and granted entry by Receptionist Rachel Chung after explaining the reason for the visit. Administrator (AD) Denise Gilroy arrived during the inspection. During the inspection, LPAs inspected the facility, conducted health and safety checks on residents, and requested and reviewed the resident roster, staff roster, and resident files. AD agreed to send LPA all previously requested resident files by close of business on September 2, 2026. Based on observation, no deficiency is being cited today. An exit interview was conducted with AD, and a copy of this report was discussed and provided at the end of the visit.the state’s words, verbatim · CDSS document, Sep 1, 2026

Type of visit: Case Management - Health Checks

On August 31, 2026, at 9:32 AM, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced Case Management visit at the facility. LPA met with administrator Denise Gilroy. The purpose of the visit was to inspect the facility for health and safety. During the visit, the Licensing Program Analyst (LPA)Dabuet conducted a thorough tour of the facility. The building is three stories tall. The first floor includes a memory care area, while the second floor features resident rooms, an activity area, a dining area, a kitchen, a medication area, and a lobby. The third floor is dedicated to a combination of assisted living and memory care rooms. Residents were observed in their individual rooms, as well as in the common areas and dining area. The facility was clean and odor-free, with well-maintained interiors, clear walkways, and adequate lighting. All fire extinguishers, smoke detectors, and carbon monoxide detectors were operational. The hot water temperature for personal care was within the required range of 105 to 120 degrees Fahrenheit. Additionally, both a working landline and internet service were available. Gilroy mentioned that one resident had been relocated from Hayworth Terrace. However, a review of Resident 1's (R1's) records revealed inconsistencies in the admission dates across various service records, medical records, medical appraisals, and other intake documents. An interview with (R1) confirmed that the admission dates listed on the service records are incorrect. (Evaluation Report continues LIC 809-C) **87207**False Claims - The inspection revealed that the facility falsified (R1's) service records with an improper admission date. Based on interviews, observations, and record reviews, the licensee violated the California Code of Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiencies were documented, and an exit interview was conducted with Denise Gilroy. A copy of this report is provided along with the appeal rights.the state’s words, verbatim · CDSS document, Aug 31, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Sep 7, 2026

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by Based on the interview and record review, the licensee falsified R1's admission date on service records. This violation poses/posed a potential risk to persons in care.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Licensee will adhere to Title 22- 87207 and correct (R1's) admission dates on all of (R1's) service records—proof of correction by POC due 09/07/26 to attn: Ernand Dabuet at 424-544-1016.

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies based on the facility not providing the documents requested during the Case Management – Health Checks inspection conducted on August 18, 2026. LPA met with Administrator (AD) Denise Gilroy and explained the reason for today’s inspection. During the Case Management – Health Checks inspection conducted on August 18, 2026, the following documents were requested for the 91 registered residents by close of business August 19, 2026: Face Sheets (which includes verification of source of income), Physician's Reports, Admission Agreements, medication lists (which will include information regarding the pharmacy used by each resident), and fire alarm inspection report. As of today’s date, the documents for only 30 residents out of 91 have been provided and the fire alarm inspection report has not been provided. The facility did not provide LPA the documents requested timely as agreed. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 26, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(d) · Plan of correction due date: Aug 28, 2026

87506 Resident Records … (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement was not met as evidenced by: Based on interviews and documents, the licensee agreed to submit all requested documents by August 19, 2026, but as of August 26, 2026 has still not provided all requested documents, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 26, 2026

Plan of correction: Licensee stated they will submit the remaining documents to LPA by POC due date.

Type of visit: Case Management - Health Checks

On August 18, 2026, Licensing Program Analyst (LPA) Jessica Cho made an unannounced case management for the purpose of conducting health checks. LPA was greeted and granted entry by Receptionist Rachel Chung after explaining the reason for the visit. The receptionist notified Administrator (Admin) Judith Lee by telephone the reason for the visit. On today's date, LPA conducted health and safety checks on residents and toured the facility accompanied by Administrator Lee. LPA observed ample perishable and non-perishable food. LPA inspected the storage room with Maintenance Staff James Lee where emergency food and water supplies were stored. Admin indicated that there are no reported cases of bed bugs or scabies at the facility. Copies of the resident roster, personnel report summary, and staff contacts were obtained during the visit. Due to the request for a substantial volume of resident records, Administrator Lee will provide the following requested documents for the 91 registered residents to LPAs Cho and Sean Haddad via email by close of business August 19, 2026: Face Sheets (which includes verification of source of income), Physician's Reports, Admission Agreements, medication lists (which will include information regarding the pharmacy used by each resident), and fire alarm inspection report. Based on observation, no deficiency is being cited today. An exit interview was conducted with Administrator Judith Lee, and a copy of this report was discussed and provided at the end of the visit.the state’s words, verbatim · CDSS document, Aug 18, 2026

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20260709085231. LPA met with Staff #1 (S1) Judith Lee and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed staff, residents, and witnesses, and obtained and reviewed copies of the resident roster and staff roster. On June 29, 2026, LPA received written notification that the facility’s administrator has left. During today’s inspection, LPA asked S1 if the facility has a current certified administrator. Per S1, they do not have an administrator certificate, but are in the process of obtaining one, and do not know if the facility has a certified administrator. Based on the information obtained, the facility does not have an administrator. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Aug 10, 2026

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator… This requirement was not met as evidenced by: Based on interviews and documents, the licensee does not have a certified administrator, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 13, 2026

Plan of correction: Licensee stated they will appoint a certified administrator and submit all required documents to LPA by POC due date.

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad and Regional Manager (RM) Monica Tran for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20260622113001. LPA and RM met with Staff #1 (S1) Judith Lee and explained the reason for today’s inspection. During the course of the investigation, LPA and RM inspected the facility and observed the following: the hard wood flooring in certain areas of the first floor memory care hallway is cut, peeling, lifting, and shredding, which poses a potential fall risk to residents and visitors, and the third floor common area flooring around room 325 is cut, peeling, lifting, and shredding, which poses a potential tripping hazard to residents and visitors. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jul 21, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidenced by: Based on observation, the flooring in the first floor memory care and the third floor is cut, peeling, lifting, and shredding, which poses a potential safety risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Jun 23, 2026

Plan of correction: Licensee stated they are already working on fixing the floor and will submit proof that the floor has been repaired to LPA by POC due date.

Allegation investigated: Staff are mismanaging residents medication

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with staff Man Park and explained the reason for today’s inspection. The investigation into the allegation that staff are mismanaging residents medication revealed the following: During the course of the investigation, LPA inspected the facility, interviewed Administrator (AD) Michelle Song, residents, and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) IV Order dated March 13, 2026, Resident #2’s (R2) IV Order dated March 16, 2026, and Medication Administration Records. CONTINUED Substantiated It was alleged that R1 received IV infusions with an IV bag that had a partially peeling or missing label, R2 received IV infusions with an IV bag that had another resident’s name on it, and the facility had no doctor’s orders for the IV infusions. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed AD who admitted the allegation, stating that on March 16, 2026, R1 and R2 were administered IV infusions due to weakness and not eating, the IV infusions were ordered by the residents’ nurse practitioner verbally but a written order was not received until the nurse practitioner arrived at the facility on March 18, 2026, and that the IV bags given to these residents were from the facility’s stock and were not delivered to the facility for these residents. LPA reviewed R1’s IV Order dated March 13, 2026, and R2’s IV Order dated March 16, 2026, which per AD were written on March 18, 2026, but given verbally on March 16, 2026, and noted they are for “IV 05 ½ NS”. LPA observed six IV bags at the facility, none of which were labeled for R1 or R2. Two bags were labeled for Resident #3 (R3), who per AD is no longer a resident of the facility and moved out on October 31, 2025. All six IV bags are labeled as “Sodium Chloride 0.9% Solution”. However, the labels of the bags actually administered to R1 and R2 are no longer available. AD stated they are not knowledgeable about IV bags, but the nurse who administered them would have handled it. LPA attempted to interview the nurse that administered the IVs to R1 and R2, but was unsuccessful. LPA interviewed two staff who were unable to provide information regarding this allegation. LPA reviewed the Medication Administration Records for R1 and R2, which did not contain orders for IV infusions or document the IV infusions administered. Although the facility eventually received written doctor’s orders documenting that IV infusions were ordered for R1 and R2, R1 and R2 received IV bags that were delivered to the facility other residents and it is unknown if they received the correct IV bags as ordered by their doctor. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that Resident #1 (R1) and Resident #2 (R2) received IV infusions at the facility without staff or licensed supervision present. LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA interviewed AD who denied the allegation, stating that the IV infusions were administered by the facility’s on-call registered nurse. LPA interviewed two staff who were unable to provide additional information. When interviewed, R2 was unable to provide information regarding the allegation, but R1 stated a nurse administered their IV and staff stayed with them while it was in place. LPA attempted to interview the nurse who administered the IV, but was unsuccessful. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 22-AS-20260317114133

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(e) · Plan of correction due date: Apr 17, 2026

87465 Incidental Medical and Dental Care (e) For every … medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, … and a label on the medication This requirement was not met as evidenced by: Based on documents and admission, the licensee had a nurse administer IV bags to R1 and R2 that were not labeled as theirs and could have been a different formulation than that ordered, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: The licensee stated they will conduct medication training, including about this scenario, and submit proof to LPA by POC due date.

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with staff James Lee and Administrator (AD) Michelle Song and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 7:45AM, LPA and staff James Lee conducted a preliminary inspection of the facility. At about 1:30PM, LPA, AD, and staff James Lee conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a large commercial facility. Facility is a 170-bedroom, 180-bathroom, 3 story building. There is 1 large patio with patio covers for the residents. Resident Bedrooms: the 19 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 19 resident bedrooms inspected. LPA tested the call button in multiple resident rooms in assisted living and memory care and noted prompt staff responses. LPA tested the delayed egress system in the first floor memory care and observed it to be functioning properly. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 degrees and 122 degrees F, before corrections, in the 12 resident bathrooms inspected. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have not been paid but are not yet due. At about 9:00AM, LPA reviewed 10 resident files and 10 staff files, interviewed 6 residents and 5 staff, and inspected medications for 10 residents. Facility does not handle resident money. During the inspection, LPA and AD observed the following: based on observation, out of the 12 bathroom faucets tested, all were within range except Room 123 which tested at 122 degrees F; based on documents, S3's health screening is dated more than 6 months before their association date, S4 did not have a health screening in their file, and S9's health screening states they are positive for tuberculosis which S9 states is a mistake and S9's doctor stated over the phone they believe is a false positive and they will order a chest x-ray to confirm; based on documents, S5, S6, and S9 did not have records of their 40 hour initial training; based on documents, S2, S3, S4, S7, and S8, did not have records of their 20 hour continuing training; based on documents, S4 and S5 did not have current first aid certificates in their files; based on documents, the facility has a memory care unit but their training records indicate that no staff has received 12 hours of dementia initial training or 8 hours of dementia continuing training; based on documents, medication technician S8's medication training records do not document the number of hours or type of training and medication technician S9 had no medication training at the facility; based on documents, the physician's reports for R1 through R10 are on the old form and do not include required information, such as descriptions of behavioral expressions; based on documents, the appraisals for R2, R6, R7, R8, R9, and R10 are more than a year old; and based on documents, the admission agreement in R2's file was blank. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Feb 12, 2026

The state marks this report as 11 pages; the online copy we transcribed has 10. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on November 19, 2025 regarding Resident #1 (R1). LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During today’s inspection, LPA inspected the facility, interviewed AD, and requested and reviewed copies of the resident roster, staff roster, and resident files. Per the incident report received in the OCRO on November 19, 2025, on November 2, 2025, R1 left the facility without staff noticing around 6AM, was found by the police miles away, and was sent to the hospital. LPA inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. LPA reviewed R1’s Physician’s Report dated February 6, 2025, which indicates R1 has mild cognitive impairment but can leave the facility unassisted. Per AD, R1 did not have dementia, but lived in the memory care unit due to psychiatric issues. Per AD, R1 is still at the hospital, R1 escaped by using a chair to jump a fence in the memory care courtyard and did not trigger the facility’s delayed egress alarms, and R1 was hospitalized after fighting with police when they were found on November 2, 2025 but AD is unaware of any injuries to R1. LPA reviewed R1’s involuntary evaluation application dated October 30, 2025, which indicates that prior to R1’s elopement on November 2, 2025, R1 was detained by Garden Grove Police Department during another elopement on October 30, 2025, due to being gravely disabled, being observed walking in street traffic due to their dementia. Per facility staff, R1 leaving on October 30, 2025, was also not noticed by staff and no delayed egress alarms were triggered and it is believed R1 jumped another fence. Per facility staff, on October 30, 2025, R1 was hospitalized but was cleared to go back to the facility the same day or the next day by the doctor at the hospital, facility staff protested R1’s return to the facility to the doctor at the hospital, but R1 was still returned to the facility and the doctor said they would send new medications to R1’s pharmacy. Per AD and facility staff, the facility did not have a chance to reassess R1 as they eloped again in the next few days on November 2, 2025, and it is unclear if the new medications ever arrived. Facility staff stated they put R1 on 30-minute checks after their first elopement, but there are no logs available, and the checks provided by facility staff were insufficient to meet R1’s care and supervision needs. Based on the information obtained, the facility did not put in place sufficient measures to address R1’s elopement even after knowing of their previous elopement a few days earlier. LPA inspected the delayed egress doors in the memory care unit and confirmed they work properly. LPA reviewed the incident reports received in the OCRO and noted that R1’s elopement on October 30, 2025 was not reported. Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Nov 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 20, 2025

87464 Basic Services … (f) Basic services shall at a minimum include: (1) Care and supervision. This requirement was not met as evidenced by: Based on interview and documents, the licensee did not ensure R1 received care and supervision to meet their needs resulting in a second elopement in less than week, an altercation with police, and hospitalization, which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: Licensee stated they will retrain staff on elopements and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Nov 26, 2025

87211 Reporting Requirements (a) … (1) ... (D) Any incident which threatens the welfare, safety or health … unexplained absence of any resident. This requirement was not met as evidenced by: Based on interview and documents, the licensee did not report R1’s elopement on October 30, 2025, to the OCRO, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: Licensee stated they will retrain staff on reporting requirements and submit proof to LPA by POC due date.

Allegation investigated: Facility staff did not properly document resident medications Facility staff did not dispose of expired medications Facility staff did not ensure resident wound care was properly documented

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegations. LPA met with Administrator (AD) Michelle Song, discussed the purpose of the inspection, and explained the allegations. The investigation into the allegations that facility staff did not properly document resident medications, facility staff did not dispose of expired medications, and facility staff did not ensure resident wound care was properly documented revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, and obtained and reviewed copies of the resident roster, staff roster, the facility’s centrally stored medication records, the facility’s medication administration records, and Resident #1’s (R1) hospice medical records. Substantiated Regarding the allegation that facility staff did not properly document resident medications: it was alleged that the facility did not document R1’s Morphine and Lorazepam, Resident #2’s (R2) Morphine and Lorazepam, and Resident #3’s (R3) Morphine. LPA inspected the facility, conducted health and safety checks on R1, R2, and R3, and observed no health and safety issues. LPA interviewed AD, who admitted the allegation, stating that these residents were on hospice and had these medications delivered to the facility upon being admitted to hospice but the centrally stored medication records and medication administration records for these residents did not include these medications despite AD’s multiple attempts to get the hospice company and pharmacy to include these medications on these documents. LPA reviewed the centrally stored medication records and medication administration records for R1, R2, and R3 and confirmed that these medications were not included on these documents when the medications were delivered to the facility and in the case of R1 and R2 were not included on these documents for multiple months. Regarding the allegation that facility staff did not dispose of expired medications: it was alleged that on October 30, 2025, bottles of expired antacids and anti-gas medications were found in the medication room with expiration dates of August 2025, multiple expired suppositories were found in the medication room refrigerator with expiration dates of July 2025, and AD and the medication technician were notified and stated they would destroy these expired medications and reorder new ones. LPA interviewed AD who admitted the allegation, stating that expired medications were found in the facility’s medication room and that after being made aware of the expired medications, facility staff destroyed them following the facility’s protocol. AD stated they did not believe these medications were given to residents after they expired. Regarding the allegation that facility staff did not ensure resident wound care was properly documented: it was alleged that R1 did not have documentation of the wound care for R1’s stage 1 pressure wound. LPA reviewed R1’s hospice medical records which indicate that on October 24, 2025, R1’s doctor diagnosed R1 with a stage 1 pressure ulcer and gave an order for wound care. LPA interviewed AD who admitted the allegation, stating that the facility was unaware that R1 had a wound or was receiving wound care and the facility did not have documentation for the wound care provided by R1’s hospice company as of October 30, 2025, but that the facility requested and received the wound care records at a later date. AD stated that apart from the wound care R1 received from their hospice care team, R1 received the facility’s standard repositioning care from the facility’s own staff, but that this care was not documented either. LPA reviewed R1’s hospice medical records which shows that R1 received wound care from their hospice care team, but this documentation was not obtained by the facility until weeks after the wound care began and is still incomplete for the time period between October 24, 2025 and November 10, 2025. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Nov 14, 2025 · control 22-AS-20251110164147

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(k) · Plan of correction due date: Nov 28, 2025

87633 Hospice Care of Terminally Ill Residents … (k) The licensee shall maintain a record of dosages of medications that are centrally stored for each resident receiving hospice services in the facility. This requirement was not met as evidenced by: Based on documents and admission, the licensee did not ensure all the medications of R1, R2, and R3 were documented on their centrally stored medication records and medication administration records, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Nov 14, 2025

Plan of correction: The licensee stated they will ensure the centrally stored medication records and medication administration records for all residents contain all of their medications and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(i) · Plan of correction due date: Nov 28, 2025

87465 Incidental Medical and Dental Care (i) Prescription medications which are not… returned to the issuing pharmacy … which are otherwise to be disposed of shall be destroyed in the facility…This requirement was not met as evidenced by: Based on admission, the licensee did not timely dispose of or destroy expired medications, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Nov 14, 2025

Plan of correction: The licensee stated they will submit a medication destruction record documenting the destruction of the expired medications to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87631(a)(3)(B) · Plan of correction due date: Nov 28, 2025

87631 Healing Wounds (a)… (3) Residents with a stage one or two pressure injury… (B) All aspects of care performed by the medical professional and facility staff shall be documented in the resident's file. This requirement was not met as evidenced by: Based on admission and documents, the licensee did not ensure R1’s wound care from their hospice care team, or the repositioning care of the facility’s own staff, was documented in R1’s file, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Nov 14, 2025

Plan of correction: The licensee stated they will create a protocol for reviewing hospice files for new diagnoses and treatment plans to ensure all requirements are met and submit proof to LPA by POC due date.

Type of visit: Case Management - Other

This unannounced Case Management – Other inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of obtaining resident files. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During the inspection, LPA inspected the facility and requested and reviewed copies of the resident roster, staff roster, and resident files. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Oct 22, 2025

Allegation investigated: Staff do not ensure the facility is free from mold

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Michelle Song, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that staff do not ensure the facility is free from mold revealed the following: During the course of the investigation, LPA inspected the facility, conducted health and safety checks on residents, interviewed AD, and obtained and reviewed copies of the resident roster, staff roster, and photographs. CONTINUED Substantiated It was alleged that the facility has visible mold in the kitchen where staff prepare food. LPA reviewed photographs showing black mold on the ventilation pipes in the kitchen with condensation dripping down onto food prep areas. LPA inspected the kitchen and observed that the exterior of the ventilation pipes had been partially cleaned, but that some of the mold was still present on the pipes, and also observed staff conducting a deep cleaning of the kitchen. LPA observed additional black mold behind a short chest freezer in the kitchen that had not been cleaned and as well as additional mold near the vents in the first floor memory care common area and second floor chapel room. LPA interviewed AD who stated the facility is currently deep cleaning the kitchen, has taken alternative measures to ensure residents are receiving safe and healthy food, and that the facility has already called a professional to clean the mold and ensure the facility is mold free. While the facility is now taking steps to address the mold, the information obtained corroborated that the facility did not timely address the mold as it grew throughout the facility, including the kitchen. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Sep 11, 2025 · control 22-AS-20250910130607

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Sep 25, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on observation and interview, the licensee did not ensure the kitchen, first floor memory care, and second floor chapel were free of black mold, which poses a potential health risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Sep 11, 2025

Plan of correction: Licensee stated that they will clean, disinfect, and have the affected areas professionally confirmed to be mold free and submit proof to LPA by POC due date.

Type of visit: POC

This unannounced POC inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of verifying correction of deficiencies issued during the Case Management – Deficiencies inspection conducted on June 11, 2025. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During the inspection, LPA inspected the facility, conducted health and safety checks on residents present, and observed no health and safety issues. During the inspection, LPA and AD observed the following: Type A Violation cited under California Code of Regulations (CCR) Title 22, Section 87208(a) pertaining to the third floor memory care with delayed egress has been CLEARED. During the inspection, LPA confirmed that the delayed egress system has been permanently deactivated and AD previously stated that the residents on the third floor do not need to be in a memory care and that any that did were relocated to the first floor memory care. Type A Violation cited under Health & Safety Code (HSC) section 1569.605 pertaining to liability insurance has not been cleared. The facility has not provided proof to LPA that the facility has obtained liability insurance that meets the requirements. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report, clear letters for all citations cleared during this inspection, and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.605 · Plan of correction due date: Jul 16, 2025

… all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least ... ($1,000,000) per occurrence and ... ($3,000,000) in the total annual aggregate... This requirement was not met as evidenced by: Based on documents, the licensee did not maintain liability insurance covering injury to residents and guests in the amounts required due to sub-limits on injuries typical in this facility type, which poses an immediate personal rights risk to up to 93 persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: Licensee stated they will obtain liability insurance that complies with Health & Safety Code section 1569.605 and submit proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20240724111701 and while reviewing the facility’s insurance policy. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During today’s inspection, LPA inspected the facility and observed the following: while the facility was licensed with a single memory care on the first floor, LPA observed that an additional memory care has been set up on the third floor with functional delayed egress doors. Per interviews with AD and Licensee (LE) Erik Doan, the facility began keeping residents with memory issues in this third floor memory care early in 2025 in order to provide closer supervision and to separate them from the ambulatory memory care residents in the first floor memory care. AD and LE provided conflicting information regarding whether these residents needed to be in a memory care. However, the facility did not notify LPA of this new memory care with delayed egress, request an update to its plan of operation, or receive approval for this change and LPA first learned of this new memory care after observing it months after it was created. During the inspection, the maintenance manager attempted the deactivate the delayed egress doors but was unsuccessful. LE stated they will deactivate and permanently disassemble the delayed egress system on the third floor and will ensure all residents who need to be in a memory care are relocated to the first floor memory care. LPA advised LE on the process for properly requesting a new memory care for approval if LE is interested in adding a third floor memory care. CONTINUED On April 23, 2025, Department staff requested a copy of the facility’s insurance policy. On April 23, 2025, LE submitted to LPA the facility’s insurance certificate and binder for the period November 12, 2024 to November 12, 2025 for the insurance policy ending in 8506. However, review of this insurance binder revealed that the facility’s insurance does not provide the required coverage of “injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees,” including because the insurance contains sub-limits of one hundred thousand dollars ($100,000) per occurrence and three hundred thousand dollars ($300,000) in the total annual aggregate for claims relating to elopement, sexual abuse, and pressure injury, which are typical injuries and issues seen in this facility type. Based on the information obtained, the facility currently does not have insurance that is compliant with Title 22 Regulations. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 11, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87208(a) · Plan of correction due date: Jun 12, 2025

87208 Plan of Operation (a) … Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval… This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not notify LPA or obtain approval for a new memory care on the third floor not included in the facility’s plan of operation when the facility was licensed, which poses an immediate safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Licensee stated they will deactivate and permanently disassemble the delayed egress system on the third floor and will ensure all residents who need to be in a memory care are relocated to the first floor memory care and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.605 · Plan of correction due date: Jun 12, 2025

… all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least ... ($1,000,000) per occurrence and ... ($3,000,000) in the total annual aggregate... This requirement was not met as evidenced by: Based on documents, the licensee did not maintain liability insurance covering injury to residents and guests in the amounts required due to sub-limits on injuries typical in this facility type, which poses an immediate personal rights risk to up to 93 persons in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Licensee stated they will obtain liability insurance that complies with Health & Safety Code section 1569.605 and submit proof to LPA by POC due date.

Allegation investigated: Staff lack of care and supervision resulting in resident sustaining unstageable pressure injury.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. The investigation into the allegation of staff lack of care and supervision resulting in resident sustaining unstageable pressure injury revealed the following: During the course of the investigation, Department staff inspected the facility, interviewed witnesses and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) UCI Medical Records, R1’s Physician’s Report dated March 23, 2024, R1’s undated Appraisal/Needs and Services Plan, and R1’s Nurse Progress Notes. CONTINUED Substantiated It was alleged that, due to lack of care and supervision by facility staff, R1, who is bedridden and wheelchair bound, sustained an unstageable wound on their tailbone at the facility. Per R1’s UCI Medical Records, on July 15, 2024, R1 was admitted to the hospital and diagnosed with a 2.5 centimeter by 2.5 centimeter unstageable bed sore on the tailbone which is black in appearance. Per R1’s Physician’s Report dated March 23, 2024, R1 has Dementia, is non-ambulatory and uses a wheelchair, and is incontinent. R1’s undated Appraisal/Needs and Services Plan indicates R1 is incontinent, uses diapers, and requires staff to change their diapers. Four staff described that R1 needs assistance with all activities of daily living and spends a majority of their time in bed. Based on this information, R1 was at risk for developing pressure injuries. Three staff stated that residents are repositioned and checked for skin conditions every two hours, as well as during clothing changes, diaper changes, and showers, but no body check logs are maintained and instead any issues are reported verbally to the medication technician. Staff #1 (S1), who changed R1 at least once during the overnight shift from 10:30PM on July 14, 2024, to 7:00AM on July 15, 2024, denied seeing any wounds on R1, but also denied that they were properly repositioning R1 because R1’s body is very rigid. Staff #2 (S2) stated they noticed a quarter-sized red wound on R1’s tailbone around July 8, 2024, they reported it to Staff #4 (S4), the facility’s medication technician, and they put cream on the wound but were unable to tell if the wound was improving. S4 claimed they first learned of R1’s wound on July 15, 2024, confirmed they are not qualified to provide wound care, and stated that when they learned of R1’s wound on July 15, 2024, they reported to Witness #1 (W1), a third-party nurse who was present at the time. W1 stated they have previously provided treatment for R1’s occasional rashes, on July 15, 2024, they were advised by S4 of R1’s wound, they were unable to assess the wound due to R1 having a separate injury which required transfer to the hospital, but they were able to place a bandage on the wound prior to R1 going to the hospital. R1’s Nurse Progress Notes, which date from May 18, 2024, through R1’s hospitalization on July 15, 2024, do not document that any wounds were noticed or treated. Based on the information obtained, facility staff were not properly repositioning R1 and did not obtain assessment or treatment for R1’s wound for a week after its discovery around July 8, 2024. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that, due to lack of care and supervision by facility staff, R1, who is bedridden and wheelchair bound, sustained a right femur fracture which required hospitalization. Per R1’s Physician’s Report dated March 23, 2024, R1 has Dementia, is non-ambulatory and uses a wheelchair, and leans forward while in a wheelchair which indicates that R1 is a fall risk. Four staff described that R1 needs assistance with all activities of daily living, spends a majority of their time in bed, cannot get out of bed or their wheelchair alone and does not attempt to do so, and requires two staff to transfer between their bed and wheelchair. Per Staff #1 (S1), on July 15, 2024, between 5:30AM and 6:00AM, they checked on R1, observed R1 moving around in bed, was starting to change R1 but heard a noise like a bone moving, did not observe any visible injuries, and reported the issue to Staff #2 (S2) and Staff #3 (S3) at shift change. S1 worked the overnight shift from 10:30PM on July 14, 2024, to 7:00AM on July 15, 2024, and had changed R1 previously during this same shift and did not notice any issues with R1. Per S2 and S3, on July 15, 2024, around 5:30AM, they went to R1’s room, saw R1 in bed, were advised by S1 that R1 was not acting normal, but noted that R1 was comfortable, eating breakfast, and not complaining of pain. S2 also provided a conflicting statement that they saw R1 on the floor and placed R1 back in bed, but later rescinded this statement. S2 and S3 had also worked on July 14, 2024, changed and bathed R1, and did not notice any issues with R1 on that day. Two additional staff provided statements that they observed no issues with R1 on July 14, 2024, and staff interviews and facility records did not reveal any reported falls for R1 relating to this injury. Staff #4 (S4), the facility’s medication technician, stated they were advised of the situation with R1 on the morning of July 15, 2024, they checked on R1 and noted R1’s upper right thigh was swollen, and they called an ambulance and requested an assessment from Witness #1 (W1), a third-party nurse who was present at the time. Per W1, after being advised of the issue with R1, they assessed R1, observed swelling on R1’s thigh but no redness or bruising, and noted R1 did not complain about pain. R1’s UCI Medical Records reveal that on July 15, 2024, R1 was diagnosed with a “displaced comminuted fracture of shaft of right femur”, which is a fracture in the large upper leg bone where the bone is in at least three pieces which are no longer in alignment, R1 underwent “R femur ORIF” on July 16, 2024, which is a surgery to realign and connect the broken pieces of bone using a plate and screws, and R1 was recommended for hospice. One of R1’s treating physicians provided a statement indicating they could not definitively say what caused R1’s fracture, it is highly likely it was caused by a rotational injury, but due to R1’s age and poor quality of bone structure, it is possible the fracture may have been caused when R1 moved or their leg was moved by another person to change them. The information obtained regarding what caused R1’s fracture is conflicting and did not corroborate the allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 4, 2025 · control 22-AS-20240724111701

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Jun 5, 2025

87465 Incidental Medical and Dental Care (a)… (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not ensure R1 received proper wound assessment and care for their unstageable pressure injury, which poses an immediate health risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Jun 4, 2025

Plan of correction: Licensee stated they will retrain staff on repositioning, noticing skin conditions, and obtaining proper care for any noticed skin conditions and will submit proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20240724111701. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During the course of the investigation, Department staff inspected the facility, interviewed staff, and obtained and reviewed copies of the resident roster, staff roster, an Incident Report dated July 15, 2024, and Resident #1’s (R1) UCI Medical Records. Per an Incident Report dated July 15, 2024, on July 15, 2024, at 9:00AM, R1 was found with a right swollen leg and sent to the hospital. R1’s UCI Medical Records and staff interviews revealed that R1 was diagnosed at the hospital with a femur fracture as a result of this incident. However, based on Orange County Regional Office (OCRO) records, the facility did not submit the Incident Report dated July 15, 2024, to the OCRO or submit any other incident reports regarding this injury as required. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Jun 11, 2025

87211 Reporting Requirements (a) … (1) A written report shall be submitted to the licensing agency … within seven days of the occurrence of … (B) Any serious injury... This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not report R1’s femur fracture to the OCRO, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 4, 2025

Plan of correction: Licensee stated they will create a protocol to ensure incidents are being properly reported and submit proof to LPA by POC due date.

Type of visit: Office

Licensing Program Analyst (LPA) Sean Haddad conducted an office meeting on April 23, 2025, to follow up on a substantiated complaint investigation. LPA Haddad met with Licensee Erik Doan and reviewed the report. On November 2, 2023, the Department concluded a complaint investigation regarding the following allegation: Facility staff did not adequately supervise resident resulting in resident wandering from facility and sustaining multiple injuries. The allegation was substantiated, and the licensee was cited under California Code of Regulations (CCR) § 87464(f)(1) Basic Services. At the time of the complaint visit on November 2, 2023, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation. This is evidenced by the licensee not providing proper care, supervision, and not providing sufficient staffing. Continued on LIC809-C This resulted in a resident eloping from the facility, suffering significant facial injuries, including extensive bruising and multiple fractures which required medical intervention. Today April 23, 2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on November 2, 2023, the amount of the civil penalty issued today will be $9,500. An exit interview was conducted. A copy of the report was issued. Appeal Rights provided to Licensee Erik Doan and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Apr 23, 2025

Type of visit: Office

Licensing Program Analyst (LPA) Sean Haddad conducted an office meeting on April 23, 2025, to follow up on a substantiated complaint investigation. LPA Haddad met with Licensee Erik Doan and reviewed the report. On November 9, 2023, the Department concluded a complaint investigation regarding the following allegation: Resident went AWOL from the facility due to lack of care and supervision. The allegation was substantiated, and the licensee was cited for California Code of Regulations (CCR) § 87464(f)(1) Basic Services. At the time of the complaint visit on November 9, 2023, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(e). The Department has concluded an analysis and has determined that a civil penalty is warranted for a violation that Department determines resulted in the death of the resident in accordance with health and Safety Code Section § 1569.49. This is evidenced by the licensee not providing proper care, supervision, and not having sufficient personnel. This resulted in R1 eloping from the facility, R1 being struck by a car, and dying. Continued on LIC809-C Today April 23, 2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(e) for a violation that the Department determines resulted in the R1’ death in the amount of $15,000. However, since an immediate civil penalty of $500 was previously issued on November 9, 2023, the amount of the civil penalty issued today will be $14,500. An exit interview was conducted. A copy of the report was issued. Appeal Rights provided to Licensee Erik Doan and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Apr 23, 2025

Allegation investigated: Staff did not seek a resident timely medical attention due to a fall.

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA arrive at facility was greeted and granted entry by staff. LPA spoke with Michelle Song, Administrator and explained the purpose of the visit. Findings are based upon this investigation which included resident file review, tour of the physical plant of the facility and interviews conducted. It is alleged that facility staff did not seek a resident timely medical attention due to a fall. Complaint detail stated resident (R1) was in the hospital on April 13, 2023, and had a fall three days prior. Records review revealed that the department received an LIC624 incident report for R1 incident date April 12, 2024. Report indicated that resident’s daughter was visiting them at the facility and requested for R1 to be sent Continued on LIC9099-C Unsubstantiated out to the hospital. In record review there was no other incident reported or fall on record for R1 prior to April 12, 2023. Interview with 3 of 3 staff stated that R1 was sent out by request of the daughter due to observation of weakness and not eating well. Upon request staff immediately called ambulance services and was sent out. R1 had no incident of falls prior to being sent out. Records review reflects R1 having general weakness, but did not require any mobility equipment, did not have any physical difficulties, and had the functional skills ability for self. No record of fall or R1 being fall risk. Based on the information gathered during the investigation, interviews and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. This report was reviewed with Administrator and a copy was furnished to the facility.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 22-AS-20240417084403

Allegation investigated: Memory Care residents are not being showered. Resident has an infection due to neglect by staff. Staff are not assisting residents who needs assistance with feeding.

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegation. LPA arrive at facility was greeted and granted entry by staff. LPA spoke with Michelle Song, Administrator and explained the purpose of the visit. Findings are based upon this investigation which included resident file review, tour of the physical plant of the facility and interviews conducted. It is alleged that memory care residents are not being showered. Record review reflects that facility uses a schedule as well as a shower body check from that caregivers use when showering the residents. The shower schedule reflects two shower schedules for morning and evening showers. Schedule and log reflect the residents in memory care that received showers and the time. Interview with 6 of 6 residents Continued on LIC9099-C Unsubstantiated stated that they get help with showers, and they have never had an issue with getting a shower. It is alleged that resident has an infection due to neglect by staff. Interview with resident (R1) states that they have a nurse that comes out every 8 days to check their catheter and overall health, that same nurse comes once a month to change out the catheter. R1 states they have never had an issue as the nurse is consistent with her visits. Facility staff help with everything they need and are very friendly and nice to them. They have always gotten me the help that they have needed. R1 indicated that they get assistance with showers, repositioning, food delivery, but he doesn’t need help with eating. R1 doesn’t recall every having an infection while being at the facility. Interview with 2 of 2 staff that assist R1 states that they help R1 with showers, bringing food trays and anything else that R1 may need. They don’t recall R1 having an infection every while here at the facility. It is alleged that staff are not assisting residents who need assistance with feeding. On January 2, 2025, LPA Mason conducted a complaint visit and observed resident in various dining rooms at the facility eating their own meals not needing assistance. Staff was delivering food trays and on the third floor observed two residents in the dining room receiving feeding support from staff during lunch. On todays visit LPA Martinez observed various residents in all dining rooms receiving assistance with feeding. LPA observed staff spoon feeding residents and/or guiding resident with feeding. LPA Martinez made the observation in the breakfast and lunch times. Interview with 3 of 3 staff stated that caregivers help those residents that need assistance with feeding by either doing spoon feeding and/or giving stand by assist with feeding. Trays are delivered to residents’ room and if resident needs assistance with feeding another caregiver comes to provide that assistance. Interview with 6 of 6 residents stated that they have been assisted or have observed that staff help residents with feeding. Based on the information gathered during the investigation, interviews and review of all documents obtained, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. This report was reviewed with Administrator and a copy was furnished to the facility.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 22-AS-20241223122921

Allegation investigated: Excluded person is operating the facility Facility is not properly screening residents for Tuberculosis Facility is not allowing residents to select their own medical providers Facility is not ensuring residents’ medical needs are met Administrator is not on the premises a sufficient number of hours to adequately manage the facility Facility falsified records Facility staff left residents unsupervised Facility staff are not providing medications as prescribed Facility staff are violating residents' personal rights Facility has insufficient food supplies Residents are not receiving treatment for scabies

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on April 23, 2024. LPA was greeted and granted entry into the facility and met with Administrator (AD) Michelle Song. LPA explained the reason for the visit. This Department has investigated the complaint alleging that excluded person is operating the facility. Regarding the allegation the following was revealed: During the course of the interviews one of fourteenth individuals interviewed confirmed the allegations. During the course of the investigation LPA reviewed documents including the Licensing Information System (LIS) Facility Personnel Report Summary dated May 02, 2024. During the subsequent visit on April 11, 2025, LPA reviewed the Guardian Employee Roster dated April 10, 2025. Per LIS Facility Personnel Report Summary and Guardian Employee Roster, Staff 1 (S1) is not associated to the facility. During the course of the interviews with residents, Resident 1 (R1) reported that she does not know if an excluded person is operating the facility. CONTINUED ON LIC9099-C... Unsubstantiated During the course of the interviews with staff, S2 reported that S1 used to work when she started but no more. Per S3 an excluded person is not operating the facility and stated that she does not know S1. Regarding the allegation that facility is not properly screening residents for Tuberculosis, the following was revealed: During the course of the interviews with staff, S3 reported that she believes that residents get screened properly for Tuberculosis. During the course of the interviews with residents, R1 reported that residents get screened for Tuberculosis. During the investigation LPA reviewed documents including the Physician Reports (LIC602s) for R1-R5. Per Physician Report dated September 16, 2024, R1 tested negative for Tuberculosis. Per Physician Report dated April 10, 2024, R2 tested negative for Tuberculosis. Per Physician Report dated February 06, 2025, R3 tested negative for Tuberculosis. Per Physician Report dated unknown, R4 tested negative for Tuberculosis. Per Physician Report dated January 14, 2025, R5 tested negative for Tuberculosis. Regarding the allegation that facility is not allowing residents to select their own medical providers, the following was revealed: During the course of the interviews with residents, R1 reported that residents are allowed to select their preferred medical provider. During the course of the interviews with staff, S2 reported that residents can choose their own Doctor. Per S4 the residents have options when it comes to selecting their medical provider. Per S5 the residents choose their own medical provider. LPA reviewed documents including the Grace Retirement Village Admission Agreement. Per Admission Agreement under Resident Participation in Decision Making it states as a resident, you, or your representative, or both, are entitled and encouraged to participate in decision-making regarding your care and services. Per Health and Safety Code section 1569.80(a) it states a resident of a residential care facility for the elderly, or the resident’s representative, or both, shall have the right to participate in decision-making regarding the care and services to be provided to the resident. Regarding the allegation that facility is not ensuring residents’ medical needs are met, the following was revealed: During the course of the interviews with residents, R1 reported that her medical needs are being met. During the course of the interviews with staff, S2 reported that the residents’ needs are being met and stated that the residents get transported to their medical appointments via medical transportation vans. S3 reported that the residents' medical needs are being met and stated that the Nurses always come to check on the residents. S4 stated that the residents’ medical needs are being met. Per S5 the facility is meeting the residents' medical needs. CONTINUED ON LIC9099-C... Regarding the allegation that Administrator is not on the premises a sufficient number of hours to adequately manage the facility, the following was revealed: During the course of the investigation LPA reviewed documents including the Personnel Report (LIC500) dated April 01, 2024. Per Personnel Report AD is schedule to work Monday through Friday from 9:00 a.m. to 5:00 p.m. LPA also reviewed the Personnel Report dated April 04, 2025. Per Personnel Report AD Michelle Song is scheduled to work Monday through Friday from 9:00 a.m. to 5:00 p.m. During the course of the interviews with residents, R1 reported that the AD is always in and out of the facility and stated that the AD is helpful. During the course of the interviews with staff, S2 reported that the AD is at the facility at 8:00 a.m. and is still here after she is off at 3:30 p.m. Per S4 the AD is at the facility from 8:00 a.m. to 6:00 p.m. Per S5 the AD is at the facility every day for a couple of hours. Regarding the allegation that facility falsified records, the following was revealed: During the course of the interviews one of fourteenth individuals interviewed confirmed the allegation. During the course of the interviews with residents, R1 reported that she does not know if staff falsify records. During the course of the interviews with staff, S2 reported that staff have never falsified records. Per S3 she is not aware if the staff have falsified records. S5 reported that staff have not falsified facility records. Regarding the allegation that facility staff left residents unsupervised, the following was revealed: During the course of the interviews with residents, R1 reported that staff never leave the residents unsupervised. During the course of the interviews with staff, S2 reported that staff have never left the residents unsupervised. Per S3 she has never seen residents being left unattended. S4 stated that staff never leave the residents unsupervised. Per S5 caregivers check on the residents every two to three hours. During the two subsequent visits LPA observed one Medication Technician and six caregivers on duty for 99 residents in care. Regarding the allegation that facility staff are not providing medications as prescribed, the following was revealed: During the course of the investigation LPA reviewed documents including the Medication Administrator Record (MAR) dated April 2025 for R1-R5. Per MAR R1-R5 are getting their medications as prescribed. During the course of the interviews with residents, R1 reported that she gets her medications as prescribed. During the course of the interviews with staff, S4 reported that staff are giving the medications as prescribed. Per S5 staff give the medications as prescribed by the Doctor. CONTINUED ON LIC9099-C... Regarding the allegation that facility staff are violating residents' personal rights, the following was revealed: During the course of the investigation LPA reviewed documents including the Resident Personal Rights in-service training dated November 07, 2024. LPA also reviewed the Health and Safety of Residents in-service training dated January 15, 2025. During the course of the interviews with residents, R1 reported that staff respect the residents' personal rights and reported that staff are nice. During the course of the interviews with staff, S2 reported that staff are not violating the residents' rights and reported that staff do their best. Per S3 staff are very respectful and always respect the residents’ personal rights. S4 stated that staff are very educated and reported that staff do not violate the residents' personal rights. Regarding the allegation that facility has insufficient food supplies, the following was revealed: During the subsequent visit on April 11, 2025, LPA tour the kitchen and observed the following: onions, oranges, lemons, carrots, lettuce, eggs, broccoli, rice, frozen meats and unexpired canned food. During the subsequent visit on April 22, 2025, LPA tour the facility and observed the following: LPA observed staff cooking squash with shredded chicken for lunch. LPA observed unexpired canned foods such as green beans, mixed vegetables, diced tomatoes, white chicken, salmon, peanut butter, beans and mashed potatoes. LPA also observed bread, bananas, potatoes and carrots. During the investigation LPA reviewed documents including the Grace Retirement Village weekly menu dated March 20, 2025. Per weekly menu the residents get a different meal for breakfast, lunch and dinner. Per weekly menu under alternatives, it states: ham/turkey sandwich, egg salad sandwich, chef salad, omelette, peanut butter and jelly or hot dog. During the course of the interviews with residents, R1 reported that the food is not that great and reported that she gets enough food and can substitute an item that she does not like. During the course of the interviews with staff, S2 reported that the facility has enough food and stated that if a resident wants more that they can ask for seconds. Per S3 if a resident asks for a substitution the kitchen staff will provide it. S4 stated that the facility has enough food and reported that the residents have not complained about the food. Regarding the allegation that Residents are not receiving treatment for scabies, the following was revealed: During the course of the interviews with residents, R1 reported that she has not had scabies and reported that she does not know if there were scabies. During the course of the interviews with staff, S3 reported that she has never seen scabies and stated that management has never informed staff about scabies. S3 stated that she has been working here for five years and reported that she has never had an infection. S3 reported that if there were scabies that she would be infected since she provides showers. Per S4 no resident has had scabies. CONTINUED ON LIC9099-C... During the investigation LPA reviewed documents including the Grace Retirement Village Infection Control. Per Infection Control standard precautions include a group of infection prevention practices that apply to all residents, regardless of suspected or confirmed infection status. Per Infection Control these practices include: hand hygiene, use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with AD Song, and a copy of this report was provided to the facility. Per California Code of Regulations under Resident Records section 87506 it states: Each resident’s record shall contain at least the following information: Physician Report (LIC602), Appraisal/Needs and Services Plan, Personal Rights, Admission Agreement, I.D. and Emergency Information, Centrally Stored Medication Destruction Record, and Safeguards for Cash Resources. Based on observations and the interviews which were conducted, the preponderance of evidence standard has been met, therefore the following allegation: Resident files do not contain all required information is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted with AD Song and a copy of this report along with the Appeal Rights were provided at the time of this visit.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 22-AS-20240423112858

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(a)(b) · Plan of correction due date: Apr 23, 2025

Resident Records 87506(a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. (b) Each resident’s record shall contain at least the following information. This requirement was not met as evidence by: files for R1-R5 only had the Physician Report (LIC602), Appraisal/Needs and Services Plan, Personal Rights and Admission Agreement.the state’s words, verbatim · CDSS document, Apr 22, 2025

Plan of correction: Licensee to update the Resident Records and email LPA proof by POC due date. A written statement will be submitted by the Licensee/Administrator that the he/she understood the regulation and will comply. Each resident’s record shall contain at least the following information: Physician Report (LIC602), Appraisal/Needs and Services Plan, Personal Rights, Admission Agreement, I.D. and Emergency Information, Centrally Stored Medication Destruction Record, and Safeguards for Cash Resources.

Allegation investigated: Staff did not obtain timely medical treatment after resident sustained an unwitnessed fall.

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA Tirre was greeted and granted entry into the facility by Administrator Michelle Song and explained the reason for the visit. During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation including Los Angeles Community Hospital Records. The purpose of today’s visit is to follow up on an investigation conducted by the Department regarding the above allegation. The investigation conducted revealed the following: Resident 1 (R1) was admitted to the facility on May 26, 2023. Per physician report dated June 07, 2023, R1 has a primary diagnosis of hypertension with no cognitive impairments. R1 is further listed as having a diagnosis of osteoporosis and able to communicate needs. On July 17, 2023, R1 was admitted to Los Angeles Community Hospital at 9:47 PM, after informing facility staff they had sustained an unwitnessed fall and began complaining of hip pain. CONTINUED ON 9099C Unsubstantiated At the time of being admitted, hospital records report R1 was unable to move or walk. Upon being admitted, R1 was diagnosed with a pelvic fracture. Based on interview, a facility staff (S1) stated on 7/17/23, R1 informed S1 that they had fallen in their bedroom after lunch but denied experiencing any pain or discomfort. S1 did not observe bruises or swelling on R1; however, R1 appeared to be in pain at the hip prompting S1 to persuade R1 to go to the hospital. S1 did not contact 911, as the situation was not considered an emergency or life-threatening. Instead, S1 called area hospitals, and Los Angeles Community Hospital was the only nearby hospital with medical transport vehicles available. An ambulance arrived and transported R1 to the hospital. R1’s Power of Attorney (POA) was notified prior to the transport. When interviewed, R1 could not recall how they fell but stated they felt safe at the facility. R1’s Power of Attorney (POA) reported last seeing R1 on July 15, 2023, at which time R1 appeared to ambulate fine and did not complain of any pain or discomfort. Per facility needs and assessment plan dated May 26, 2023, R1 uses a walker when ambulatory and has no limitations when transferring to bed. Although R1 sustained an unwitnessed fall and staff did not immediately call 9-1-1, R1 was able to communicate their pain level to staff and did not present in dire need to be medically evaluated. Based on R1’s assessment, R1 was alert and able to accurately communicate their needs. Therefore, based on interviews conducted and documents reviewed, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator Song, and a copy of this report and confidential names list was left at the facility.the state’s words, verbatim · CDSS document, Apr 15, 2025 · control 22-AS-20230718165749

Allegation investigated: Resident developed a stage 3 pressure injury while in care due to neglect

Licensing Program Analyst (LPA) Jenifer Tirre met with Administrator Michelle Song for the purpose of delivering findings for the above allegations. The investigation consisted of the following: On October 5, 2023, the department toured the facility, obtained records, interviewed staff and witnesses. Based on records review, R1 was admitted to the facility on May 26, 2023. R1 is ambulatory and uses a walker, and no history of skin condition or breakdown according to physician’s report dated August 23, 2023. R1’s appraisal/needs and services plan dated August 23, 2023, indicates R1 uses a walker to ambulate, no limitation when transferring to bed, no disorientation, and occasionally incontinent. The department interviewed four staff (S1, S2, S3, S4). Medication technician (S1) stated caregivers reported to S4, a Licensed Vocational Nurse (LVN) that R1 has a sore on the back on September 15, 2023. Three staff (S1, S2, S3) stated they observed redness, a rash, or a small “red spot” at R1’s coccyx area that was treated with some type of ointment by the facility LVN (S4). CONTINUED ON 9099C Substantiated S3 stated they assisted R1 with bathing, clothing, diaper changes, feeding and checked R1 every two to three hours. S3 denied there was a care log to keep track of the care and services provided to R1. During this investigation, the department made several attempts (dated January 12, 2024, January 17, 2024, January 18, 2024 & January 22, 2024) to reach S4 but was unsuccessful in reaching S4. All three staff members (S1, S2, S3) confirmed that S4 no longer works for the facility. All three staff denied R1 had home health services while in care at the facility. The department conducted interviews with five witnesses. One witness (W1) revealed on September 17, 2023, W1 observed R1’s buttocks was red and had black dark spots. Other witnesses (W2 and W3) denied being aware of R1’s pressure injury while in care at the facility. On September 19, 2023, S1 stated R1’s vital signs were checked and found that R1 was not in good condition, 911 was called and R1 was taken to Providence St. Jude Medical Center. R1 was admitted to the hospital for multiple medical conditions and hospital staff discovered the pressure injury on R1. Per review of hospital records and photos, it was revealed that R1 had multi-medical problems including an unstageable coccygeal decubitus ulcer. That was confirmed by a Medical Consultant II of the Division of Medi-Cal Fraud and Elder Abuse, Office of the Attorney General, Department of Justice, who specializes in Elder Abuse who reviewed R1’s medical records. On September 22, 2023, R1 was admitted to hospice at Providence St. Jude Medical Center. R1 deceased at the hospital on September 23, 2023 due to cardiopulmonary arrest, sepsis, urinary tract infection and metastatic ovarian cancer per death certificate dated September 28, 2023. It was revealed that R1’s cause of death was unrelated to pressure injury. Based on observations, interviews and records reviewed, the preponderance of evidence has been met, the allegation, “Resident developed a stage 3 pressure injury while in care due to neglect” is SUBSTANTIATED. An Enhanced Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f) The facility is being cited per Title 22, Division 6 of the California Code of Regulations. An Immediate Civil Penalty is being assessed. An exit interview was conducted with Administrator Song, and a copy of this report, 9099-D Page, Copy of Civil Penalty Assessment Form and appeal rights was provided. During visit on 10/5/2023, LPA Tirre observed 13 staff members present and assisting residents with meals and activities of daily living. LPA Tirre did not observe any health and safety risks of residents in care during investigation. Based on staff interviews and observations the allegation facility lacks staffing to meet resident’s needs is deemed UNSUBSTANTIATED. Based on the information gathered through interviews and observations, there was not a preponderance of evidence to prove or disprove that the Facility lacks staffing to meet residents needs. An exit interview was conducted with Administrator Michelle Song and a copy of this report was provided to facilitythe state’s words, verbatim · CDSS document, Apr 15, 2025 · control 22-AS-20231004105837

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Apr 17, 2025

87615 (a) Prohibited health conditions. Persons who require health services for or have a health condition including, but not limited to those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on observations, interviews, and record review, the licensee retained R1 who had prohibited health condition of unstageable pressure injury while in care at the facility. The licensee failed to seek a higher level of care for R1. This poses an immediate health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2025

Plan of correction: The administrator agreed to ensure all residents with prohibited conditions are not admitted or retained in the facility. The administrator shall conduct an in-service training on pressure injury prevention to all direct care staff. The administrator shall self-certify understanding and compliance to the section 87615(a)(1). POC shall be submitted to jenifer.tirre@dss.ca.gov by the POC due date.

Type of visit: Case Management - Other

This unannounced Case Management – Other inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of hand delivering a Noncompliance Conference letter dated April 14, 2025 (NCC Letter). LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. Licensee (LE) Erik Doan appeared via telephone. During the inspection, LPA inspected the facility, conducted health and safety checks on residents, and observed no health and safety issues. LPA hand-delivered the NCC Letter to AD scheduling a Noncompliance Conference to be held in-person at the Orange County Regional Office on Wednesday, April 23, 2025, at 10:30 AM. LE confirmed receipt of the NCC Letter and confirmed his attendance at the currently scheduled time. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Apr 15, 2025

Allegation investigated: Staff member did not treat residents with dignity and respect

Regarding the allegation: Staff member did not treat residents with dignity and respect 10 of 11 individuals denied the compliant allegation. During the investigation it was discovered the incident involving the police arriving at the facility was not caused or related to (S3). It is unclear exactly who the police were called on, but the police were not called because of a facility staff member or a facility resident. The police were called on someone visiting one of the residents or attempting to visit one of the residents. According to Staff 2 (S2) someone came to visit Resident 1 (R1) and the person arrived with an attitude. S2 explained that when the person was asked to sign in, the person refused, and the person was saying a lot of “F” words. S2 said the person was yelling and yelling, so S2 called 911 twice. S2 said R1’s family was also contacted. When a family member of R1 arrived at the facility, the family member of R1 had the person who was attempted to visit, arrested. Continued on LIC9099C Unfounded Witness 2 (W2) claims the police were called to the facility because a visitor showed up (to the facility) and was not willing to do what they (staff) wanted them to do. The person thought they could do whatever they wanted to, according to the witness. W2 claims, the person who arrived at the facility and was being disruptive, struck (hit) one of the workers (S3) before eventually being arrested. According to S3, who was present when the person arrived at the facility, said the person grabbed S3’s chest area and S3 ran to a resident’s room because S3 was scared. According to S2, the family member/POA for R1 was contacted by facility staff, arrived at the facility, and had the person who was being disruptive arrested. Based on the information gathered during through interview, observation, and document review, the following allegation: Staff member did not treat residents with dignity and respect, is deemed Unfounded, meaning the allegation is false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 14, 2025 · control 22-AS-20240711144555

Allegation investigated: Staff member handles residents in a rough manner

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to complete the investigation into the allegation above. During the visit LPA Haley conducted, interviews, collected additional documents and toured the facility to make observations. The complaint investigation consisted of interviews with 11 individuals, including interviews with facility residents and staff. Regarding the allegation: Staff member handles residents in a rough manner 10 of 11 individuals denied the complaint allegation. Staff 1 (S1) denied the allegation and added that Staff (3) is loved by the residents and added that, S3 is a good caregiver. Staff 4 (S4) said the same thing when specifically asked about S3. According to S4, S3 treats the residents good and some of the resident love S3. S4 added, S3’s voice is loud, but that’s just S3’s personality. S3 is not yelling. Further, during interviews with S4 and Staff 5 (S5) both said they would make a report if they ever witness a resident being handled rough or not treated with respect. Continued on LIC9099C Unsubstantiated S5 said, I will report it. We’re here to help them. They’re innocent, that’s why we’re hear… to help them. Based on the information gathered during interviews and document review, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 14, 2025 · control 22-AS-20240711144555

Allegation investigated: Facility staff did not obtain timely medical care for resident. Facility staff did not ensure that resident was administered their medication(s) as prescribed. Facility staff offered oxygen to resident without a doctor's order. Facility staff failed to notify responsible party of injury.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. The investigation into the allegations that facility staff did not obtain timely medical care for resident, facility staff did not ensure that resident was administered their medication(s) as prescribed, facility staff offered oxygen to resident without a doctor's order, and facility staff failed to notify responsible party of injury revealed the following: During the course of the investigation, Department staff inspected the facility, interviewed witnesses and staff, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Physician’s Report dated February 28, 2024, R1’s Primary Care Medical Records, R1’s Home Health Medical Records, a facility communication log entry dated April 7, 2024, R1’s Chapman Global Medical Records, R1’s Chapman Care Center Medical Records, R1’s Garden Grove Hospital Medical Records, R1’s Medication Administration Records for March 2024, and R1’s Medication List dated February 29, 2024. Substantiated Regarding the allegation that facility staff did not obtain timely medical care for resident: it was alleged that the facility did not obtain timely medical care for R1 after their fall. R1’s responsible party stated that, prior to April 2024, R1 was able to talk, walk, and eat, and that R1 had been seen by their doctor and determined to be in good health. Per R1’s Physician’s Report dated February 28, 2024, R1 had confusion but was able to follow instructions and communicate their needs. Per R1’s Primary Care Medical Records, R1 was referred to home health for physical therapy relating to movement on February 29, 2024, R1 had diagnoses of Dementia, major depressive disorder, abnormalities of gait and mobility, and generalized muscle weakness, and R1 required a walker. Per R1’s Primary Care Medical Records, R1’s doctor examined R1 on March 22, 2024, and noted R1 to be alert to person, place, and time and determined R1’s physical examination to be within normal limits. R1’s Home Health Medical Records revealed that R1 required assistance with most activities of daily living, could not independently make changes in body position, required a walker for walking, and had multiple risk factors for falling, including a prior history of falls within three months. R1’s Home Health Medical Records indicate that physical therapy sessions were conducted at the facility, R1 had good participation in all exercises, was making progress, had a good appetite during the March 28, 2024, and April 4, 2024, sessions, but was noted as having new pain and weakness during the April 11, 2024, session. R1’s physical therapist stated that they had noticed a bruise on R1’s face, were advised by R1 that they had fallen, and reported the fall to the facility. R1’s responsible party stated that on April 8, 2024, shortly after 12:00PM, they visited R1 at the facility and found that R1 was lying in bed, was unable to open their eyes, had difficulty speaking, had a bruise on their left eyelid, and complained of pain when they were touched. R1’s responsible party was told by Staff #1 (S1) that R1 had fallen while trying to go the bathroom and that R1 was not injured, but S1 did not say when the fall occurred or provide additional details. R1’s doctor stated they were not notified of the fall by the facility and per R1’s Primary Care Medical Records, R1’s doctor only learned of R1’s injury on April 18, 2024, when R1’s responsible party told them about it. A facility communication log entry dated April 7, 2024 indicates that at 11:00AM, Staff #2 (S2) reported that R1 was lying on the floor, R1 denied falling, S1 checked R1’s vitals which were normal and noted no bruises or bleeding, R1 refused to go to the hospital, S1 gave R1 Tylenol, R1 went the rest of the day “without any symptoms”, and Staff #3 (S3) was present during this incident as well. Per facility staff, S1 no longer works at the facility and multiple attempts to interview S1 were unsuccessful. S2 remembered seeing R1 on the floor on April 7, 2024, but could not recall any other details from the incident. S2 stated that the last time they saw R1 before the fall was between 8:30AM and 9:00AM. S3 recalled seeing R1 on the floor on April 7, 2024, at 11:00AM, stated that they had last checked on R1 around 10:30AM, and did not recall seeing any injuries on R1. Per R1’s responsible party, on April 9, 2024, R1’s family visited R1 and noted R1 was unable to eat solid food, speak, or open their eyes. On April 10, 2024, R1’s responsible party visited R1, was not told anything by staff about R1 having a fall, and noted R1 could not open their eyes or speak and that every movement R1 made was so painful that R1 screamed. On April 11, 2024, R1’s responsible party visited R1 and noted R1 could not talk, had a new bruise on their right cheek, and was unable to walk. On April 12, 2024, R1’s responsible party visited R1 and noted R1 appeared to be getting worse and requested that R1 be taken to a hospital. Per R1’s Chapman Global Medical Records, R1 was seen in the emergency department on April 12, 2024, with chief complaints of hip and face pain, swelling above the right eye, decreased appetite, and increased pain. Testing revealed a right subdural hematoma (brain bleed) up to 14 millimeters thick, a comminuted (three or more pieces of broken bone) depressed fracture of the right zygomatic arch (cheek bone), but no skull fracture. R1 was determined to need a higher level of care, was admitted for inpatient treatment that same day, and was thereafter discharged to Chapman Care Center on May 1, 2024. Per R1’s Chapman Care Center Medical Records, R1 was admitted for skilled nursing care on May 1, 2024, R1’s diagnoses included traumatic subdural hemorrhage (brain bleed) without loss of consciousness, R1 had hip pain but no hip fracture, and R1 was transferred to Garden Grove Hospital on May 16, 2024, because they needed a higher level of care. Per R1’s Garden Grove Hospital Medical Records, R1 was admitted on May 16, 2024, with a chief complaint of respiratory distress and a history that included subdural hemorrhage (brain bleed), R1 had difficulty breathing, and R1 passed away on May 17, 2024. Based on the information obtained, after R1 fell on April 7, 2024, the facility did not properly report R1’s fall or subsequent change of condition to R1’s doctor and did not have R1 timely medically assessed. Regarding the allegation that facility staff did not ensure that resident was administered their medication(s) as prescribed: it was alleged that on April 11, 2024, R1’s responsible party visited R1 in the morning, stayed with R1 in their room until 7:30PM, noticed R1 had not received their evening medications, inquired with staff and was told the medications should have been given around 5:00PM, and then observed a medication technician hurriedly give R1 their evening medications. Per facility staff, S1, the facility’s medication technician at the time, no longer works at the facility and multiple attempts to interview S1 were unsuccessful. Per R1’s Medication Administration Records for March 2024, two medications, Atenolol (a blood pressure medication) and Simvastatin (a cholesterol medication), were not given for the last three days of the month, but no reason was documented for withholding these medications. Per a facility communication log entry dated April 7, 2024, S1 administered Tylenol to R1 after a fall on that date. R1’s Primary Care Medical Records dated April 18, 2024, do not indicate that these two medications were discontinued or that there were any instructions for withholding these medications and also do not list Tylenol as an ordered medication. R1’s Medication List dated February 29, 2024, also does not list Tylenol as an ordered medication. The information obtained corroborated that facility staff did not administer R1’s medications as prescribed. Regarding the allegation that facility staff offered oxygen to resident without a doctor's order: it was alleged that on April 8, 2024, R1 was seen with an oxygen tank in their room and S1 stated they had tried to give R1 oxygen because R1 could not breath. R1’s Medication List dated February 29, 2024, and R1’s Primary Care Medical Records do not include orders for oxygen. However, per a facility communication log entry dated April 7, 2024, S1 offered oxygen to R1 and R1 refused the oxygen. Per facility staff, S1, the facility’s medication technician at the time, no longer works at the facility and multiple attempts to interview S1 were unsuccessful. Although R1 refused the oxygen during this particular incident, facility staff still offered R1 a medication for which they did not have a doctor’s order. The information obtained corroborated the allegation. Regarding the allegation that facility staff failed to notify responsible party of injury: it was alleged that on April 8, 2024, R1’s responsible party observed that R1 had sustained an injury at the facility, S1 confirmed that R1 had fallen but was unable to explain how or when R1 had fallen, R1’s responsible party had not been notified of this injury, and S1 stated they did not notify R1’s responsible party of R1’s injury because they did not have the authority to do so. Review of Orange County Regional Office (OCRO) records revealed that the facility did not report this incident or any other incident involving R1 to the OCRO. R1’s doctor stated they were not notified of the fall by the facility and per R1’s Primary Care Medical Records, R1’s doctor only learned of R1’s injury on April 18, 2024, when R1’s responsible party told them about it. A facility communication log entry dated April 7, 2024, indicates that R1’s fall occurred at 11:00AM on April 7, 2024, however it is unknown when this document was given to R1’s responsible party and it does not include all required information such as R1’s identifying information, the physician’s name, findings and treatment, and the disposition of the case. The information obtained corroborated the allegation. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. A Civil Penalty is pending determination by the Community Care Licensing Division (CCLD) per Health & Safety Code section 1569.49(f). An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. Regarding the allegation of questionable death: it was alleged that lack of care and supervision resulted in R1 passing away. R1’s responsible party stated that, prior to April 2024, R1 was able to talk, walk, and eat, and that R1’s doctor had seen R1 on March 22, 2024, and determined R1’s physical examination to be within normal limits. R1’s responsible party stated that on April 8, 2024, shortly after 12:00PM, they visited R1 at the facility and found that R1 was lying in bed, was unable to open their eyes, had difficulty speaking, had a bruise on their left eyelid, and complained of pain when they were touched. R1’s responsible party was told by Staff #1 (S1) that R1 had fallen while trying to go the bathroom and that R1 was not injured, but S1 did not say when the fall occurred or provide additional details. R1’s doctor stated they were not notified of the fall by the facility and per R1’s Primary Care Medical Records, R1’s doctor only learned of R1’s injury on April 18, 2024, when R1’s responsible party told them about it. A facility communication log entry dated April 7, 2024 indicates that at 11:00AM, Staff #2 (S2) reported that R1 was lying on the floor, R1 denied falling, S1 checked R1’s vitals which were normal and noted no bruises or bleeding, R1 refused to go to the hospital, S1 gave R1 Tylenol, R1 went the rest of the day “without any symptoms”, and Staff #3 (S3) was present during this incident as well. Per facility staff, S1 no longer works at the facility and multiple attempts to interview S1 were unsuccessful. S2 remembered seeing R1 on the floor on April 7, 2024, but could not recall any other details from the incident. S2 stated that the last time they saw R1 before the fall was between 8:30AM and 9:00AM. S3 recalled seeing R1 on the floor on April 7, 2024, at 11:00AM, stated that they had last checked on R1 around 10:30AM, and did not recall seeing any injuries on R1. Per R1’s responsible party, on April 9, 2024, R1’s family visited R1 and noted R1 was unable to eat solid food, speak, or open their eyes. On April 10, 2024, R1’s responsible party visited R1, was not told anything by staff about R1 having a fall, and noted R1 could not open their eyes or speak and that every movement R1 made was so painful that R1 screamed. On April 11, 2024, R1’s responsible party visited R1 and noted R1 could not talk, had a new bruise on their right cheek, and was unable to walk. On April 12, 2024, R1’s responsible party visited R1 and noted R1 appeared to be getting worse and requested that R1 be taken to a hospital. Per R1’s Chapman Global Medical Records, R1 was seen in the emergency department on April 12, 2024, with chief complaints of hip and face pain, swelling above the right eye, decreased appetite, and increased pain. Testing revealed a right subdural hematoma (brain bleed) up to 14 millimeters thick, a comminuted (three or more pieces of broken bone) depressed fracture of the right zygomatic arch (cheek bone), but no skull fracture. R1 was determined to need a higher level of care, was admitted for inpatient treatment that same day, and was thereafter discharged to Chapman Care Center on May 1, 2024. Per R1’s Chapman Care Center Medical Records, R1 was admitted for skilled nursing care on May 1, 2024, R1’s diagnoses included traumatic subdural hemorrhage (brain bleed) without loss of consciousness, R1 had hip pain but no hip fracture, and R1 was transferred to Garden Grove Hospital on May 16, 2024, because they needed a higher level of care. Per R1’s Garden Grove Hospital Medical Records, R1 was admitted on May 16, 2024, with a chief complaint of respiratory distress and a history that included subdural hemorrhage (brain bleed), R1 had difficulty breathing, and R1 passed away on May 17, 2024. R1’s Certificate of Death identifies the causes of death as cardiopulmonary arrest (within minutes), acute respiratory failure (within days), septic shock (within days), and pneumonia (within days) with no other contributing factors noted. Based on the information obtained, R1 was in stable condition and making improvements prior to their fall and R1’s fall triggered a sudden decline in R1’s condition which led to R1’s hospitalization. However, R1 received inpatient and skilled nursing care for more than a month before they passed away. Regarding the allegation that the facility does not have enough staff to meet residents' needs: it was alleged that on April 10, 2024, R1’s responsible party activated R1’s signal system for assistance, but no care staff came, and R1 inquired with the receptionist and was advised to just wait because there were no care staff available to help. Per interviews with three staff who worked at the facility between April 8, 2024, and April 12, 2024, status checks were conducted on R1 at least every two or three hours. Interviews with two residents revealed that staff are responsive to calls on the signal system and status checks are conducted on residents throughout the day. The staff in charge of overseeing the facility’s signal system reported that calls are usually answered immediately unless the staff are busy providing care to another resident and the longest wait is usually around five minutes. Per the facility’s April 2024 staff schedule, there are nine care staff scheduled for the morning shift, six care staff scheduled for the afternoon shift, and three care staff scheduled for the overnight shift, in addition to the medication technician, receptionist, and activity coordinator. One staff interviewed reported that there are two caregivers assigned to the 30 residents in the memory care during the day shifts. While response times for the signal system may fluctuate, the information obtained regarding whether there are enough staff to meet residents’ needs is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. Per facility staff, S1, the facility’s medication technician at the time, no longer works at the facility and multiple attempts to interview S1 were unsuccessful. Per S1’s Staff File, S1’s medication training and first aid training were up to date. On April 17, 2024, LPA reviewed 10 staff files, including the file of S1, and confirmed they had all completed their required training, including training on reporting requirements. Interviews with two residents did not reveal issues relating to staff training. The information obtained did not corroborate the allegation and showed that facility staff had completed all required training. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Mar 26, 2025 · control 22-AS-20240624114306

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 27, 2025

87465 Incidental Medical and Dental Care (a)… (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not notify R1’s doctor or obtain a medical assessment after R1’s fall and did not obtain medical care for R1 in response to R1’s change of condition, which poses an immediate health risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: Licensee stated that they will retrain staff on obtaining medical assessments and care for residents following falls and changes of condition and will submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Mar 27, 2025

87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by Based on documents and interviews, the licensee did not ensure R1 received assistance with medications by not giving them their prescribed medications for multiple days, which poses an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: The licensee stated that they will retrain staff on ensuring residents receive their medications as prescribed and properly completing the Medication Administration Record and will submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(5)(A) · Plan of correction due date: Mar 27, 2025

87465 Incidental Medical and Dental Care. (a) … (5) ... Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician. This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R1 received assistance with medications by offering R1 oxygen and giving R1 Tylenol which were not prescribed, which poses an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: The licensee stated that they will retrain staff on not giving residents medications that are not on their med lists and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Apr 9, 2025

87211 Reporting Requirements (a) … (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days … shall include the resident's name, age, sex and date of admission; date and nature of event… This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not provide a written report of R1’s fall to the OCRO or R1’s responsible party, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: Licensee stated that they will create a plan to ensure incidents are properly reported and will submit proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20240624114306. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During the course of the investigation, Department staff inspected the facility, interviewed staff, and obtained and reviewed copies of the resident roster and staff roster. Department staff requested information on facility staff who worked at the facility between April 8 and April 12, 2024. On October 22, 2024, Licensee Erik Doan identified Staff #4 (S4), Staff #5 (S5), Staff #6 (S6), and Staff #7 (S7) by first name only, stated they had worked at the facility during this time period, but could not provide any additional identifying information because they no longer work at the facility, and did not maintain staff files for these staff as required. Per Guardian records, S4, S5, and S7 were not background cleared while working at the facility. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Mar 26, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Mar 27, 2025

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance… This requirement was not met as evidenced by: Based on admission and documents, the licensee did not ensure S4, S5, and S7 were background cleared prior to working at the facility, which poses an immediate safety risk to persons in case. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: Licensee stated that will either have these individuals background cleared or confirm they no longer work at the facility and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Apr 9, 2025

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee... This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not maintain personnel records for 4 staff, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 26, 2025

Plan of correction: Licensee stated that since October 2024, they have ensured that all staff have staff files. On February 25, 2025, LPA reviewed the staff roster and 10 staff files and confirmed. POC CLEARED.

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20250313083618. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility and obtained and reviewed copies of the resident roster and staff roster. LPA inspected the facility and observed that the fire extinguishers in the assisted living section were last inspected in 2025. However, LPA observed two fire extinguishers in the memory care and two fire extinguishers just outside the memory care that were last inspected in 2023. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Mar 19, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Apr 2, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on observations, the licensee did not ensure 4 fire extinguishers were inspected within the last year, which poses a potential safety risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Mar 19, 2025

Plan of correction: Licensee stated that they will ensure all fire extinguishers in the facility have been serviced in the last year and submit proof to LPA by POC due date.

Allegation investigated: Staff at the facility do not have a criminal record clearance

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Administrator (AD) Michelle Song, discussed the purpose of the inspection, and explained the allegation. The investigation into the allegation that staff at the facility do not have a criminal record clearance revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, and obtained and reviewed copies of the resident roster, staff roster, and staff schedule. CONTINUED Substantiated It was alleged that multiple staff at the facility have been working at the facility without a criminal record clearance. LPA inspected the facility, including the assisted living section and memory care unit, multiple bedrooms, kitchen, medication room, and common areas and observed no health and safety issues. LPA observed 17 staff present, obtained their names and dates of birth, and checked their background clearance status on the Licensing Information System (LIS). Out of the 17 staff present, LPA determined using LIS that staff Sung Ae Byun and Carlota Olguin were not background cleared. AD confirmed neither had been background cleared and that Sung Ae Byun had started working at the facility on March 3, 2025, and Carlota Olguin had started working at the facility on March 5, 2025. LPA reviewed the facility’s staff roster and staff schedule and did not note any additional background clearance issues. During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Mar 6, 2025 · control 22-AS-20250303114031

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Mar 7, 2025

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance… This requirement was not met as evidenced by: Based on admission and documents, the licensee did not ensure staff Sung Ae Byun and Carlota Olguin were background cleared prior to working at the facility, which poses an immediate safety risk to persons in case. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Mar 6, 2025

Plan of correction: During the inspection, the licensee removed both staff from the facility and LPA confirmed. Licensee stated they will have both staff background cleared, submit proof to LPA by POC due date, and ensure these staff are not allowed back to the facility until they are background cleared.

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Michelle Song and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 10:45AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a large commercial facility. Facility is a 170-bedroom, 180-bathroom, 3 story building. There is 1 large patio with patio covers for the residents. Resident Bedrooms: the 10 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 10 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 degrees F and 114 degrees in the 10 resident bathrooms inspected. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have not been paid and are due today. At about 12:00PM, LPA reviewed 10 resident files and 10 staff files, interviewed 5 residents and 5 staff, and inspected medications for 10 residents. Facility does not handle resident money. CONTINUED During the inspection, LPA and AD observed the following: based on Guardian records and interview, Staff #1 (S1) is background cleared but is not associated to the facility and has been working at the facility for a long time; based on documents, the facility has been allowing Resident #1 (R1) to store and administer their own medications, but R1's physician's report indicates R1 is not able to store or administer their own medications; and based on observation, the facility's fire extinguishers have not been inspected since 2023. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Feb 25, 2025

Allegation investigated: Facility is malodorous

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of delivering findings for the investigation into the above identified complaint allegation. LPA met with (AD) Michelle Song and explained the reason for today’s inspection. The investigation into the allegation that the facility is malodorous revealed the following: During the course of the investigation, LPA inspected the facility, interviewed witnesses, and obtained and reviewed copies of the resident roster and staff roster. It was alleged that nearly every resident room has the “overwhelming smell of urine and feces.” On October 24, 2024, and November 4, 2024, LPA inspected the facility, including 35 resident rooms, and conducted health and safety checks on approximately 65 residents and LPA’s observations corroborated this allegation. LPA noted mild bad odors, including urine and feces odors, in the memory care common area, hallway, and resident rooms. LPA did not note any odors in the assisted living area section of the facility. LPA interviewed two witnesses who corroborated the allegation. The evidence obtained corroborated the allegation. Substantiated During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegation mentioned above. The preponderance of evidence standard has been met; therefore, the above allegation is Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative. It was alleged that witnesses observed that the facility had placed 15 to 20 residents in one room, all of whom were wearing only diapers and infected with scabies. On October 24, 2024, and November 4, 2024, LPA inspected the facility, including 35 resident rooms, and conducted health and safety checks on approximately 65 residents and did not obtain information corroborating this allegation. LPA interviewed AD who denied the allegation. LPA interviewed two witnesses who did not provide information corroborating this allegation. LPA interviewed five of the residents who, per AD, have received treatment for scabies, but did not obtain reliable information corroborating the allegation due to the residents’ diagnoses of dementia. LPA interviewed six staff who did not corroborate the allegation. The information obtained did not corroborate the allegation. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative. It was alleged that visitors and family members are not permitted to enter residents’ rooms and that instead residents are brought out to common areas for visits. LPA interviewed AD and one staff who denied the allegation. LPA interviewed two witnesses who did not provide information corroborating this allegation. On November 5, 2024, LPA inspected the facility and observed visitors in resident rooms in the assisted living section of the facility, but did not observe visitors in the memory care unit. LPA has also previously observed visitors in resident rooms in the assisted living section of the facility on multiple occasions. LPA reviewed the facility’s visitation log for October 2024 and noted four memory care residents who had visitors in October 2024. LPA interviewed the visitors for the four residents, three of whom denied the allegation and one of whom did not corroborate the allegation. No information was obtained corroborating the allegation. The Department has investigated the above allegation and found it to be Unfounded, meaning the allegation was false, could not have happened, or is without reasonable basis. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Nov 6, 2024 · control 22-AS-20241023161245

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 20, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on observation and interviews, the licensee did not ensure the memory care unit was free for mild bad odors, which poses a potential personal rights risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: Licensee stated that they will create a housekeeping protocol to address the mild bad odors in the memory care unit, train housekeeping staff on the protocol, and submit proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20241023161245. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed AD, residents, staff, and witnesses, and obtained and reviewed copies of the resident roster and staff roster. A witness reported that they observed 15 to 20 residents in one room, all of whom were wearing only diapers. LPA interviewed AD, two additional witnesses, five residents, and six staff and obtained a corroborating statement that residents in the memory care unit are kept only in diapers and a shirt to make it easier for staff to change them over night because there are fewer staff overnight. Based on the information obtained made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Nov 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Nov 7, 2024

87468.1 Personal Rights of Residents in All Facilities (a) … (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews, the licensee does not ensure memory care residents’ dignity when they are kept in only diapers and a shirt overnight, which poses an immediate personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: Licensee stated that they will provide an explanation as to why they were engaged in this practice, train all care staff to ensure residents are fully clothed at all times, and submit proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20241023161245. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed AD, residents, staff, and witnesses, and obtained and reviewed copies of the resident roster, staff roster, and staff schedule. Per the facility’s staff schedule, Staff #1 (S1) Alma Cervantes works at the facility regularly. Per admission from Licensee (LE) Erik Doan, S1 has worked at the facility for more than five days. LPA determined using the Licensing Information System that S1 is not background cleared and has been working at the facility since May 12, 2023, per their staff file. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421BG. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Nov 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Nov 7, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance… This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not S1 was background cleared prior to working at the facility for at least 5 days, which poses an immediate safety risk to persons in case. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: Licensee stated that they will have S1 background cleared and submit proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20241023161245. LPA met with Administrator (AD) Michelle Song and explained the reason for today’s inspection. During the course of the investigation, LPA inspected the facility, interviewed AD, residents, staff, and witnesses, and obtained and reviewed copies of the resident roster and staff roster. On October 24, 2024, and November 5, 2024, LPA inspected the facility, including 35 resident rooms, and observed black mold under the sinks of the private resident bathrooms in resident rooms 104, 112, 113, 114, and 116 in the memory care unit. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Nov 5, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 11, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on observation, the licensee did not ensure resident rooms 104, 112, 113, 114, and 116 were free of black mold, which poses a potential health risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Nov 5, 2024

Plan of correction: Licensee stated that they will clean and disinfect resident rooms 104, 112, 113, 114, and 116 and all other areas of the building that have molds and will submit proof to LPA by POC due date.

Type of visit: POC

This unannounced POC inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of verifying correction of deficiencies issued during the Case Management – Deficiencies inspection conducted on August 19, 2024, and the POC inspection conducted on September 12, 2024. LPA met with Administrator (AD) Michelle Song and discussed the purpose of the inspection. During the inspection, LPA and AD toured the facility and observed the following: Type A Violation cited under California Code of Regulations (CCR) Title 22, Section 87202(a) pertaining to delayed egress doors has been CLEARED. The facility’s memory care unit is located on the first floor. All three delayed egress doors in the memory care unit functioned properly. The first and second east outside gates, which can only be accessed by going through a delayed egress door, are operational and kept unlocked and have now been alarmed. There were no deficiencies observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Oct 24, 2024

Allegation investigated: Facility staff served expired food to residents. Facility does not have sufficient night staffing to meet residents needs.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegation listed above. LPA met with Administrator Michelle Song and explained the reason for the visit. LPA and the Administrator toured the facility including the kitchen. The investigation into the allegation, facility staff served expired food to residents revealed the following. LPA toured the kitchen. LPA observed the kitchen is clean and organized. LPA observed the refrigerators and freezers are kept at the required temperatures. LPA inspected the stored food supplies. LPA observed 49 boxes of cereal stored in the kitchen are expired. LPA verified with the Administrator who agreed 49 boxes of cereal are expired. The preponderance of evidence standard has been met, therefore the allegation is substantiated. The investigation into the allegation facility does not have sufficient night staff to meet residents needs revealed the following. Substantiated LPA interviewed the Administrator and staff. LPA reviewed facility documents and records. Facility has 3 stories/levels and a total 170 rooms. The memory care unit has 29 rooms is on the first level and has a secured perimeter. According to the staff schedule there are only two staff members for the whole facility from 10:30 pm until 6:00 am. The facility Administrator reported that there are 3 staff members but it is from 11:00pm until 7:30 am but it is not listed on the schedule. The Administrator reported that the staff members who start at 10:30pm are constantly checking the residents throughout the facility. The facility has multiple levels and wings and is required to have a signal system. Each room has a call button and it goes to a central panel at the front lobby desk. LPA tested the signal system and it is operational. According to CCR 87415 the facility is required to have, 87415(a)(3) In facilities caring for one hundred one (101) to two hundred (200) residents, one employee shall be on call, on the premises; one employee shall be on duty on the premises and awake; and one employee shall be on call and capable of responding within ten minutes. CCR 87415 (a)(5) In facilities required to have a signal system, specified in Section 87303, Maintenance Operation, at least one night staff person shall be located to enable immediate response to the signal system. If the signal system is visual only, that person shall be awake. Based on CCR 87415, three people shall be at the facility from 10:00 pm to 6:00 am, one person on call on the premises, one on duty awake on the premises and one person shall be located to enable immediate response to the signal system. LPA informed the Administrator that even if the schedule reflected the 3 staff members present from 11:00 pm until 7:30 am the regulatory requirement is not being met because 3 staff members must be present from 10:00 pm to 6:00 am. The preponderance of evidence standard has been met, therefore the allegation is substantiated. Deficiencies are being cited per Title 22 division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.the state’s words, verbatim · CDSS document, Oct 16, 2024 · control 22-AS-20241010093603

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87415(a)(5) · Plan of correction due date: Oct 17, 2024

In facilities required to have a signal system, specified in Section 87303, Maintenance Operation, at least one night staff person shall be located to enable immediate response to the signal system. If the signal system is visual only, that person shall be awake. This requirement is not being met as evidenced by record review and interviews verified the facility does not have a staff person monitoring the signal system to provide immediate response. This poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: Licensee agrees to schedule a minimum of 3 staff members between the hours of 10:00 pm to 6:00 am everyday. Licensee to forward proof to LPA.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(8) · Plan of correction due date: Oct 17, 2024

All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not being met as evidenced by, LPA observed 49 boxes of cereal stored in the kitchen that have expired. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: Licensee agrees to discard all expired food. Licensee agrees to train staff on CCR 87555 General Food Service Requirements and to submit proof of training to LPA.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA met with Administrator Michelle Song and explained the reason for the visit. During the 10-day visit for complaint #22-AS-20241010093603 LPA observed the following which is not directly related to the complaint being investigated. LPA and the Administrator toured the facility. LPA observed the See Something, Say Something Poster (PUB 475) measures 10 inches by 16 1/4 inches. LPA observed resident room 233 where Resident 1 lives did not have a smoke detector. LPA observed wires hanging from the ceiling where the smoke detector goes. The Administrator reported that Resident 1 is moving to room 321 and the staff is in the process of moving Resident 1's belongings. LPA informed the Administrator all resident rooms are required to have a smoke detector. The Administrator verified that the there is no smoke detector in room 233. Room 233 still has Resident 1's clothes and personal items. LPA interviewed Staff 1 and LPA reviewed the facility Guardian roster. Staff 1 is not associated to the facility. LPA informed the Administrator and Staff 1 that they cannot be at the facility until they are associated to the facility. Staff 1 does have a background clearance but is not associated to the facility. LPA observed Staff 1 leave the facility. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Civil penalties being issued for the deficiencies cited; CCR 87203 and CCR 87355(e)(2). An exit interview was conducted and a copy of the report LIC 809, LIC 809D, LIC 421 IM, LIC 421 BG, provided along with appeal rights.the state’s words, verbatim · CDSS document, Oct 16, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Oct 17, 2024

(e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility(2)Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement was not met as evidenced by, through record review LPA observed Staff 1 has a background clearance but is not associated to the facility. This poses an immediate health and safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: Licensee agrees to associate Staff 1 to the facility and to submit a statement that they have read and understand the regulation 87355 Criminal Record Clearance. Licensee agrees to forward proof of correction to LPA.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87203 · Plan of correction due date: Oct 17, 2024

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not being met as evidenced by: LPA observed Resident 1's room, 233 did not have a smoke detector. This poses an immediate Health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 16, 2024

Plan of correction: Licensee agrees to have a smoke detector installed in each resident room.

Type of visit: Case Management - Deficiencies

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting a case management visit in order to issue citations for deficiencies observed during a separate unannounced joint visit made for the initial investigation of the allegations contained in complaint reference number #22-AS-20240925103324. During the visit, LPA observed a cleaning cart in use in the hallway of the facility's memory care unit on the facility's first level. Cleaning cart was observed to contained powdered bleach and bleach in liquid form, both left fully accessible to memory care residents. Additionally, the memory care laundry area's door was found to be unlocked. An uncovered tub of powdered laundry detergent was observed to be present. A type A citation is cited per Title 22 Division 6 of the California Code of Regulations and documented on an attached form LIC809-D. A makeshift table made of a wooden platform with a broken glass cover with a sharp edge accessible, balanced on two refrigerators and one cabinet was also observed to be placed in the memory care secure courtyard. A type A citation is cited per Title 22 Division 6 of the California Code of Regulations and documented on an attached form LIC809-D. An exit interview was conducted and a copy of this report, attached citations along with appeal rights were provided to a facility representative.the state’s words, verbatim · CDSS document, Oct 2, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Oct 3, 2024

Per CCR Section 87705(f)(2) on the Care of Persons with Dementia: "The following shall be stored inaccessible to residents with dementia: (...) toxic substances such as (...) cleaning supplies and disinfectants". This requirement is not met as evidenced by: Based on observation conducted during the visit, cleaning supplies and potential toxic substances were left unattended in the memory care unit. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: Licensee will replace the current cleaning carts with lockable carts that enable staff to ensure cleaning products are out of reach of residents in care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(a) · Plan of correction due date: Oct 3, 2024

Per CCR Section 87303(a): "The facility shall be clean, safe, sanitary and in good repair at all times." This requirement is not met as evidenced by: Based on observation, the presence of a makeshift table balanced on refrigerator, with a broken glass cover constitutes an immediate risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: Licensee stated they would proceed to the immediate removal of the dangerous item.

Type of visit: POC

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a plan of corrections visit following up on the type A deficiency citation issued on August 18, 2024 after two out of three delayed egress exits in the memory care unit were observed to be inoperational. LPA accompanied by administrator toured the memory care unit and observed that no repairs had been conducted on the exits at this time. Delayed egress doors are therefore still not in operation. A type A deficency is cited on this day on an attached form LIC809-D.the state’s words, verbatim · CDSS document, Sep 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Sep 13, 2024

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department… This requirement was not met as evidenced by: Based on observation, documents, and admission, the licensee was not following its approved fire clearance because 2 out of 3 delayed egress doors were not functioning as required and the facility has been keeping the west delayed egress door open, which poses an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 12, 2024

Plan of correction: Licensee states that a pricing proposal and scheduled appointment will be made before end of business day. This is a repeat/continuation of the initial deficiency cited on August 18, 2024. No additional immediate civil penalty cited at this time.

Type of visit: Office

On today’s date, an Office Conference was held at the Orange County Adult and Senior Care Regional Office (Office) in Orange, California per request of the Licensee Erik Doan. Regional Manager (RM) Marina Stanic appeared via Microsoft Teams and Licensing Program Analyst (LPA) Sean Haddad and Licensee Doan were present at the Office. Licensee Doan had requested the Office Conference to discuss his concerns with facility operations. During the Office Conference, the following items were discussed: • Licensee Doan shared that he is concerned about the facility’s compliance issues as evidenced by recent citations and that they have had trouble handling the facility as it is their first assisted living facility, they are not able to be present at the facility 24/7 to oversee their administrators, and that they have language and cultural barriers with residents and staff. • Licensee Doan requested a copy of the accusation against their predecessor facility, Bok Senior Hotel (306005182). LPA provided Licensee Doan with a public copy of the legal action against Bok Senior Hotel. • Licensee Doan expressed concerns regarding the interactions with investigative staff and requested the contact information of the Investigations Branch supervisor. LPA provided Licensee Doan the requested contact information. • RM and LPA answered Licensee Doan’s questions regarding the process of applications and changes of ownership and also the Department’s tools for bringing any facility into compliance. An exit interview was conducted and a copy of this report was discussed with and provided to Licensee Doan.the state’s words, verbatim · CDSS document, Aug 28, 2024

Type of visit: Case Management - Deficiencies

This unannounced Case Management – Deficiencies inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20240724111701. LPA met with Staff #1 (S1) Man Park and Staff #2 (S2) James Lee and explained the reason for today’s inspection. Administrator (AD) Michelle Song was not present during the inspection. Licensee (LE) Erik Doan appeared via telephone. During the course of the investigation, LPA inspected the facility, conducted health and safety checks on residents, and requested and reviewed copies of the resident roster, staff roster, and resident files. LPA observed that the two east outside gates from the memory care unit were not alarmed. During today’s inspection, LPA, S1, and S2 inspected the memory care and tested all exit doors, reviewed the facility’s fire clearance and pre-licensing documents, and observed the following: The facility’s memory care unit is located on the first floor. The main delayed egress door is in the center of the memory care unit near the common area and dining room and leads to an elevator and stairs to access the second floor of the facility. Per the facility’s fire clearance and pre-licensing inspection, the main delayed egress door must unlock after pressure is applied for 15 seconds and trigger an alarm. LPA, S1, and S2 tested the main delayed egress door and observed that it failed to unlock after multiple attempts. CONTINUED The east delayed egress door is the first door on the east side of the memory care unit, at the end of the hallway, and leads to the second east hallway door. Per the facility’s fire clearance and pre-licensing inspection, the east delayed egress door must unlock after pressure is applied for 15 seconds and trigger an alarm. LPA, S1, and S2 tested the east delayed egress door and observed it to be functioning properly. A few feet further east of the east delayed egress door, in the same hallway and leading to an outside area marked as “Exit” on the facility’s fire clearance, is the second east hallway door. LPA, S1, and S2 tested the second east hallway door and observed that it did not have delayed egress functionality or an alarm, but per the facility’s fire clearance and pre-licensing inspection, the second east hallway door is not required to have delayed egress functionality or an alarm, as the east delayed egress door already serves that function and Room 101 is not a part of the memory care unit. The west delayed egress door is on the west side of the memory care unit in the common area and dining room and leads to an outside courtyard to the west of the memory care unit. Per the facility’s fire clearance and pre-licensing inspection, the west delayed egress door must unlock after pressure is applied for 15 seconds and trigger an alarm. LPA, S1, and S2 tested the west delayed egress door and observed that it was readily openable without any delayed egress functionality or alarm being triggered. S1, S2, and LE stated that the west delayed egress door is kept open during the day and closed at night to provide fresh air to the memory care unit and allow residents access to the outside courtyard. At the north end of the memory care unit’s outside courtyard, there is the north outside gate. LPA, S1, and S2 observed that the north outside gate is kept lock. Per the facility’s fire clearance, this gate is not to be used as an exit in case of an emergency. Per S2, the fire department did not approve of this door’s use as an emergency exit because it leads to stairs going up. At the south end of the memory care unit’s outside courtyard, there is an outside pathway leading east to the outside of the east side of the memory care unit. At the end of this outside pathway, there is the first east outside gate which is operational and kept unlocked and leads north. LPA, S1, and S2 tested the first east outside gate and observed it to not have delayed egress functionality or a functioning alarm. While the first east outside gate did appear to have an alarm mechanism, the alarm did not function. North of the first east outside gate is an outside pathway leading north. This area is marked as “Exit” on the facility’s fire clearance and can also be reached via the second east hallway door. At the north end of the “Exit” area is the second east outside gate which is operational and kept unlocked and leads north to the outside of the facility. LPA, S1, and S2 tested the second east outside gate and observed it to not have delayed egress functionality or a functioning alarm. While the second east outside gate did appear to have an alarm mechanism, the alarm did not function. LE stated they will immediately repair the main delayed egress door and the west delayed egress door. LE stated they understand that the first and second east outside gates cannot be locked. LE stated that, while the west delayed egress door is an essential part of the facility’s delayed egress system, the west delayed egress door is kept open during the day and closed at night to provide fresh air to the memory care unit and allow residents access to the outside courtyard and staff supervision is used to prevent wandering. In light of the risk of residents wandering from the outside courtyard, licensee stated they will install alarms on the first and second east outside gates and will consult with LPA and the local fire department to determine whether installing a delayed egress system on one of the two east outside gates is necessary and allowable and will install one if it is necessary and allowable or take other measures as required to address the risk of residents wandering from the outside courtyard. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Aug 19, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Aug 20, 2024

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department… This requirement was not met as evidenced by: Based on observation, documents, and admission, the licensee was not following its approved fire clearance because 2 out of 3 delayed egress doors were not functioning as required and the facility has been keeping the west delayed egress door open, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Aug 19, 2024

Plan of correction: Licensee stated they will immediately repair the main delayed egress door and the west delayed egress door by POC due date and will take all required and allowable measures to address the risk of residents wandering from the outside courtyard.

Allegation investigated: Staff did not follow proper food handling techniques

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of investigating the above-mentioned complaint allegation. LPA met with Assistant Administrator (AA) Michelle Song and explained the reason for today’s inspection. The investigation into the allegation that staff did not follow proper food handling techniques revealed the following: During the course of the investigation, LPA inspected the facility, interviewed residents, staff, and witnesses, and obtained and reviewed copies of the resident roster and staff roster. Regarding the allegation that staff did not follow proper food handling techniques: it was alleged that a witness observed staff giving one resident’s leftover food that they had started eating but did not finish to another resident because the kitchen had run out of that particular food item. LPA interviewed the witness who identified the staff at issue. LPA interviewed the staff at issue who denied the allegation. Unsubstantiated LPA inspected the kitchen and observed it to be clean and organized, the refrigerator and freezer were at proper temperatures, and the facility has a two-day supply of perishables and a seven-day supply of non-perishable food is available as required by regulations. LPA interviewed six additional staff, including three kitchen staff and three caregivers, one of whom was unable to provide information due to a language barrier. These staff stated that the facility cooks enough food for the residents’ meals, the facility does not run out of food during meals, there is extra food during meals, and facility staff do not give food that was already served to another resident. LPA also observed two large food serving trays containing dozens of the residents’ plates from lunch that was served recently and noted a large amount of food leftover on the plates, which corroborates that the facility makes and serves enough food and would not need to re-serve food that was already served to a resident as a regular practice. LPA interviewed six residents and did not obtain information corroborating the allegation. The information obtained is conflicting. Based on the information gathered during the investigation and review of all documents obtained, the Department is unable to ascertain if the above allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, May 15, 2024 · control 22-AS-20240507092306

Type of visit: POC

This unannounced POC inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of verifying correction of deficiencies issued during the Required – 1 Year Inspection conducted on March 27, 2024. LPA met with Administrator (AD) Erik Doan and discussed the purpose of the inspection. During the inspection, LPA and AD toured the facility, reviewed documents, and observed the following: Type B Violation cited under Health & Safety Code (HSC) section 1569.695(c) pertaining to fire drills has been CLEARED. LPA reviewed records for a fire drill conducted on April 1, 2024. Type B Violation cited under California Code of Regulations (CCR) Title 22, Section 87156(a) pertaining to licensing fees has not been cleared. The plan of correction due date has not yet passed and AD stated they will mail a check and send proof to LPA. Technical Violation issued under CCR section 87412(a) pertaining to personnel records has been addressed. The staff files are present at the facility. LPA reviewed 10 staff files and LPA and AD observed the following: the files of Staff #1 (S1) and Staff #2 (S2), who are medication technicians, do not contain evidence of the required medication technician training; AD’s administrator certificate is expired and the licensee has not yet designated an administrator with an active certificate. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report, clear letters for all citations cleared during this inspection, and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Apr 17, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(a)(1) · Plan of correction due date: May 15, 2024

§ 1569.69(a) … (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training... This requirement was not met as evidenced by: Based on documents, the licensee did not ensure S1 and S2 had documented medication technician training, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Apr 17, 2024

Plan of correction: Licensee stated they will have S1 and S2 complete the required medication technician or properly document the training they already received and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: May 15, 2024

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. This requirement was not met as evidenced by: Based on documents, the licensee did not ensure an administrator with an active administrator’s certificate was properly designated, which poses a potential safety risk to persons in care. CIVIL PENALTY ASSESSED.the state’s words, verbatim · CDSS document, Apr 17, 2024

Plan of correction: Licensee stated they will submit the necessary documents to designate a qualified administrator to LPA by POC due date.

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Assistant Administrator (AA) Anna Jung and discussed the purpose of the inspection. Administrator (AD) Erik Doan arrived during the inspection. LPA reviewed Infection Control requirements. At about 10:00AM, LPA and AA conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and medication room and observed the following: Structure: this is a large commercial facility. Facility is a 170-bedroom, 180-bathroom, 3 story building. There is 1 large patio with patio covers for the residents. Resident Bedrooms: the 10 resident bedrooms inspected are spacious and will easily accommodate the residents’ furnishings. Furniture for 10 resident bedrooms inspected. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 105 degrees F and 118 degrees in the 10 resident bathrooms inspected. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed. Appliances: stove burners, microwave, washers, and dryers inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the storage rooms. Medication room: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. The facility’s licensing fees have not been paid. At about 1:00PM, LPA reviewed 10 resident files, interviewed 10 residents and 5 staff, and inspected medications for 10 residents. Facility does not handle resident money. CONTINUED During the inspection, LPA and AA observed the following: R1 moved in on 01/13/24 but the facility still does not have a Physician's Report for R1; the facility has not been conducting emergency disaster drills; and the licensee did not ensure their licensing fees were paid and has a past-due balance. The facility’s staff files were not available during the inspection and a technical violation was issued. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. Civil penalties for repeat violations are being assessed. See LIC421FC. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Mar 27, 2024

The state marks this report as 8 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Resident sustained unexplained injuries while in care.

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Receptionist Joo Eun Ra. LPA explained the reason for the visit. Administrator Assistant (ADA) Anna Jung arrived shortly after. Resident 1 (R1) was admitted to the facility on May 03, 2023. R1’s Physician report dated May 06, 2023, lists R1 as having a diagnosis of Hypertension and Type II Diabetes. R1 is noted as not being able to communicate needs but able to leave the facility unassisted. Four days later R1’s physician report was updated on May 10, 2023, as being able to communicate their needs with a note that said R1 wanted to handle their needs by themselves. During the investigation the Department spoke with the physician listed as completing the physician reports. A true signature was presented by the physician and their attorney. The Department determined the signature presented by the physician and the signature observed on the reports CONTINUED ON LIC9099-C... Substantiated did not match. On May 31, 2023, R1 was hospitalized after an unwitnessed fall. R1 was hospitalized at St. Jude Medical Center and was admitted for severe sepsis. At the time of being admitted, hospital staff observed R1 with multiple burns and skin tears across the upper and lower body. Staff interviewed denied observing burns and stated the burns were carpet burns. Pictures taken by hospital staff depict skin tears and burns resulting in blisters over R1’s extremities including arms, fingers and legs. When shown the pictures, Staff 1 (S1) advised investigators carpet burns don’t blister. Hospital records diagnose R1 with a history of dementia but are unclear where/how they came to know R1 had a history of dementia. Emergency Medical Technicians (EMTs) reported R1’s records were unavailable upon arriving to the facility as records were locked inaccessible to staff. EMT personnel interviewed recalled speaking with their partner and saying the arm injury observed on R1 was “definitely not a skin tear” as reported by staff. The responder recalled seeing the resident’s arm as having some sort of burn but could not recall if it was or was not wrapped upon arrival. Although it remains unclear exactly how the resident sustained the injuries, it is clear the injuries sustained occurred while in care at the facility and contributed to the R1’s hospitalization. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f) An exit interview was conducted, and a copy of this report, 9099-D Page, and Appeal Rights was left at the facility.the state’s words, verbatim · CDSS document, Dec 20, 2023 · control 22-AS-20230531150652

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 21, 2023

87464(f)(1) Basic Services. Basic services shall at a minimum include: Care and supervision…This requirement was not met as evidence by: Licensee failed to ensure R1 was receiving care and supervision which resulted in R1 sustaining a burn from an unknown cause while in the care of the facility as evidence by interviews conducted and hospital records reviewed. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: Per Administrator Assistant facility will conduct an in-house training with all staff. Administrator Assistant to email proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Receptionist Joo Eun Ra. LPA explained the reason for the visit. Administrator Assistant (ADA) Anna Jung arrived shortly after. During the course of the investigation, the following deficiencies were observed and are being cited via this case management deficiency. On August 24, 2023, during an investigatory follow up visit, Department staff made an unannounced visit to the facility and requested to speak to the Med Tech on duty after being informed Administrator Erik Doan and Licensed Vocational Nurse (LVN) Grace Park were not present. After waiting 15 minutes with no response, Department staff texted Administrator Erik Doan requesting for a status update. After an additional 15 minutes Doan responded that he would return to the facility once done with his meeting and that no one would be interviewed until he was present on site. It was discovered during the investigation process Resident 1 (R1) had left the property on May 21, 2023, unbeknown to the staff. R1 was disoriented and appearing ill out in on the public street shortly after 2:00 AM and was transported to the hospital. It was not until they were admitted to the hospital that Grace Retirement Village was notified of their whereabouts. On May 31, 2023, Resident 1 (R1) was hospitalized following an unwitnessed fall. Emergency Medical Technicians (EMTs) reported R1’s records were unavailable upon arriving to the facility as records were locked inaccessible to staff. The following is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report, 9099-D Page, and Appeal Rights was left at the facility.the state’s words, verbatim · CDSS document, Dec 20, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 21, 2023

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This regulation was not met as evidenced by: On May 21, 2023, R1 eloped from the facility and was transported to the hospital unbeknownst to the facility This poses an immediate risk to resident’s health and safety.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: Per Administrator Assistant facility will conduct an in-house training with all staff. Administrator Assistant to email proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Dec 27, 2023

Administrator Qualifications and Duties. …When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section… This regulation was not met as evidenced by: Licensee failed to have a qualified designated substitute when Administrator was not in the facility on 8/24/23 as evidenced by Department staff observations and comments made by Administrator. This poses a potential risk to residents health and safety while in care.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: Licensee to update Designation of Facility Responsibility (LIC308). Licensee to email updated LIC308 to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87755(b) · Plan of correction due date: Dec 27, 2023

Inspection Authority of the Licensing Agency. The licensee shall ensure that provisions are made for private interviews with any resident or any staff member... This regulation was not met as evidenced by: Licensee failed to ensure provisions were made for private interviews with staff on 8/24/23 as evidenced by Administrator’s statements. This poses a potential risk to residents’ personal rights and safety while in care.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: Licensee/Administrator agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87469(c)(1) · Plan of correction due date: Dec 27, 2023

Advanced Directives and Requests Regarding Resuscitative Measures. Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel… This regulation was not met as evidenced by: Licensee failed to ensure records were made available to emergency personnel as evidenced by records being locked inaccessible to staff. This poses a potential risk to resident’s health and safety while in care.the state’s words, verbatim · CDSS document, Dec 20, 2023

Plan of correction: Per Administrator Assistant the facility will develop a Plan of Action to ensure resident records are available to emergency personnel upon request. Administrator Assistant to email proof to LPA by POC due date.

Type of visit: POC

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced Plan of Correction (POC) visit to follow up on citations issued on 11/09/2023. LPA was greeted and granted entry into the facility by Receptionist Joo Eun Ra. LPA explained the reason for the visit. Administrator Assistant (ADA) Anna Jung arrived shortly after. *Deficiency cited under Title 22 Regulation 87464(f)(1) pertaining to Basic Services has been cleared. Licensee submitted a Plan of Action to prevent future elopements and conducted an in-house training and submitted correction timely. Licensee has complied with the POC. *Deficiency cited under Title 22 Regulation 87411(a) pertaining to Personnel Requirements has been cleared. Licensee submitted a Plan of Action to have sufficient personnel at all times and submitted correction timely. Licensee has complied with the POC. *Deficiency cited under Title 22 Regulation 87456(a) pertaining to Evaluation of Suitability for Admissions has been cleared. Licensee submitted a Plan of Action and submitted correction timely. Licensee has complied with the POC. *Deficiency cited under Title 22 Regulation 87405(h)(1) pertaining to Administrator- Qualifications and Duties has been cleared. Licensee submitted correction timely. Licensee has complied with the POC. *Deficiency cited under Title 22 Regulation 87207 pertaining to False Claims has been cleared. Licensee submitted correction timely. Licensee has complied with the POC. CONTINUED ON LIC809-C... *Deficiency cited under Title 22 Regulation 87506(a) pertaining to Resident Records has been cleared. Licensee submitted a Plan of Action and submitted correction timely. Licensee has complied with the POC. Licensee has been advised to maintain compliance in all items previously cited. An exit interview was conducted with ADA Jung and a copy of this was provided at exit.the state’s words, verbatim · CDSS document, Dec 7, 2023

Allegation investigated: Resident went AWOL from the facility due to lack of care and supervision

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Administrator Assistant Anna Jung and explained the reason for the visit. During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation including the Physician Report (LIC602) dated April 29, 2022, Unusual Incident/Injury Report dated May 1 2022, Appraisal/Needs and Services Plan dated April 29, 2022, for Resident 1 (R1), Personnel Report (LIC500), Resident Roster, Fire Safety Inspection Request dated February 16, 2023 and Plan of Operation related to care of persons with Dementia. The purpose of today’s visit is to deliver the findings regarding the above allegation. The investigation conducted revealed the following: R1 was admitted to the facility officially on April 29, 2022, as per signed admission agreement provided by the facility staff; however, R1 was not physically present at the facility until the next day CONTINUED ON 9099-C... Substantiated on April 30, 2022 when R1 started to reside at the facility. Prior to being admitted to the facility, R1 had previously been admitted to two other board and care facilities and eloped from both homes within 24 hours of being admitted. Interviews with facility staff confirmed the facility received R1’s hospital discharge paperwork from Kaiser Hospital on April 29, 2023, at 11:15 AM what is approximately 10 hours prior to R1 residing at the facility. Although the Licensee reported not reading the paperwork and that the hospital had dropped R1 off blindly, interviews with the facility Administrator Hyo Sok Kim disclosed that they were aware of R1’s exit seeking behaviors and combative and believed R1 would be easily controlled using medications. Kaiser Hospital discharge records dated April 14, 2022, confirmed R1’s diagnosis of dementia with behavioral disturbances and exit seeking behaviors. On May 6, 2022, two of three staff interviewed reported that R1 had become combative with staff and exited the facility memory care unit. At the time of the incident, staffing records show only Staff 1 (S1) was working at the facility memory care unit. After exiting the memory care unit, R1 continued to the facility entrance. At approximately 11:30 AM R1 eloped from the facility unassisted. Despite knowing R1’s history and seeing R1 walk out of the facility, no staff followed behind to provide R1 with supervision when exiting. S2 contacted La Habra Police to report R1 missing at 1:49 PM, approximately three hours after R1 left the facility. On May 4, 2022, R1’s remains were discovered by the San Bernadino Sheriff’s Department (SBSD) after being struck by a vehicle driver on the 10 freeway. The autopsy report obtained lists R1’s cause of death as multiple blunt force injuries, instantaneous. Despite being made aware of R1’s behaviors and history of exit seeking, the facility still chose to admit R1 to the facility as agreed upon per signed admission agreement. By accepting R1 to the facility, the facility agreed to provide care and supervision as necessary to meet R1’s needs. Facility Administrator Hyo Sok Kim admitted she had filled out R1’s paperwork prior to R1 being admitted and assessed. Despite being provided with R1’s history of exit seeking and behaviors, R1 failed to be properly assessed and later it was determined R1 was not a good fit for the facility. Licensee Eric Doan stated the facility had not received R1’s paperwork prior to being admitted and that the hospital had dropped R1 off after hours and on the weekend. This was a false statement as investigation revealed that the facility did in fact received R1’s paperwork prior to R1 being admitted. They were expecting R1 in advance of them being placed with the facility but failed to properly conduct an assessment. CONTINUED ON 9099-C... On May 1, 2022, R1 eloped from the facility at approximately 11:30 AM after becoming agitated with S2. No staff followed behind R1. S2 awaited until 1:49 PM, approximately 3 hours later, to notify La Habra Police R1 was missing. Despite signing the agreement, the facility failed to provide proper supervision resulting in R1 eloping from the facility and dying three days later. Therefore, based on interviews conducted and records reviewed the allegation that Resident went AWOL from the facility due to lack of care and supervision has been deemed Substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(e) An exit interview was conducted, and a copy of this report, 9099-D Page, and Appeal Rights were left at the facility.the state’s words, verbatim · CDSS document, Nov 9, 2023 · control 22-AS-20220502151946

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 10, 2023

Basic Services (f)Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This regulation was not met as evidence by: Based on interviews conducted and records reviewed the Licensee did not provide care and supervision to R1 resulting in R1 eloping from the facility and dying. Prior to being admitted the facility was made aware of R1’s exit seeking behaviors and still chose to admit R1 to the facility. This poses an immediate risk to health risk to residents in care. An immediate civil penalty of $500 is being assessed.the state’s words, verbatim · CDSS document, Nov 9, 2023

Plan of correction: Per Administrator Assistant facility will develop a Plan of Action to prevent future elopements and will conduct an in-house training with staff. Administrator Assistant to email proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by Assistant Administrator Anna Jung and explained the reason for the visit. During the course of the investigation, the following deficiencies were observed and are being cited via this case management deficiency. During course of the investigation it was determined Resident 1 (R1) was admitted to the facility on April 30, 2022. However, R1’s admission agreement was signed and dated April 29, 2022. Facility AD Hyo Sok Kim admitted she had filled out R1’s paperwork prior to R1 being admitted and assessed. Despite being provided with R1’s history of exit seeking and behaviors, R1 was failed to be properly assessed and later it was determined R1 was not a good fit for the facility. Licensee Eric Doan stated the facility had not received R1’s paperwork prior to being admitted and that the hospital had dropped R1 off after hours and on the weekend. This was a false statement as investigation revealed that the facility did in fact receive R1’s paperwork prior to R1 being admitted. They were expecting R1 in advance of them being placed with the facility but failed to properly conduct an assessment. On May 1, 2022, R1 eloped from the facility at approximately 11:30 AM after becoming agitated with the Staff 2 (S2). No staff followed behind R1. S2 awaited until 1:49 PM, approximately 3 hours later, to notify La Habra Police R1 was missing. The following deficiencies are being cited per Title 22 Division 6. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Nov 9, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87456(a) · Plan of correction due date: Nov 10, 2023

(a) Evaluation of Suitability for Admission. Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8:..conduct an interview…perform a pre-admission appraisal…obtain and evaluate a recent medical assessment…This regulation was not met as evidenced by: Based on interviews conducted and records reviewed the Licensee did not evaluate R1 for suitability prior to accepting them. This poses an immediate risk to resident’s health and safety.the state’s words, verbatim · CDSS document, Nov 9, 2023

Plan of correction: Per Administrator Assistant the facility will develop a Plan of Action to evaluate residents suitability prior to being admitted to the facility. Administrator Assistant to email proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(h)(1) · Plan of correction due date: Nov 10, 2023

Administrator- Qualifications and Duties. The administrator shall have the responsibility to: Administer the facility in accordance with these regulations and established policy… This regulation was not met as evidenced by: Based on interviews conducted and records reviewed the Licensee did not ensure the facility was following regulatory and policy regarding acceptance and retention due to failure to evaluate R1 for suitability prior to accepting them and providing required supervision. This poses an immediate risk to resident’s health and safety.the state’s words, verbatim · CDSS document, Nov 9, 2023

Plan of correction: Licensee/Administrator agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Nov 10, 2023

False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This regulation was not met as evidence by: Based on interviews conducted and records reviewed the Licensee provided false statements to the Department by stating they had not received R1’s paperwork prior to being admitted and was dropped off at the facility blindly without Licensee consent. Statements were proven to be false. This poses an immediate risk to resident’s safety.the state’s words, verbatim · CDSS document, Nov 9, 2023

Plan of correction: Licensee agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Nov 16, 2023

Resident Records. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility…This regulation was not met as evidence by: Based on interviews conducted and records reviewed the Licensee did not maintain a complete record for R1 as evidenced by incomplete appraisal and unsigned physician report. This poses a potential risk to resident’s health and safety.the state’s words, verbatim · CDSS document, Nov 9, 2023

Plan of correction: Per Administrator Assistant the facility will develop a Plan of Action to have current and complete Resident Records. Administrator Assistant to email proof to LPA by POC due date.

Type of visit: Case Management - Deficiencies

On this day Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. made an unannounced visit. LPA was greeted and granted entry into the facility by Administrator Assistant Anna Jung. On this day an amended report of LIC809-D dated 9/11/23 was served to the facility. Changes made to the report included a change to requested plan of correction to meet Title 22 requirements. Updated POC request is due by 11/16/23.the state’s words, verbatim · CDSS document, Nov 9, 2023

Allegation investigated: Facility staff did not adequately supervise resident resulting in resident wandering from the facility and sustaining multiple injuries.

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility to deliver findings for the complaint received on 6/20/23. LPA arrived at the facility and explained the purpose of today’s visit, was greeted and granted entry by staff on duty. Facility administrator (AD) Erik Doan was notified but was unable to be present during today’s visit. LPA De Perio met with assistant facility administrator Anna Jung. The complaint was investigated by the Department which involved interviews and record review. It is alleged that facility staff did not adequately supervise residents resulting in resident wandering from the facility and sustaining multiple injuries.The investigation revealed that resident (R1) was admitted to the facility on May 4, 2023, of which facility administrator and staff were informed that R1 was a fall risk but not an elopement risk because there was no history of R1 eloping. On May 4, 2023, a discharge summary report was completed by the Pasadena Care Center prior to R1 being admitted to the facility and it revealed that R1 is diagnosed with unspecified dementia. Substantiated Upon admission, R1’s physician report dated for May 5, 2023, indicated that R1 was non-ambulatory. R1 began receiving Home Health Services on May 6, 2023, and was discharged from Home Health Services June 5, 2023, due to no further skilled care needed. R1 had several diagnoses such as: Type 2 diabetes mellitus with unspecified complications, major depressive disorder, recurrent, mild unspecified dementia, unspecified severity, history of falling. Interviews conducted with the facility staff stated that R1 liked to walk around the facility but never made any attempts to leave. On June 18, 2023, staff (S1) conducted a room check at 8:30PM and observed R1 was sleeping. S1 returned to R1’s room to conduct a second check between 10:30PM-11:00PM and did not observe R1 in the room. S1 observed that R1’s sliding glass door which led to the street was open. S1 notified staff on duty and La Habra Police Department (LHPD). Per LHPD report dated June 18, 2023, the R1 was found four hours later with facial injuries by Whittier Police Department and taken to the hospital. R1 was hospitalized and upon admission at the hospital, R1 was observed with blunt trauma to face and per-orbital fracture. The following injuries were noted on R1: multiple depressed fractures at the left zygoma, lateral wall of the left orbit, and left maxillary sinus, slightly displaced left orbital floor fracture, left periorbital/facial soft tissue injury, blood products in the left maxillary sinus. It was observed that R1’s face had extensive dark bruising on left temple area, below left eye and on left chin and cheek and multiple scratches/marks around R1’s nose, mouth, chin, and bruising on left side of R1’s nose. Eight days later, the facility submitted an incident report to Community Care Licensing on June 26, 2023, regarding R1’s June 18, 2023 elopement. On June 23, 2023, an interview was conducted with the facility administrator (AD) who stated that R1 did not have an alarm on their door and was unsure if the facility documented watch logs per resident. The day following the interview, AD provided the Department with a document titled “Watch Log” starting from June 18, 2023, which was the day R1 eloped, and was noted for the times of 6:00AM to 11:00PM. It was observed that there was a staff initial next to every hour. A follow-up interview was conducted with the staff members who had initials on the Watch Log. S1 admitted to never seeing or using a Watch Log, and also denied of initialing a Watch Log document. An interview was conducted with staff 2 (S2) who provided AD the Watch Log, and S2 stated that the log was for the facility’s own personal use and that S2 was unaware it was sent to the Department. S2 then stated the log was made as an example for AD to possibly use in the future. When AD was asked to explain how the log was accidentally sent to the Department, AD stated that AD was unaware if the facility documented room checks, and stated the document was for S2’s personal documentation and was not meant to be disseminated. It was also observed that the document was not accurate because the initials of S1 indicated that S1 checked on R1 between 9:00 PM and 10:00 PM, however an interview was conducted with S1, who denied the of initiating a document. This document was later determined to be a false document that was completed by S2, therefore it became a concern that there may be additional documents that were provided that also may have been falsified. Upon additional investigation involving interviewing R1’s physician, it was determined that R1’s physician’s report dated for May 5, 2023 was falsified. The report had the physician’s name handwritten on it with the exam date of May 5, 2023, however the indicated physician confirmed that the report was not signed by him as R1 had not been evaluated by the physician until June 18, 2023. Per falsified physician report provided by the facility dated May 5, 2023, R1 was reported to only have Mild Cognitive Impairment, is unable to leave the facility unassisted, is non-ambulatory, and that R1 did not have dementia. However, the Pasadena Care Center discharge summary dated for May 4, 2023 and the admission summary from Whittier Hospital dated for June 19, 2023, indicated that the R1 is diagnosed with dementia. During the investigation, evidence shows that the physician’s report was falsified, because the physician denied of ever evaluating R1 on May 5, 2023 and that the physician report the facility presented did not align with the diagnoses specified on the Pasadena Care Center documents. It was determined that R1 did not have a medical exam prior to being admitted to the facility, therefore, the facility was unaware of the level of care R1 required, resulting in R1 eloping and sustaining multiple injuries. Based on interviews which were conducted by the Department, review of documents obtained, and observations, the preponderance of evidence standard has been met, therefore the allegation is SUBSTANTIATED. See LIC9099D for cited deficiencies and immediate civil penalty as per Title 22 Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49. An exit interview was conducted with assistant administrator Jung. A copy of this report, and appeal rights were provided and explained.the state’s words, verbatim · CDSS document, Nov 2, 2023 · control 22-AS-20230620133756

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 3, 2023

87464(f)(1) Basic Services (f) Basic services shall... include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Based on the documents obtained and interviews conducted, the facility did not obtain a proper medical evaluation for the resident, therefore was unaware of the care and supervision the resident needed, resulting into the resident wandering out of the facility and sustaining injuries. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 2, 2023

Plan of correction: As a plan of correction (POC), facility is to conduct an in-service training to all staff regarding the regulation cited and will submit proof to assigned LPA on or by 11/3/2023.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced case management visit. LPA De Perio explained reason for visit, met with assistant administrator Anna Jung. On August 22, 2023, LPA De Perio conducted a case management visit to the facility to collect random resident physician reports. Physician reports for resident 1 2, 3, 4, 5, and 6 (R1, R2, R3, R4, R5, R6) were completed and indicated that the same doctor had evaluated residents. The doctor was interviewed and presented with copies of those physician reports. The doctor verified of never seeing R1, R2, R3, R4, R5 and R6, denied of ever signing reports for residents R1, R2, R3, R4, R5, and R6 and stated that the signature had be falsified. For this visit, citations were issued according to Title 22 California Code of Regulations. An exit interview was conducted with assistant administrator Jung. A copy of this report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Nov 2, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Nov 3, 2023

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidence by: Based on LPA’s observation, records obtained and interviews, it was revealed that the doctor indicated on R1, R2, R3, R4, R5, and R6 physician's report denied of evaluating the residents and stated that the physician signature was falsified. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 2, 2023

Plan of correction: As a POC, licensee stated that no employee or officer of a licensee will make or disseminate any false or misleading statement or documents. The Licensee stated all staff will be trained on ethical conduct and truthful reporting and will submit proof to assigned LPA on or by 11/3/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87458(a) · Plan of correction due date: Nov 3, 2023

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician... This requirement is not met as evidence by: Based on the reviewed documents obtained, interviews conducted, and direct admission from the indicated physician on the reports, facility did not obtain a physician report and medical evaluation for R1, R2, R3, R4, R5, and R6. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 2, 2023

Plan of correction: As a POC, licensee stated that all physician reports for residents will be obtained and an assessment will be conducted by the physician prior to admission. Licensee will provide an in-service to all staff regarding the regulation cited and will submit proof to assigned LPA on or by 11/3/23.