Grand Oak Manor Suite II

Type of visit: Case Management - Other

On 8/11/26, LPA K. Nguyen received an email from S1 regarding a facility administrator change because the current Administrator resigned unexpectedly. LPA conducted an unannounced case management visit to gather information. LPA spoke with the licensee, confirming that there will be a temporary Administrator in place while waiting for S1's administrator certification to be active. Currently, the facility is still under operation by the licensee and care staff. LPA requested the following documents to be submitted by POC date 8/14/26 for review, including but not limited to: RCFE Administrator Certification -LIC 200 Application (listing new administrator name and email address) -LIC 308 Designation of Facility Recipient Responsibility form - Management Company, LLC: Appointment of administrator -LIC 501 Personnel Record -LIC 503 Health Screening Report -LIC 508D Out-of-State Disclosure and Criminal Record Statement -Copy of California Driver's License -Copy of First Aid Certification - Personal Resume No deficiency issues today, date. Exit interviews are conducted, and a copy of this report is provided.the state’s words, verbatim · CDSS document, Aug 11, 2026

Type of visit: Required - 1 Year

On 07/08/2026 at 11:45 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a pre-license inspection. LPA met with lead staff; Jason Salvador explained the purpose of the visit. ADM Digna Ramos arrived at a later time. The facility currently has 10 residents. Fire clearance was approved for 3 ambulatory and 11 non-ambulatory. LPAs toured the facility, including but not limited to 7 bedrooms, 3 bathrooms, a kitchen, common areas, and a backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Lines and hygiene supplies were observed inside cabinets. There is sufficient lighting throughout the facility. The room temperature was maintained at 71 degrees F. Smoke detectors and carbon monoxide detectors were operational. The fire extinguisher was last serviced on 5/27/2026. A fire drill was conducted on 5/15/26. Report continues on LIC 809c... Report continues LIC 809c... Dinner and silverware were observed to be sufficient for residents' use. Food supplies were checked and found to be sufficient for 7 days of non-perishable items. The facility was observed equipped with a refrigerator, microwave, dishwasher, washer, and dryer. The cabinet for knives, cleaning supplies, and central medication storage was observed to have locks. The outdoor activity space was observed to be furnished with tables, chairs, and shade. LPA reviewed six (6) residents' files and five (5) staff files; all staff are associated with the facility. LPA samples resident medications. The following deficiency was observed during the visit: Storage rooms are being used as a resting area for staff. The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report are provided.the state’s words, verbatim · CDSS document, Jul 8, 2026

Type of visit: Case Management - Deficiencies

On 3/24/2026 at 12:45 PM, Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced case management visit due to an unusual incident report (UIR) received on 3/21/2026. R1 had a fall due to R1 refusing assistance when in the private bathroom for R1's privacy. LPA met with care staff, Jason Salvador, and explained the purpose of the visit to Administrator Digna Ramos via phone. Digna Ramos later arrived at 1:49 PM. LPA observed 2 residents in the living room watching TV and eating. The other residents are observed to be walking in and out of their rooms. LPA reviewed R1 after the visit summary dated 3/21/26 shows that the doctor saw R1 for the fall. No fracture is indicated, and indicated there are no follow-up appointments. LPA conducted a file review, which shows that the R1 physician report is incomplete, with missing pages, including but not limited to pages 5 and 6. Deficiency observed on today's visit: R1 physician report is incomplete. Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by the plan of correction due dates, and any repeat violations within 12 months, may result in civil penalties. Deficiency, plan, and proof of corrections were discussed. Exit interview conducted, and appeal rights copy of this report provided via email.the state’s words, verbatim · CDSS document, Mar 24, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Mar 31, 2026

87506 Resident Records (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. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not having a completed R1 physician report avalible at the facility during files review.the state’s words, verbatim · CDSS document, Mar 24, 2026

Plan of correction: The Administrator should ensure that all resident records, including physician reports, are complete, current, and maintained in full. A standardized file review process should be implemented to verify that all required pages are present upon admission and during periodic audits. Missing or incomplete documents should be promptly obtained from the appropriate healthcare provider. The Administrator agrees to obtain the missing pages (including pages 5 and 6) of R1’s physician report and ensure the document is complete and up to date. The Administrator agrees to review the cited regulation in its entirety and complete a self-certification attesting to their understanding of the requirements. Documentation of the completed self-certification will be submitted to CCLD by the specified POC due date.

Allegation investigated: Staff did not provide adequate care and supervision to a resident Staff verbally abused a resident

On 3/17/2026 at 1:00 PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a 10-day initial complaint and deliver for the above allegations and met with care staff, Jason Salvador. Administrator (ADM) Dina Ramos was informed via phone regarding the purpose of the visit. ADM arrived around 3 PM. Allegation: Staff did not provide adequate care and supervision to a resident. Substantiated LPA conducted interviews with the Administrator, staff, and 12 residents. Based on information obtained through interviews, it was determined that the staff did not provide adequate care and supervision for a resident. Witness statements from W1 and W9 indicated that they observed and heard that staff member S6 did not respond when R1 called for assistance. Additionally, S1 and S3 reported that they witnessed and/or heard that S6 did not assist R1 at the time help was requested. Report Continue on LIC 9099c... Substantiated Report continues... The evidence supports that staff failed to adequately monitor and respond to the residents’ needs, resulting in a lapse in supervision. This deficiency poses a potential health and safety risk to residents in care. Therefore, the allegation is substantiated. Allegation: Staff verbally abused a resident- Substantiated LPA conducted interviews with the Administrator, staff, and 12 residents. Information obtained through these interviews determined that staff engaged in verbal abuse toward a resident. Witness statements from W1 and W9 indicated that they observed and heard staff member S6 speak in an inappropriate and verbally aggressive manner toward R1. Additionally, S1 and S3 reported that they also witnessed and/or overheard the interaction, corroborating concerns regarding S6’s conduct. The preponderance of evidence supports that staff behavior was inconsistent with providing respectful and appropriate care and constitutes verbal abuse. This violation poses a potential risk to the resident’s emotional well-being and personal rights. Therefore, the allegation is substantiated. An exit interview is conducted, and a copy of the appeal rights and report is provided via email.the state’s words, verbatim · CDSS document, Mar 17, 2026 · control 15-AS-20260313101254

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Mar 24, 2026

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: This requirement is not met as evidenced by: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on information obtained through interviews, it was determined that the staff did not provide adequate care and supervision for a resident. Witness statements from W1 and W9 indicated that they observed and heard that staff member S6 did not respond when R1 called for assistance.the state’s words, verbatim · CDSS document, Mar 17, 2026

Plan of correction: Administrator(ADM) agree that ADM will review and re-train all staff on supervision requirements and resident care needs to ensure compliance with regulations. Submit attance and traning topic to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Mar 24, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Base on information obtained through these interviews determined that staff engaged in verbal abuse toward a resident. Witness statements from W1 and W9 indicated that they observed and heard staff member S6 speak in an inappropriate and verbally aggressive manner toward R1.the state’s words, verbatim · CDSS document, Mar 17, 2026

Plan of correction: Administrator (ADM) agree to provide Proof of training, updated supervision plan, and a statement of understanding will be submitted to CCLD by the POC due date.

Type of visit: Case Management - Deficiencies

On 3/17/2026, during a complaint investigation 115-AS-20260313101254, Licensing Program Analyst (LPA) K. Nguyen discovered that S1, who was working in the facility from the beginning of March 2026 to March 12, 2026, was not fingerprint clear. The administrator confirmed that S1 was not fingerprint clear. A civil penalty was assessed on this date of $400. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. An exit interview is conducted, and a copy of the appeal rights and report is provided via email.the state’s words, verbatim · CDSS document, Mar 17, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(d)(3) · Plan of correction due date: Mar 25, 2026

87355(d)(3) Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury (3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by having staff working without finger print clearance which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 17, 2026

Plan of correction: Administrator agreed to have staff printed and cleared before S1 can return to work. Administator will provide CCLD with clearance for S1 by POC date.

Type of visit: Case Management - Other

On 3/17/2026, during a complaint investigation 115-AS-20260313101254, Licensing Program Analyst (LPA) K. Nguyen observed and interviewed the Administrator that in the facility's common area, there is a camera; these cameras have audio. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. An exit interview is conducted, and a copy of the LIC 421BG appeal rights and report is provided via email.the state’s words, verbatim · CDSS document, Mar 17, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(2) · Plan of correction due date: Mar 24, 2026

§1569.269(a)(2)Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (2) To be granted a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the internet, and meetings of resident and family groups. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above bythe state’s words, verbatim · CDSS document, Mar 17, 2026

Plan of correction: Administrator agree to submit confirmation from vivint company confirming that those camera located in the common area do not have audio submitted via email to CCLD by POC date.

Allegation investigated: Staff did not issue resident a refund Staff did not provide resident with records

On 2/26/2026 at 8:00 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a 10-day initial complaint and deliver for the above allegations, met with Administrator (ADM) Dina Ramos, and explained the purpose of the visit. During the course of the investigation, LPA conducted an interview with the Administrator, RP, and RPB. Allegation: Staff did not issue the resident a refund This allegation was investigated on 12/04/2025 under control number 15-AS-20251204095734. On 02/18/2026, the LPA conducted interviews with the Reporting Party (RP) and the Responsible Party Brother (RPB). Report continued on LIC 9099c... Unsubstantiated The RP stated they did not file a complaint regarding a refund and reported that their brother was responsible for payment for the stay at the facility. The RPB stated they did not file a complaint regarding a refund and reported that the facility contacted them to explain the situation. The RPB further stated that the Administrator established a payment plan and confirmed the facility had issued the first refund payment. Based on information obtained during the investigation, the allegation is found to be unsubstantiated. Allegation: Staff did not provide the resident with records During the course of the investigation, the LPA interviewed the Reporting Party (RP) on 2/18/26 and the Administrator on 2/26/26. The RP reported that the facility did not complete a form requested by State Farm and that the requested information was not received. The RP later acknowledged that, after clarification, they were responsible for directly requesting the document from the facility and providing authorization for the release of information. The RP stated they initially believed the facility was responsible for submitting the information; however, the facility is unable to release personal information without proper consent. Based on information obtained during the investigation, the allegation was found to be unsubstantiated. This agency investigated the allegation above. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report is provided.the state’s words, verbatim · CDSS document, Feb 26, 2026 · control 15-AS-20260218095146

Allegation investigated: Staff did not address a pest infestation

On 12/18/2025 at 9:00AM, Licensing Program Analysts (LPAs) Kelly Nguyen and Andrew Christy arrived unannounced to open a 10 Day Complaint Investigation and deliver findings. LPAs met with Cre staff Jason Salvador and explained the nature of the visit. Administrator Digna Ramos was contacted and could not be available in person, and stated that caregivers have permission to sign any forms. During the course of investgation LPAs conducted interviews with care staff and residents. LPAs toured facility, including but not limited to 7 bedrooms, 3 bathrooms, kitchen, common areas, living room, and garage. Allegation: Staff did not address a pest infestation- Unsubstainted Report continued on LIC 9099c... Unsubstantiated Per allegation, there is vermin in the residents' rooms eating food in the rooms. During the tour of the facility, LPAs checked all resident rooms and observed that there are droppings in all of the residents room. However, interview conducted with Staff 1 (S1) and documents reviewed the facility is contracted with a pest prevention company (Official Pest Prevention an anticimex) that install three smart meter around the facility and is monitoring the facility with pest concern. This agency investigated the allegation above. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Dec 18, 2025 · control 15-AS-20251212192124

Type of visit: Case Management - Deficiencies

On 12/18/2025 at 10:30 AM, during a complaint investigation 15-AS-202512121 92124, Licensing Program Analysts (LPAs) K. Nguyen and A. Christy observed that the facility is not clean and sanitary due to rodent droppings in all of the resident room including but not limited to corners, closets, and also in the garage. In additional there was a black cockroach found in a pest glue trap. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. An exit interview is conducted, and a copy of the appeal rights and report is provided.the state’s words, verbatim · CDSS document, Dec 18, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a)(1) · Plan of correction due date: Jan 1, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on observations by the Department, Licensee did not comply with the regulation cited above by the facility is not clean and sanitary due to rodent droppings in all of the resident room including but not limited to corners, closets, and also in the garage. In additional there was a black cockroach found in a pest glue trap.the state’s words, verbatim · CDSS document, Dec 18, 2025

Plan of correction: Administrators agree to clean all rodent droppings in all residents' rooms, including but not limited to behind the furniture, closets, and all corners. Send pictures of POC to CCLD by POC dates.

Allegation investigated: Staff did not provide a refund to the resident

On 12/4/2025 at 8:45 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 10 day initial complaint and deliver for the above allegations and met with care staff, Jason Salvador, Administrator (ADM) Dina Ramos was informed via phone regarding the purpose of the visit. ADM was not available during the time of the visit and gave permission to the care staff to sign the report. On 12/4/2025 at 8:45 AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct 10 day initial complaint and deliver for the above allegations and met with care staff, Jason Salvador, Administrator (ADM) Dina Ramos was informed via phone regarding the purpose of the visit. ADM was not available during the time of the visit and gave permission to the care staff to sign the report. Allegation: Staff did not provide a refund to the resident- Substantiated Report continue on LIC 9099c... Substantiated During the course of the investigation, LPA obtained FR files and interviewed with the Administrator. Based on record reviews and interviews, Fromer Resident (FR) was admitted at the facility on 10/10/2025 and moved out on 11/13/25. LPA interviewed with ADM and recorded reviews. ADM stated that ADM took a security deposit in the amount of $6500 and recorded reviews showing that ADM took a security deposit amount of $6500 and a preadmission fee amount of $3250 a refund of the amount $5850 to FR. Security Deposit in the amount of $6500 Preadmission Fee in the amount of 3250 minus 60 percent of FR stayed and minus an excess of $500 Monthly rent in the amount of $6500 Based on LPA’s interviews, which were conducted and record review(s), the preponderance of evidence standard has been met; therefore, the above allegation was found to be SUBSTANTIATED. An exit interview is conducted a copy of appeal right and report is provided.the state’s words, verbatim · CDSS document, Dec 4, 2025 · control 15-AS-20251204095734

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.651(h)(3) · Plan of correction due date: Dec 31, 2025

1569.651(h)(3) Preadmission fee or deposit for elderly at residential care facilities; written statement describing costs and stating whether fee is refundable; conditions for refund; refund rate schedules (h) Unless subdivision (g) applies, preadmission fees in excess of five hundred dollars ($500) shall be refunded according to the following: (3) If the resident leaves the facility for any reason during the second month of residency, the resident shall be entitled to a refund of at least 60 percent of the preadmission fee This requirement is not met as evidenced by: Based on record review and interviews by the Department, Licensee did not comply with the regulation cited above, by not refunding to FR. LPA interviewed with ADM and recorded reviews, showing that ADM took a security deposit amount of $6500 and a preadmission fee amount of $3250, minus 60 percent of the FR stated and minus excess cost of 500 a refund of the amount $1650 to FR.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: ADM agree to refund the amount of $1650 to resposible party. ADM agree to send in confirmation once ADM paid the amount to CCLD by POC date.

Type of visit: Case Management - Deficiencies

On 12/4/2025 at 1:30PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a case management visit. LPA met with care staff, Jason Salvador, Administrator (ADM) Dina Ramos was informed via phone regarding the purpose of the visit. ADM was not available during the time of the visit and gave permission to the care staff to sign the report. While LPA K. Nguyen was at the facility for a complaint investigation (#15-AS-20251204095734), the following deficiency was observed. During the interview, and record was reviewed, showing that on the LIC 604A on page 4, under refund indicated “nonrefundable.” However, FR only resides at the facility from October 10, 2025, to November 13, 2025. ADM stated that ADM collected an additional security deposit of $6500, and first month's rent in the amount of $ 6500, and a preadmission fee in the amount of $ 3250. ADM is responsible for refunding the amount of $5850 to FR. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. An exit interview is conducted a copy of appeal right and report is provided.the state’s words, verbatim · CDSS document, Dec 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.651(b) · Plan of correction due date: Dec 31, 2025

1569.651(b) Preadmission fee or deposit for elderly at residential care facilities; written statement describing costs and stating whether fee is refundable; conditions for refund; refund rate schedules (b) If a licensee charges a preadmission fee, the licensee shall provide the applicant or his or her representative with a written general statement describing all costs associated with the preadmission fee charges and stating that the preadmission fee is refundable. The statement shall describe the conditions for the refund as specified in subdivision (g). A licensee shall only charge a single preadmission fee as defined in subdivision (e) per resident admission. This requirement is not met as evidenced by: Based on record review and interviews by the Department, Licensee did not comply with the regulation cited above buy collecting a collected an additional security deposit of $6500, and first month's rent in the amount of $ 6500, and a preadmission fee in the amount of $ 3250.the state’s words, verbatim · CDSS document, Dec 4, 2025

Plan of correction: ADM agree to refund the amount of $5850 to resposible party. ADM agree to review the LIC 604A and facility admission agreement and submit an adendum to changes chages that is being made. ADM agree to send in confirmation once ADM paid the amount to CCLD by POC date.

Type of visit: Case Management - Other

On 7/21/25 at 9:25 AM, Licensing Program Analyst (LPA) K. Nguyen arrived and announced to conduct pre-licensing inspection (POC visit). LPA met with Administrator, Digna Ramos, and explained the purpose of the visit. LPA toured facility and observed all wheelchairs are cleared, and all objects including but not limited to the back, are removed from the side and in front of the garage. Garage doors are operating during the time of the POC visit. LPA will conduct COMP III to administrator. No issues noted during inspection. LPA observed that the facility is ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by CAU. Additional requirements may still be required. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 21, 2025

Type of visit: Case Management - Other

On 07/21/2025 at 10:50 am, Licensing Program Analyst (LPA), K. Nguyen arrived unannounced to conduct a Case Management COMP III visit. LPA met with Administrator, Digna Ramos and explained the purpose of the visit. LPA presented Component III PowerPoint during visit and discussed the regulations embodied in the PowerPoint. LPA observed that the participants gained knowledge about running and maintaining the facility following regulations. A license has not yet been granted to this facility. Licensure is subject to final review and approval by the Centralized Applications Unit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 21, 2025

Type of visit: Prelicensing

On 06/12/2025 at 12:10 PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a pre-license inspection. LPA met with lead staff; Jason Salvador explained the purpose of the visit. The administrator (ADM) was not available at the time of the inspection. LPA received verbal consent from ADM for the lead staff to sign the report. The facility currently has 10 residents. Fire clearance approved for 3 ambulatory and 11 non-ambulatory. LPAs toured facility, including but not limited to 7 bedrooms, 3 bathrooms, kitchen, common areas, and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside cabinets. There is sufficient lighting throughout the facility. The room temperature was maintained at 70 degrees F. Smoke detectors and carbon monoxide detectors were operational. Fire extinguisher was last serviced on 6/3/2025. Prior to licensure, the following shall be corrected and proof sent to CCL by 06/20/2025. - Store/ de-clutter all wheelchairs that are not being used - Remove all objects from including but not limited to the back, the side, and in front of the garage. - Fix the garage door that cannot operate correctly. Issues were noted during inspection. LPA observed that facility is not ready to be licensed. This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 12, 2025