Grove Home Care

Allegation investigated: Resident's change of condition was not brought to the attention of the resident's physician and the resident's responsible person Staff handled resident in a rough manner Staff spoke inappropriately to resident in care Staff did not provide adequate accommodations to resident in care Staff did not safeguard resident’s confidential records Staff did not follow the doctor’s orders for resident in care Staff did not safeguard resident’s personal belongings Staff falsified resident records

On August 27, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrive at this facility unannounced to conduct a follow-up complaint investigation and deliver findings regarding the allegations noted above. LPA met with Administrator, Lucia Boboc, and stated the purpose of the visit. Overview: The complaint involves resident (R1) and several concerns about R1’s care and treatment at this facility. The complainant (RP) alleges that staff did not provide proper care, including leaving R1 sitting in urine, handling R1 roughly, and speaking to R1 in a rude or disrespectful way. RP also reports that R1 developed a wound on the thigh area and that staff did not report to R1’s family or doctor. Other concerns include staff not following doctor’s orders, not providing proper accommodation, going through R1’s personal belongings, and not protecting R1’s private records. RP also alleges that staff threatened R1, and falsified or backdated records. {1} Unsubstantiated Allegation - Resident's change of condition was not brought to the attention of the resident's physician and the resident's responsible person. The investigation into this allegation consisted of interviews and focused mainly on resident (R1). Interview was conducted with Administrator Lucia regarding R1’s change in condition and communication with R1’s physician and responsible person. Lucia stated that R1’s Power of Attorney (POA) did not allow Lucia or facility staff to speak with R1’s doctors, the hospital or other services involved in R1’s care. Lucia reported that she tried to speak with R1’s home health nurse, but the nurse stated that she did not want to be involved in the disagreement between the R1’s family and the facility. Lucia stated that, sometimes, she had contacted R1’s other POA, who she described as more pleasant to communicate with. Lucia also stated that the hospital contacted her when R1 needed to be discharged. Lucia told the hospital that R1 needed rehabilitation because the facility could not provide the level of care R1 needed. R1 was then discharged to a rehabilitation facility and did not return to the facility. Lucia stated that she wanted the home health nurse to connect her with a social worker so she could discuss R1’s change in condition. Lucia also stated that R1’s POA did not share information with the facility about R1’s doctor appointments most of the time, until the last minute. Lucia reported that she had requested updated Medical Assessment (LIC602 form) from the POA since 2024 and again in 2025, but the POA refused. On January 16, 2026 interview, Lucia stated that she was in constant contact with R1’s responsible person regarding R1’s declines and other challenges. Lucia stated that the responsible person visited the facility every day, and they spoke often about R1. On January 16, 2025, staff member S1 was interviewed. S1 stated that when a resident has a change in condition, Lucia is contacted right away. S1 stated that even when a resident has a cold, Lucia contacts the resident’s doctor for direction and contacts the responsible person for that resident. S1 stated that the family is informed right away and that staff communicate with the doctor when needed. {2} On January 16, 2026, R2’s responsible person was interviewed and stated that the administrator texts them immediately when something happens to their parent. R3’s responsible person was also interviewed on January 16, 2026, and did not report any concerns related to the allegation. Based on the interviews, the evidence does not establish that the facility failed to notify the responsible person when there was a change in a resident’s condition. The interviews did not provide sufficient evidence, therefore, the allegation that resident's change of condition was not brought to the attention of the resident's physician and the resident's responsible person was unsubstantiated. ********************************************************************************************* Allegation - Staff handled resident in a rough manner. The investigation into this allegation consisted of interviews. On January 16, 2026, R2’s responsible person was interviewed regarding the allegation. The responsible person stated that they had not seen staff handle R2 in a rough manner. The responsible person stated that they visit the facility three times a day and also visit on weekends. They stated that they are at the facility often and have not seen anything bad happen there. On January 16, 2026, R3’s responsible person was interviewed. The responsible person denied seeing staff handle residents in a rough manner. They stated that the facility is always very pleasant. On September 3, 2025, R2 was interviewed and did not report any concerns about staff handling them in a rough manner during care. On the same date, R1 was interviewed and stated that staff had never handled R1 in a rough manner. R1 stated that staff always tried to help R1 and had never harmed R1. On September 3, 2025, staff member S1 was interviewed. S1 stated that she had never seen staff handle residents roughly or speak to residents in a harsh manner. S1 also stated that she had never handled residents in this way and had not seen other staff do so. {3} On September 16, 2025, LPA Moleski interviewed residents receiving care at the facility, including R1. None of the residents reported that staff harassed residents or were rude or inappropriate toward them. Administrator Lucia was interviewed and denied the allegation that staff handled a resident in a rough manner. Lucia, along with S1, corroborated that R1 sometimes did not want to be touched, especially in the genital area. Staff stated that R1 would cry even when the nurse came to provide care. Staff also stated that R1 would cry during physical therapy (PT), and the PT would sometimes stop and leave the session because R1 was crying. Lucia stated that R1 cried when someone touched certain parts of R1’s body that she did not want touched. Based on the interviews, no residents, responsible persons, or staff reported witnessing staff handling residents in a rough manner. R1 specifically stated that staff had never handled R1 roughly or harmed R1. The available evidence does not support the allegation that staff handled a resident in a rough manner, therefore the allegation was unsubstantiated. ********************************************************************************************** Allegation – Staff spoke inappropriately to resident in care. The investigation into this allegation consisted of interviews, record reviews and observations. On January 16, 2026, R2’s responsible person stated they had not observed staff speaking inappropriately to R2. R3’s responsible person also denied seeing inappropriate behavior and stated that staff are always nice. On September 3, 2025, R1 stated that staff were cautious when speaking to R1 and did not use harsh words or speak to R1 inappropriately. R1 also stated that staff always tried to help R1 and had never harmed R1. A review of prior unannounced facility visits conducted between August 14, 2025, and August 20, 2026, found no observations or notes of staff or the administrator yelling at or speaking inappropriately to residents or staff. {4} On September 16, 2025, LPA Moleski interviewed residents in care, including R1. No residents reported that staff harassed them or were rude or inappropriate. Based on the interviews, observations, and review of facility visit records, there was insufficient evidence to support that staff spoke inappropriately to a resident in care, therefore the allegation was unsubstantiated. ********************************************************************************************* Allegation – Staff did not provide adequate accommodations to resident in care. The investigation into this allegation consisted of interviews. The main focus of this investigation is not providing R1 with an alternative accommodation when the bedside table that R1 was using was taken away. On August 27, 2026, Administrator Lucia stated that the bedside table removed from R1’s room belonged to a hospice agency and had been loaned to a previous resident. The hospice agency later took the table back. Lucia stated that R1’s responsible person brought another table for R1 to use. Lucia also stated that if R1 needed a table, she would have provided another one. She clarified that the original table did not belong to the facility. On January 16, 2026, two family members of other residents were interviewed and they did not report concerns regarding the accommodations provided to their parents. Staff S1 stated that residents are well cared for and that staff change residents as needed, usually three to four times a day. S1 also stated that staff change bed mats and pads and clean or change bedding when needed. On September 3, 2025, in an interview with R2, R2 did not report any concerns regarding the accommodations provided. Based on the interviews, there was insufficient evidence to support that staff did not provide adequate accommodations to a resident in care, therefore, this allegation was unsubstantiated. {5} Allegation – Staff did not safeguard resident’s confidential records. The investigation into this allegation consisted of interviews and observations. On August 27, 2026, Administrator Lucia stated that resident records are kept locked in cabinets and a closet. She also stated that R1 had a locked mailbox for her mail. On January 16, 2026, R2’s responsible person stated that resident records are kept under lock and key. R3’s responsible person also stated that resident documents were secured. On September 3, 2025, interview with R1 which R1 stated that R1 was not aware of their personal information being exposed. R1 also stated that R1 could not remember a document that was left for R1 in their bedroom to sign and was unsure if R1 had signed it. Staff S1 stated that resident charts and documents are confidential and are always kept locked. S1 stated that documents are kept in folders and are only removed when needed for CCLD or the fire department. Lucia also stated that R1’s documents are kept in a locked closet and facility have a mailbox that is locked. During facility visits on August 12 and August 27, 2026, LPA observed resident files, medications, and other confidential documents stored in locked cabinets and a locked closet. Based on interviews and facility observations, there was insufficient evidence to support the allegation that resident confidential records were not safeguarded, therefore, the allegation was unsubstantiated. {6} Allegation – Staff did not follow the doctor’s orders for resident in care. The investigation into this allegation consisted of interviews and medication review. Interview was conducted with Administrator Lucia regarding R1’s change in condition and communication with R1’s physician and responsible person. Lucia stated that R1’s Power of Attorney (POA) did not allow Lucia or facility staff to speak with R1’s doctors, the hospital or other services involved in R1’s care. On January 16, 2026, R2’s responsible person stated that staff communicate well and let them know when there are concerns. R3’s responsible person also stated that they were pleased with the administrator and staff. Lucia also stated that R1’s POA did not share information with the facility about R1’s doctor appointments most of the time, until the last minute. Lucia reported that she had requested updated Medical Assessment (LIC602 form) from the POA since 2024 and again in 2025, but the POA refused. On September 3, 2025 interview, Lucia stated that R1’s responsible person brought a large bag of medication to the facility. Lucia did not accept the medications because they needed to be properly logged and stored. Lucia asked R1’s responsible person to refill a specific medication and left the empty bottle on the counter. When R1’s responsible person later brought pills and filled the bottle themselves, Lucia rejected the medication. On September 3, 2025, LPA Sommer Hayes and Lucia reviewed R1’s medications and Medication Administration Records. The medications were compared with the most current medication list, and discontinued medications were separated. LPA Hayes instructed the licensee to follow only the current prescription list and not give medications without a valid prescription. No medication discrepancies were observed during the review. Based on the interviews and medication review, there was insufficient evidence to support the allegation that staff did not follow the doctor’s orders for R1, therefore, the allegation was unsubstantiated. {7} Allegation – Staff did not safeguard resident’s personal belongings. The investigation into this allegation consisted of interviews and record reviews. A review of the Resident Personal Property and Valuables (LIC 621) for all six residents showed that the facility documented large and valuable items brought by residents upon admission and throughout their stay at this care facility. Some residents did not want to inventory their clothing, so clothing was not always listed. On August 27, 2026, staff S1 stated that resident belongings are safeguarded by labeling items with the resident’s name. S1 stated that R1’s belongings were kept in their private bedroom and were labeled. Administrator Lucia stated that the facility labels belongings with the resident’s name or room number. Lucia also stated that R1 had their own bedroom and a locked mailbox. On January 16, 2026, R2 and R3’s responsible persons denied seeing any concerns with the handling of their parents’ belongings. They described the residents’ belongings as neat, clean, and orderly. Lucia and S1 also stated that resident belongings and personal care items are kept safe, with some items stored in locked areas. On September 3, 2025, R1 was interviewed and did not report any of their belongings going missing, misplaced or mismanaged. Based on the record review and interviews, there was insufficient evidence to support that staff did not safeguard a resident’s personal belongings, therefore, the allegation was unsubstantiated. {8} Allegation – Staff falsified resident records The investigation into this allegation consisted of interviews and record reviews. In an interview, Administrator Lucia stated that R1’s responsible person (POA-1) had altered R1’s doctor visit summaries. Lucia stated that information was removed by cutting pages, using white-out, or crossing out information with markers. Lucia stated that some of the removed information may have been important to R1’s care. On January 16, 2026 interviews, R2’s responsible person stated that staff have been forthcoming and that R2 would tell him if anything happened. R3’s responsible person stated that resident documents are secured. Staff S1 stated that she did not know anything about records being falsified and stated that staff do not alter resident records. Lucia also denied falsifying documents. A review of documents that were collected throughout to this investigation did not provide sufficient evidence that resident records were falsified by facility staff. Based on the interviews and document review, there was insufficient evidence to support the allegation that staff falsified resident records, therefore, the allegation was unsubstantiated. Note: A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited. Report was reviewed with Lucia during the exit interview. A copy of this report and appeal rights were provided. {9}the state’s words, verbatim · CDSS document, Aug 27, 2026 · control 27-AS-20250902125416

Allegation investigated: Staff yelling in presence of residents.

On August 20, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrvied at this facility unannounced to conduct a follow-up complaint investigation and deliver findings regarding the allegations noted above. LPA initially met with staff on duty, Jellian Sinclair (S1) and stated the purpose of the visit. The adminsitrator, Lucia Boboc (AD), was notified and arrived shortly after. Allegation – Staff Yelling in the Presence of Residents The investigation into this allegation consisted of interviews, record reviews and observation. Interviews with other residents and their responsible parties denied witnessing the staff yelling in their presence. Staff members also denied seeing staff yell in front of residents in care. Administrator denied yelling at staff in front of residents. During an interview on September 3, 2025, R1 stated that staff always try to help R1 and have never treated R1 roughly or spoken to R1 inappropriately. R1 said staff are careful when speaking with R1 and that R1 had never heard harsh or inappropriate words. During interviews with residents on September 16, 2025, no residents reported that staff were rude, harassing, or inappropriate. Records from unannounced facility visits conducted on August 14, 2025, September 3 and 16, 2025, October 15 and 31, 2025, November 4, 2025, January 7, February 27, March 11, August 12, and August 20, 2026, did not document staff or the administrator yelling at residents, staff, or in the presence of residents. Based on the available evidence, there were no interviews, observations, or records showing that staff yelled in the presence of residents. Therefore, the allegation is unfounded. Exit interview was conducted and a copy of this report was provided. Unfounded Allegation – Staff retaliating against resident The investigation into this allegation consisted of interviews and record reviews. Records showed that R1’s care needs had increased over time. R1’s 2023 records showed that R1 already needed help with bathing, dressing, toileting, transfers, repositioning, and wheelchair use due to weakness from a prior stroke. The August 5, 2025, and September 4, 2025, assessments showed further decline. R1 was weak and unstable, could no longer turn independently in bed, and required two caregivers for transfers and personal care. R1 was also having difficulty supporting themselves and could no longer safely perform some tasks independently. The facility issued a 30-day eviction notice, dated 9/5/2025, based on its assessment that R1's care needs were beyond the level of care the facility could safely provide. The records also documented ongoing concerns regarding communication and cooperation with R1’s Power of Attorney (POA), including missing medical forms, limited communication with health care providers, and disagreements about R1’s care. Staff also documented incidents involving conflict between the POA and facility staff. Records dated October 4, 2025, stated that R1 had refused to get out of bed, shower, and eat dinner. Staff reported that this had been happening for about three months. Staff also documented that R1 was weak, could not turn in bed, slept much of the day, and could no longer give themselves eye drops. The note stated that R1’s care needs had increased and were beyond the level of care the facility could provide. The POA was notified of R1’s condition A September 7, 2025, note stated that police were called because of concerns about R1’s POA’S verbal aggression, blocking the facility entrance, refusal to follow facility safety rules, and concerns about resident privacy. The facility also documented concerns that R1’s POA’s behavior was causing distress to staff and other residents. These records describe conflict between the facility and the POA; however, they do not show that staff retaliated against R1. On October 20, 2025, staff told POA that an updated Medical Assessment (LIC602A form) was needed so the facility could properly document R1’s condition and provide the correct care. The facility reported that the form was not received. Other residents, and their responsible parties that were interviewed and denied witnessing retaliation from staff. Staff members stated that they had not seen staff retaliate against R1 at the facility. The records reviewed did not show that staff retaliated against R1. Instead, the records support that the facility was documenting R1’s decline and concerns about facility’s ability to safely meet R1’s increased care needs. Based on the interviews and records reviewed, the allegation of staff retaliation against R1 is unsubstantiated. {2 of 4} Allegation – Staff Not Assisting Resident With Medication The investigation into this allegation consisted of interviews and record reviews. Other residents and their responsible parties that were interviewed reported no medication concerns. Staff member (S1) denied the allegation and stated that staff help and guide R1 with taking their medications, including eye drops, glucose testing, and inhalers. Interview with R1 which also stated that S1 helps R1 with glucose testing. During the August 14, 2025, interview, S1 explained that R1 performs own finger prick while staff provide guidance and supervision. S1 demonstrated this process to LPA Somer Hayes and stated R1 understood that staff are not allowed to perform the finger prick for residents. Administrator Lucia Boboc stated that staff stay with R1 during medication times, prepare and administer medications, and supervise or guide R1 when R1 is unable to independently perform tasks such as glucose testing and eye drops. Lucia stated that R1’s ability to self-administer these tasks started to significantly decline beginning around May 2025. On September 3, 2025, LPA Hayes and Lucia reviewed R1’s medication records and compared R1’s medications with current and previous medication lists. Discontinued medications were identified and separated for return to the POA. LPA Hayes instructed the facility to follow only current physician orders and not administer medications without a valid prescription. No medication discrepancies were found during the review. Additional records show that R1’s physical condition declined during 2025. R1’s care records documented weakness, difficulty with mobility, and increased need for assistance with daily activities. On October 4, 2025, staff documented that R1 was unable to administer own eye drops and that R1’s care needs had increased. On October 20, 2025, staff documented concerns that the POA had provided medications that the facility could not administer without proper medical documentation. The November 9, 2025, confidential report also documented concerns involving the POA’s communication with the facility and medical providers, including delays in medical care and failure to provide updated medical information. These records show ongoing concerns regarding care coordination but do not establish that facility staff failed to assist R1 with medications. Based on the available evidence, staff provided medication assistance, supervision, and guidance based on R1’s abilities and current physician orders. No medication discrepancies were identified during the LPA’s review. Therefore, the allegation that staff did not assist R1 with medication administration is unsubstantiated. {3 of 4} Allegation – Staff Are Mishandling Resident’s Medication The investigation into this allegation consisted of interviews and record reviews. Staff member (S1) denied the allegation and stated that staff assist and guide R1 with medication administration, including eye drops and glucose testing. Interview with R1 also stated that S1 helps R1 with glucose testing. Administrator Lucia Boboc stated that she prepares R1’s medications and staff administer them. She reported that staff supervise R1 with tasks R1 can perform independently and document medication refusals. Lucia also stated that some medications were brought by the POA without physician orders, and staff could not administer them without proper documentation. On September 3, 2025, LPA Hayes and Lucia reviewed R1’s medication records, medication lists, and destruction log. Discontinued medications were separated for return to the POA. LPA Hayes instructed the facility to follow the current medication list and only administer medications with valid physician orders. No medication discrepancies were found during the review. Records showed R1’s ability to manage some medications and treatments declined over time, and staff provided supervision and guidance as needed. Although there were disagreements between the facility and POA regarding medications and medical instructions, there was insufficient evidence that staff incorrectly administered, withheld, or otherwise mishandled R1’s medications. Therefore, based on the available evidence, the allegation is unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited. Report was reviewed with AD during exit interview. A copy of this report was provided. {4 of 4}the state’s words, verbatim · CDSS document, Aug 20, 2026 · control 27-AS-20251009100804

Allegation investigated: Illegal eviction Staff did not provide adequate supervision, resulting in resident sustaining a fracture

On August 12, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived at this facility to conduct an unannounced investigation visit and deliver findings of the allegations noted above. LPA initially met with staff on duty and stated the purpose of the visit. The adminsitrator, Lucia Boboc (AD), was notified and arrived shortly after. Overview: It was alleged that the facility did not adequately supervise Resident-1 (R1) while taking antibiotics that caused R1 to be sleepy and required extra water. They say staff did not help R1 into bed, did not lift legs in wheelchair, and did not make sure R1 drank enough, which led to R1 falling from the wheelchair and breaking R1 leg. The Reporting Party (RP) also says that right after the injury, the administrator gave the family eviction notices and would not let R1 return, even though hospital staff and R1’s doctor said it was safe for R1 to go back with therapy. The RP believes the eviction notices were unfair, false, and done to bully or discriminate against R1. {1 of 4} Unsubstantiated Allegation – Illegal Eviction: The investigation into this allegation consisted of interviews and record reviews. On October 8, 2025, the POA for R1 reported that R1 was provided a 30-day eviction notice on September 10, 2025. Email correspondence showed that Administrator Lucia asked LPA Sommer Hayes to review the eviction notice that was provided to R1. Per review, LPA Hayes provided consultation to Lucia to update R1’s reappraisal. On August 6, 2025, Lucia stated that a reappraisal had been conducted for R1 but that the family refused to sign it. Lucia also reported that the POA had not provided an updated Physician’s Report at that time. The 30-day eviction notice cited Title 22, Section 87224(a)(4), and stated that R1’s care needs had increased beyond what the facility could safely provide. The notice documented that R1 required two caregivers and a Hoyer lift for transfers, had severe weaknesses, could not turn or reposition independently, and was at risk of falling or sliding from the lift. The notice also documented difficulty with personal care and administration of eye drops. The notice further documented concerns regarding the POA’s lack of cooperation, including failure to provide updated medical documents and physician information and difficulty communicating with facility staff. The notice included resident rights, complaint information, and relocation resources. An addendum to the 30-day Notice, dated November 13, 2025, continued to document the facility’s concerns regarding R1’s care needs and the POA’s reported lack of cooperation. Email correspondence between Lucia and the Department, dated January 22, 2026, showed that the POA voluntarily removed R1 from the facility. There is no evidence that the facility physically removed R1. Based on the reviewed records, the facility documented R1’s increased care needs and stated that a reappraisal had been conducted before the eviction process. Although LPA Hayes later raised concerns regarding the initial eviction notice, the available evidence does not establish that the facility failed to conduct a reappraisal or that the facility unlawfully removed R1. The evidence shows that R1 was voluntarily removed by the POA. The allegation of illegal eviction is UNSUBSTANTIATED. The evidence does not establish that the facility unlawfully evicted R1. The facility documented R1’s increased care needs, reported completion of a reappraisal, provided eviction-related rights and resources, and R1 was ultimately voluntarily removed by the POA. {2 of 4} Allegation - Staff did not provide adequate supervision, resulting in resident sustaining a fracture It is alleged that facility staff failed to provide adequate supervision to resident (R1), resulting in R1 sustaining a fracture. The investigation into this allegation consisted of interviews and record reviews. Record reviews showed that on December 21, 2025, R1 fell and injured their left knee. Medical records stated that R1 fell from a wheelchair during a transfer when a caregiver assisting R1 slipped. R1 was transported by EMS to Emergency Department (ER). R1 was diagnosed with a left knee sprain and discharged the same day. The initial X-ray did not show a fracture. On December 23, 2025, R1 returned to the ER due to continued left knee pain and delirium. A CT scan showed a fracture of the distal left femur. R1 was placed in a long leg splint and later followed up with orthopedics on January 7, 2026. The facility incident report stated that on December 21, 2025, R1 was alone in their room when the fall occurred and that the fall was unwitnessed. Staff became aware of the incident shortly after it occurred, responded immediately, contacted EMS, notified responsible parties, and had R1 transported to the hospital. Fall precautions were implemented after R1 returned to the facility. R1’s appraisal/needs service plans dated August 5, 2025, and September 4, 2025, documented that R1 had severe weakness, left-sided weakness from a prior stroke, and an increased risk of falls. The service plan stated that R1 required two caregivers for transfers and peri-care and sometimes slid from the lift because of weakness. The Physician’s Report dated November 10, 2023, also stated that R1 was non-ambulatory and unable to transfer independently. The records establish that R1 had a known fall risk and sustained a fracture following a fall. However, the evidence does not establish that staff failed to provide the required supervision or failed to follow R1’s care needs at the time of the incident. There is also conflicting information regarding the circumstances of the fall. The facility reported that the fall was unwitnessed, while the medical record stated that a caregiver was assisting R1 when the caregiver slipped. Further medical records show that staff obtained medical attention immediately after the fall. The fracture was not identified on the initial X-ray and was found two days later through a CT scan after R1 continued to experience knee pain. {3 of 4} The allegation is UNSUBSTANTIATED. Although R1 sustained a distal left femur fracture after a fall, the available evidence does not establish that inadequate supervision by facility staff caused or contributed to the fall or fracture. Staff responded promptly, obtained medical attention, notified responsible parties, and reinforced fall precautions. Therefore, there is insufficient evidence to substantiate a violation related to inadequate supervision. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator and a copy of this report was provided to Administrator. Appeal rights provided. {4 of 4}the state’s words, verbatim · CDSS document, Aug 12, 2026 · control 27-AS-20260106124813

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Christina Valerio, LPA Reza Jamaly, and Bureau Chief for the Administrator Certification Bureau Wendy Soerianata arrived to the facility unannounced to conduct an Annual continuation visit. LPAs and Bureau Chief was met by Administrator Lucia Boboc, and explained the purpose of the visit. On 02/27/2026, LPA Villanueva did the initial annual inspection. LPAs toured the facility to ensure compliance with Title 22 regulations. LPAs observed four resident bedrooms, all of which were observed to be fully furnished and free from odors. Resident bathrooms were observed to be fully stocked with hygiene supplies and sanitary. The faucet was measured to deliver hot water at 106.0 degrees F, which was within the regulatory range of 105.0 - 120.0 degree F. LPAs spoke to two (2) residents and one staff member during the visit. LPAs reviewed two (2) resident files and two (2) staff files. Files were observed to up to date with required annual documentation. All staff were observed to be fingerprint cleared and associated to the facility. LPAs reviewed the facility menu and discussed meal options for the residents with Administrator Lucia. LPA Valerio requested the following annual documentation to CCLASCPSacramentoSouthRO@dss.ca.gov: LIC 500, LIC 308, LIC 610, and copy of liability insurance. Per California Code of Regulations (CCR) - Title 22 - no deficiencies were cited during today's visit. An exit interview was held, and copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 16, 2026

Type of visit: Required - 1 Year

On 02-27-2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced to conduct the annual inspection visit. LPA initially met with staff on duty, Jellian Sinclair (S1), and stated the purpose of the visit. The Administrator, Lucia Boboc (AD) was notified and arrived shortly after. Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents, up to 6 may be non-ambulatory. Facility does manage residents’ cash resources. Facility does not have fire clearance for bedridden, delayed egress, and/or locked interior/exterior. Initial Observation: Present during today's visit were four residents in care with one staff on duty (S1). Per S1, one resident was out in their appointment. Cameras were observed in common areas and outdoor. Per interview with Lucia, they are not activated and not recording. Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA inspected 4 of 4 resident bedrooms and 2 bathrooms. Room temperature was maintained at 76 degrees. The hot water temperature was measured at 107 degrees Fahrenheit. Fire extinguisher was observed in the hallway by the kitchen and was serviced on 5/16/2025. Smoke and carbon monoxide detectors were observed throughout. LPA observed centrally stored medications, cleaning supplies/solutions, sharp objects and other dangerous items were kept locked and inaccessible to residents in care. {1 of 2} In the kitchen area, LPA observed at least seven-day non-perishable and two-day perishable food supplies. Kitchen refrigerator and freezer temperature were within regulatory standard. The laundry room and garage are locked and not accessible to residents in care. The garage houses additional refrigerator and freezer; this is also where they store their chemicals, cleaning supplies, laundry detergents, tools and miscellaneous items. Advisory was provided to store food items separately from the chemicals. Outdoor area was inspected. LPA observed shaded area and outdoor furniture for resident use. Ramps were observed to be in good repair at this time. When facing the facility from the street, tt the left side, part of the fence was observed to be slightly leaning. Advisory provided to address this issue as soon as possible. Shut off valves were identified. Tool for the gas shut off valve was available at the facility. Based on today's visit, this annual will require a continuation. The Department will return at a later time to continue the annual inspection visit. Exit interview was conducted with Lucia and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 27, 2026

Type of visit: Case Management - Other

On 1/7/26 Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced case management visit to return files to the facility that were removed earlier today to be copied at the Regional Office. LPA was met by staff on duty and stated the purpose of this visit. The Administrator gave staff permission to sign this report. LPA Villanueva returned the following files to staff on duty. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jan 7, 2026

Type of visit: Office

On 01/02/2026, a virtual meeting was held with Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Sommer Hayes, Licensee/Administrator Lucia Boboc, and Regional Ombudsman Patrice Wright to discuss Power of Attorney (POA) responsibilities and the status of Resident (R1). Legal documents reviewed indicated that both Designated Representatives (D1 and D2) each held fifty percent Power of Attorney responsibility for R1. D1 reported that they were acting as the primary POA for R1 due to reported health concerns affecting D2. Licensee/Administrator Lucia Boboc expressed concern regarding R1’s decline in both cognitive and physical functioning and reported that R1 had been absent from the facility for several weeks. The Licensee stated that R1 was currently residing in a rehabilitation center and expressed concern that R1’s condition may change to require use of a Hoyer lift and/or result in a bedridden status. The Licensee stated that such care needs would exceed the facility’s approved Plan of Operation and could not be accommodated by the facility. The Licensee further reported challenges in communicating with D1 via email and stated that current communication with D1 was occurring by text message and through the facility’s internal mailbox. The Licensee stated she would confirm that she had the correct email address for D1. LPM Richardson and LPA Hayes informed the Licensee that D1 was willing to provide outstanding documentation required for R1. Continued on 809-C On 01/02/2026, LPA sent a list of required documents and updates for R1, including suggested due dates, was sent to D1 via email. The same list was also provided to the Licensee for reference. The Licensee stated that upon R1’s discharge from the rehabilitation facility, they would obtain discharge documentation and ensure R1’s care needs remained in compliance with the facility’s approved Plan of Operation. The Licensee further stated that she would ensure all prescription medications provided by D1 would be logged into the facility’s centralized medication storage log and that all required components to medication(s) are included. A copy of this report was provided to the Licensee via email. The Licensee was instructed to sign and return a copy of the report to LPA Hayes and LPM Richardson by close of business on 01/02/2026 at sommer.hayes@dss.ca.gov and stephen.richardson@dss.ca.gov.the state’s words, verbatim · CDSS document, Jan 2, 2026

Allegation investigated: Unlawful Eviction

This is an amended report to ensure the document is correctly classified as a public document. Licensing Program Analyst (LPA) Sommer Hayes arrived and met with Lucia Boboc to deliver investigation findings regarding complaint control number 27-AS-20250808162409, Unlawful eviction. LPA reviewed resident records including the admission agreement and 30-day eviction notice dated 08/05/25. LPA finds that the allegations cited above are substantiated. LPA Hayes observed that the eviction notice (08/06/25) does not meet regulatory requirements, as it failed to include the approved eviction criteria outlined in Title 22 regulations. The notice cited R1’s pre-existing health conditions prior to admission as the reason for eviction, which does not comply with the specified regulatory standards. (Continued on 9099C) Substantiated LPA Hayes also interviewed the POA (P2) of R1, who stated they had not observed any staff performing finger pricks on R1 or any other resident. In addition, the POA of R3 reported that they had not witnessed any staff administering finger pricks in the facility. Staff member (S)1 was interviewed and stated that they only assist R1 with checking their glucose levels but do not perform the finger pricks themselves. Administrator/Licensee stated that effective 08/28/25 R1's doctor note states that R1 finger pricking has been discontinued. Based on interviews and record review, the above allegation is UNSUBSTANTIATED. Based on interviews and record reviews during the investigation, LPA Hayes was unable to corroborate the allegations. Upon record review of the resident (R1)’s file, it was determined that this resident, upon admission to this facility, had the pre-existing conditions stated in the original eviction notice dated 08/06/25 from Licensee, Lucia Boboc to R1 and R1’s POA. Making the eviction dated 08/06/25 an unlawful eviction. 87224 Eviction Procedures 87224 (a) (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. Lucia Boboc provided LPA Hayes with the first eviction notice (dated 08/06/25) on 08/06/25. This eviction notice was served to the R1 and their POA before The Department reviewed the eviction notice. A revision to the eviction notice was requested by LPA Hayes during a virtual meeting on 09/05/25 with Lucia Boboc. LPA Hayes assisted Lucia Boboc with the revision of the eviction letter which was later approved by LPA Hayes and reissued to R1 and R1’s POA. Based on interviews and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is hereby cited per Title 22 CCR Sections 87224 (a)(4). An exit interview was held with Lucia Boboc. A copy of this report and appeal rights were left with Lucia Boboc.the state’s words, verbatim · CDSS document, Nov 4, 2025 · control 27-AS-20250808162409

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a)(4) · Plan of correction due date: Nov 11, 2025

87224 Eviction Procedures 87224 (a) (4) If, after admission, it is determined that the resident has a need not previously identified and... This requirement was not met as evidenced by: Based on record review and interviews, review of the eviction notice issued by the Licensee poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: Licensee has updated the eviction notice dated 08/06/25 to reflect a lawful eviction. The eviction notice dated 09/05/25 has been approved by the Department.

Type of visit: Office

Stephen Richardson , Licensing Program Manager (LPM) and Sommer Hayes, Licensing Program Analyst (LPA), conducted an office meeting with the facility licensee, Lucia Boboc Licensee/Administrator at Grove Home Care and Patrice Wright, Regional Ombudsman, to address ongoing concerns related to Resident 1’s (R1) care, Power of Attorneys, documentation, and facility operations. This meeting was virtual and held via Microsoft Teams. The licensee reported ongoing difficulty obtaining complete and timely medical and medication documentation from R1’s Power of Attorney 1 (POA1 ), including an updated Physician’s Report (LIC 602). The licensee reported that repeated requests for updated documentation had not been fulfilled, which impacted the facility’s ability to safely administer medications and meet the resident’s care needs. LPM reiterated that medications must only be administered in accordance with written physician orders and that verbal direction from a POA is not sufficient authorization. The facility was advised not to administer medications without complete documentation and to ensure medication administration records, centrally stored logs are maintained and accurate, including appropriate measuring devices for liquid medications. The licensee reported that two individuals are identified as holding Power of Attorney for the resident, POA 1 and POA 2 at 50% each. Licensing clarified that if both individuals have legal authority, the facility must include both in communications and may not exclude one at the direction of the other. The licensee reported having previously issued a 30-day eviction notice and as of the date of this meeting, had still not received medical/medication documentation as requested. Continued on 809-C Licensee was advised to prepare an addendum to the eviction notice, documenting ongoing requests that have not been fulfilled with dates of initial and follow-up requests, lack of response, and the operational impact on the facility. Licensing clarified that Community Care Licensing (CCLD) does not provide placement or relocation services and that the eviction process is a civil matter between the parties. The licensee reported observing significant swelling and dark discoloration on the R1’s foot and had brought that to the attention of the POA 1 but had not received a response on how to seek treatment or care. LPM advised the facility to arrange for an immediate medical evaluation. The facility was advised that it remains responsible for ensuring timely medical care regardless of POA 1’s response. The licensee also reported increased difficulty with safe transfers due to the R1’s limited mobility and resistance to care, which increases fall risk. LPM advised licensee to reassess R1 and maintain documentation of changes in condition. Licensing reiterated resident rights regarding visitation and clarified that the facility may not enforce improper visitation restrictions imposed by a POA if they infringe on resident rights. The licensee was advised to maintain written documentation for R1 of all care provided, refusals, and their communications with POA 1, and to send written summaries following discussions to ensure clarity and continuity. CCLD will review submitted documentation and provide guidance as appropriate. The focus of Licensing involvement is on regulatory compliance and resident safety. A copy of this report was emailed to Licensee/Administrator Lucia Boboc for their signature and returned to Community Care Licensing (CCLD) by emailing to LPM Richardson at stephen.richardson@dss.ca.gov by close of business 01/07/26.the state’s words, verbatim · CDSS document, Oct 31, 2025

Allegation investigated: Untrained staff providing care to resident Staff are not providing adequate food service to resident Staff did not safeguard resident's personal belongings Staff are mismanaging resident's medication

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator Lucia Boboc and explained the purpose of the visit. This investigation consisted of interviews, record review, and observation. In interviews, a staff member (S3), a resident (R1), and a resident's responsible party (R1's RP) said there was a certain staff person working at this facility as a caregiver around December 2024 or January 2025, and identified this person by name (S4). Boboc was not familiar with any staff person by that name. Boboc reviewed Guardian records and was not able to identify this staff person among either active or separated employees. LPA Moleski asked for this staff person's file. Boboc did not have a file available for review. [continued on 9099-C] Substantiated 22 CCR Section 87412(h) requires personnel records to be maintained for at least three years following termination of employment. Additionally, 22 CCR Section 87411(c)(6) requires the licensee to "maintain documentation pertaining to staff training in the personnel records..." LPA Moleski reviewed R1's LIC 602, dated 11/10/23, prior to R1's admission date of 12/6/23. LPA Moleski observed that many fields of required information, including information regarding any potential medically ordered restricted diets, were not completed. The LIC 602 indicated there was an "additional patient response" form attached to the LIC 602 with the information. This additional patient response form was not included in R1's file. LPA Moleski asked Boboc if she had a copy of the patient response form. Boboc said she never had a copy of the patient response form. LPA Moleski pointed out that she had accepted a resident without full information regarding their medical needs. Boboc acknowledged this and said she was not aware of this at the time. Without a physician's order on file, licensees, staff, or attorneys-in-fact may not restrict a resident's right to personal preferences regarding meals. However, in interviews, Boboc said they had restricted R1's diet at the request of R1's attorney-in-fact (R1's RP). Boboc said this was distressing to R1, who did not understand why they could not eat what other residents were eating. In an interview, R1 voiced no concerns with the quality of food served at this facility. In interviews, both R1 and R1's RP said that staff had removed decorations from R1's room. R1 said that staff "tore" the decorations down. In an interview, Boboc said she didn't know what had happened, as she was not present. LPA Moleski was unable to contact the staff person who was working at the time. Boboc said she did not know who was on duty at the time. S3 said that they started working at the facility after S4 left, around late December 2024 or early January 2025, and at that point, the decorations had been put back up. This facility does not keep daily medication administration records. LPA Moleski performed an audit of medications during this visit, and observed physician's orders were not being followed. LPA Moleski observed a blood pressure medication, one tablet of which was to be given twice daily, unless blood pressure was too low or unless heart rate was below 55. LPA Moleski observed a start date for this medication of 9/6/25. LPA Moleski counted out the remaining tablets and observed that the medication had consistently been given twice daily since that date. However, LPA Moleski observed several days since that date wherein R1's heart rate was recorded below 55, meaning that the medication should have been held per the prescription orders. [continued on 9099-C] Although the licensee should have sought to acquire all pertinent medical information before admission, they cannot be held accountable for adhering to physician's orders which they were not provided. LPA Moleski will address the licensee's failure to acquire this crucial medical information in a separate case management report. LPA Moleski reviewed R1's admission agreement. LPA Moleski observed numerous modifications in this agreement made by R1's RP. Boboc signed the agreement, which makes all modifications enforceable. However, LPA Moleski did not observe any such provision, modified or otherwise, which would require that only female staff provide care for R1. However, LPA Moleski observed that R1's resident appraisal, signed by Boboc on 12/15/23, does indicate that R1 shall have "female staff only -- especially for intimate care." In an interview, R1 said they are only cared for by female staff. In interviews, S1-S3 said that R1 is only cared for by female staff. In an interview on 1/9/25, R1 said that staff are not harassing them, and said that staff do not speak inappropriately to them. R1 said that they regularly receive showers twice per week. R1 said they can "holler" for staff if they need assistance at night, but they don't always ask for it. R1 voiced no concerns with the quality of food served in this facility. In an interview on 9/16/25, R1 said that they are not changed frequently enough. However, R1 also said all their needs were being met and said that they do not always let staff know when they need assistance with diaper changes. LPA Moleski reviewed R1's functional capabilities assessment, dated December 2023, and observed that R1 is fully able to express themselves verbally, and has some bladder and bowel control. R1's LIC 602, dated 11/6/23, indicates that R1 does not suffer from mild cognitive impairment or dementia. R1's preadmission appraisal, dated December 2023, does not indicate that R1 needs special overnight supervision. In interviews, S1-S3 said they had not witnessed any sort of harassment or inappropriate comments being made toward R1. In interviews, the other residents of this facility, R2-R5, did not voice any concerns regarding medications, harassment, inappropriate comments, showers, or diaper changes. R2, who does not have a dementia diagnosis, said that their diapers are changed as frequently as necessary, and said that they are able to get nighttime assistance without issues. LPA Moleski observed that, starting in June, facility staff began documenting R1's daily care to ensure consistency. During this visit, all residents appeared clean and cared for. [continued on 9099-C] The department has determined the following as it relates to the allegations that staff are not abiding by a resident's admissions agreement, that staff are making inappropriate comments towards a resident, that staff are harassing a resident, that staff did not ensure a resident was showered, that staff left a resident in a soiled diaper for an extended period of time, and that staff are not following a resident's dietary needs: Based on interviews, observations, and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Boboc. The department has determined the following as it relates to the allegations that untrained staff are providing care to a resident, that staff are not providing adequate food service to a resident, that staff did not safeguard a resident's personal belongings, and that staff are mismanaging a resident's medication Based on interviews, observation, record review the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Sections 87555(b)(5), 87411(c)(6), 87217(b), and 87465(a)(4). An exit interview was held with Boboc. Appeal rights and a copy of this report were left with Boboc.the state’s words, verbatim · CDSS document, Sep 16, 2025 · control 27-AS-20250106153318

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(5) · Plan of correction due date: Sep 23, 2025

"(5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents." This requirement was not met as evidenced by: Based on interviews, staff members restricted R1's diet without physician's orders to do so, in violation of residents' rights, which poses a potential health, safety, and/or personal rights risk to residents.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: Licensee agrees to review the powers granted to R1's attorney in fact, and to review residents' rights by POC due date. Licensee shall provide LPA Moleski with a signed statement acknowledging this has been completed. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(6) · Plan of correction due date: Sep 23, 2025

"(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer." This requirement was not met as evidenced by: Based on three witness statements, a staff member worked in this facility for whom no file can be located, and no training records are available. This poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: Licensee agrees to provide LPA Moleski with a signed acknowledgement that they will be aware of which staff members are working in their facility, and that they will ensure proper documentation remains on file for all such persons, by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 17, 2025

"(4) The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by: Based on observation and interview, a resident's medication was being improperly dispensed, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: Licensee agrees to submit a signed acknowledgement that physician's orders shall be followed exactly as written in the future by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b) · Plan of correction due date: Sep 30, 2025

"(b) Every facility shall take appropriate measures to safeguard residents' ... personal property ... which have been entrusted to the licensee or facility staff." This requirement was not met as evidenced by: Based on interviews, a resident's personal property was improperly removed without consent of the resident, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: Licensee agrees to provide LPA Moleski with a signed statement acknowledging that residents' belongings are not to be disturbed without their consent by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on a complaint investigation but observed an unrelated deficiency during this visit. LPA Moleski met with facility administrator Lucia Boboc and explained the purpose of the visit. LPA Moleski reviewed R1's LIC 602, dated 11/10/23, prior to R1' admission date of 12/6/23. LPA Moleski observed that many fields of required information, including information regarding any potential medically ordered restricted diets, were not completed. The LIC 602 indicated there was an "additional patient response" form attached to the LIC 602 with the information. This additional patient response form was not included in R1's file. LPA Moleski asked Boboc if she had a copy of the patient response form. Boboc said she never had a copy of the patient response form. LPA Moleski pointed out that she had accepted a resident without full information regarding their medical needs. Boboc acknowledged this and said she was not aware of this at the time. This facility is hereby cited per 22 CCR Section 87458(c)(4). An exit interview was held with Boboc. Appeal rights and a copy of this report were left with Boboc.the state’s words, verbatim · CDSS document, Sep 16, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(c)(4) · Plan of correction due date: Sep 23, 2025

"(c) The medical assessment shall include, but not be limited to: ... (4) Identification of physical limitations of the person to determine his/her capability to participate in the programs provided by the licensee, including any medically necessary diet limitations." This requirement was not met as evidenced by: Based on interview and record review, a resident was accepted into care without all required information on file, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Sep 16, 2025

Plan of correction: Licensee agrees to provide LPA Moleski with a written plan describing how they intend to acquire the required information, including R1's restricted diet orders, by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 1/9/25 at 1:00pm on a subsequent visit. LPA met with Lucia Boboc, Administrator and stated the purpose of the visit. Caregiver present are fingerprint cleared and associated to the facility. There are 5 bedrooms and 2 bathrooms. License fees are current. The facility is licensed for a capacity of 6 Non-ambulatory residents of which 2 may receive hospice care services. There is 1 residents receiving hospice care services at this time. Administrator Certificate expires 12/17/24. Renewal documentation has been submitted to Community Care Licensing (CCL). LPA observed an LIC308 Designation of Responsibility form. LPA observed a copy if the Infection Control Plan during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 76*F which is within the required range of 68-85*F. The hot water temperature was measured at 105*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 1 resident and 1 staff file reviewed during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees-Current Liability Insurance-Submit Designation of Administrative Responsibility LIC308-Submit Administrative Organization LIC309-Submit Affidavit Regarding Client/Resident Cash Resources LIC400-NA Surety Bond LIC402-NA Personnel Report LIC500-Submit Emergency Disaster Plan (LIC610E)-Submit Criminal Record Clearances LIS536-Current Facility Floor Plan/Plot Plan LIC999-Current Fire Clearance (consistent with terms and limitations of license)-Current Qualifications of Administrator/Facility Manager-Submit Articles of Incorporation/Organization, Constitution and bylaws-NA Partnership Agreement-NA Control of Property-NAt Plan of Operation (Restricted Health Care Plan)-NA Admission Policies and Procedures-NA Health Screening Report-Facility Personnel LIC503-NA Bacteriological Analysis of Private Water Supply-NA In-service Training Program-NA Medication Procedures-NA Transportation Procedures-NA Job Description/Personnel Policies-NA Exemptions/Waivers and Exceptions-NA First aid/CPR certificates-Current -Any updates to Infection Control Plan Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.the state’s words, verbatim · CDSS document, Jan 9, 2025

Allegation investigated: Licensee did not ensure resident's medication was administered by an appropriately skilled professional. Staff do not ensure that the facility is free of pests.

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 6/26/24 at 4pm to conduct an investigation of the above-mentioned allegations. LPA met with Administrator Lucia Boboc and stated the purpose of the visit. LPA conducted interviews of residents 1-5 and staff 1-4, and the Hospice Representative during this visit. Regarding allegation, “Licensee did not ensure resident's medication was administered by an appropriately skilled professional” LPA conducted interviews of staff, residents, and hospice agency on 6/26/24. The investigation revealed that staff was not asssiting with administering morphine to R1. However, family of R1 was trained to do so. Regarding allegation, "Staff do not ensure that the facility is free of pests", LPA conducted a physical plant tour of the facility observing furniture, drawers, kitchen, and bedrooms. LPA did not observe insects in the home nor evidence of feces or droppings. Based on observation and interviews, at this time, the allegations are deemed UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, no deficiencies are being cited. An exit interview was conducted, and a copy given. Unfoundedthe state’s words, verbatim · CDSS document, Jun 26, 2024 · control 27-AS-20240619141108

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 2/1/24 at 12:30pm. LPA met with Lucia Boboc, Administrator and stated the purpose of the visit. Caregiver present are fingerprint cleared and associated to the facility. The facility is licensed for a capacity of 6 Non-ambulatory residents of which 2 may receive hospice care services. There is 0 residents receiving hospice care services at this time. Administrator Certificate expires 12/17/24. The license fees are current. LPA observed an LIC308 Designation of Responsibility form. LPA observed a copy if the Infection Control Plan during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 76*F which is within the required range of 68-85*F. The hot water temperature was measured at 112.6*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. The most recent emergency drill was conducted on 1/5/24. LPA reviewed 2 resident and 2 staff files and conducted interviews during this visit. LPA reviewed 2 staff and 2 resident files and conducted interviews during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees-Current Liability Insurance-Submit Designation of Administrative Responsibility LIC308-Submit Administrative Organization LIC309-NA Affidavit Regarding Client/Resident Cash Resources LIC400-NA Surety Bond LIC402-NA Personnel Report LIC500-Submit Emergency Disaster Plan (LIC610E)-Submit Criminal Record Clearances LIS536-Current Facility Floor Plan/Plot Plan LIC999-Current Fire Clearance (consistent with terms and limitations of license)-Current Qualifications of Administrator/Facility Manager-Submit Articles of Incorporation/Organization, Constitution and bylaws-NA Partnership Agreement-NA Control of Property-Submit Plan of Operation (Restricted Health Care Plan)-NA Admission Policies and Procedures-NA Health Screening Report-Facility Personnel LIC503-NA Bacteriological Analysis of Private Water Supply-NA In-service Training Program-NA Medication Procedures-NA Transportation Procedures-NA Job Description/Personnel Policies-NA Exemptions/Waivers and Exceptions-NA First aid/CPR certificates-Current -Any updates to Infection Control Plan Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.the state’s words, verbatim · CDSS document, Feb 1, 2024