Hanover Guest Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Staff S1 Alicia Correa Olvera. LPA stated the purpose of the visit. Staff S1 stated Administrator (ADM) Marsha Belleza and Designated Staff Wendy Sanchez were not at the facility. ADM arrived to the facility at 12:27 PM. LPA toured the interior and exterior of the facility with ADM to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the refrigerator temperature at 40 F and Freezer at 0 F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. LPA did not observe smoke detectors in the facility during inspection. ADM stated each room had a smoke detector, but is not able to find smoke detectors for each room. ADM states smoke detectors were installed two months ago, but does not know what happened to the smoke detectors in the residents. Fire extinguishers were last serviced on 1/22/2026. ADM was advised to purchase and install smoke detectors by 8/25/2026. A deficiency is being issued. Page 1 of 2 LPA reviewed the facility first aid kit, the first aid kit did not contain tweezers. LPA advised ADM to purchase a pair of tweezers. LPA reviewed the facility emergency drill logs, with the last drill being conducted on 9/12/2025. ADM stated the facility will conduct a drill by 8/28/2026. A deficiency is being issued. LPA toured 6 resident bedrooms. All 6 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 3 bathrooms. All 3 bathrooms had hand soap, hand towels, functioning lights, and covered trash bins. LPA measured water temperature with a range of 120.7 F to 138.0 F in the 3 bathrooms at approximately 12:00PM. ADM adjusted water heater during visit, however, water temperature measured 130.4 F at 3:40PM. A deficiency is being issued. LPA reviewed 2 resident records. LPA reviewed 2 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA reviewed 3 staff records. 2 Out of 3 staff records did not contain current CPR/first aid training and did not contain current caregiver training for 2026. A deficiency is being issued. S3 did not have a staff record, and S3 did not obtain a fingerprint clearance. A deficiency is being cited. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S3 working in the facility without receiving a criminal record background clearance. An exit interview was conducted with Administrator Marsha Belleza and a signed copy of this report was provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Aug 24, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Plan of Correction (POC) visit. LPA met with Staff S1 Beto Zamora. LPA called Administrator (ADM) Marsha Belleza at 3:15PM and left a voicemail stating the purpose of the visit. LPA also called Designated Administrator Wendy Sanchez at 3:15PM. Designated Administrator stated she would not arrive to the facility until 4:30PM. Designated Administrator authorized Staff S1 Beto Zamora to sign the report for today. On 4/9/2026 the facility was issued a Type B deficiency with a due date of 4/16/2026. On 4/17/2026 the Department spoke with Administrator (ADM) Marsh Belleza regarding the POC. ADM stated she would submit the POC to the Department by the end of the day. Later on that same day, ADM informed LPA she was experiencing technical issues in submitting the POC due to a power outage. On 4/20/2026, the Department spoke with ADM regarding the POC. ADM stated she had submitted the POC via email to the Department on 4/17/2026. On 4/23/2026, the Department received the POC from ADM. During today's visit, a Letter of Deficiency Citations Cleared was provided to S1. No deficiencies were cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with S1, and copy of this report was provided.the state’s words, verbatim · CDSS document, May 13, 2026

Allegation investigated: Staff does not ensure transportation arrangements are made for resident in care

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint investigation visit to deliver case findings. LPA met with Administrator Marsha Belleza. LPA stated the purpose of the visit. On 2/19/2026 the Department received a complaint with the above allegations. On 2/25/2026 the Department conducted the initial complaint investigation visit and interviewed the Administrator (ADM) Marsha Belleza and 1 Staff (S1). ADM states she does not personally drive residents to their medical or dental appointments but arranges for transportation to resident’s appointments through an outside agency. ADM states she has also informed families about outside agencies that provide transportation for appointments. Page 1 of 2 Unsubstantiated On 2/25/2026 the Department interviewed 1 Staff (S1). S1 states both she/he and ADM will make arrangements to take residents to medical or dental appointments. S1 states she is not aware of any residents not being taken to his/her appointments. S1 states she or ADM have not refused to take or arrange to take residents to his/her appointments. On 4/7/2026 the Department interviewed 3 Witnesses (W1 to W3). 3 Out of 3 Witnesses states he/she has no concerns with the care his/her loved one is receiving at the facility. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies were cited per California Code of Regulations Title 22. An exit interview was conducted Administrator (ADM) Marsha Belleza and a copy of this report was provided. On 2/25/2026 the Department reviewed 3 resident files. 2 Out of 3 resident files did not contain updated needs and services plans. R2 and R3 have neurocognitive impairment. On 4/7/2026 the Department interviewed 3 Witnesses (W1 to W3). 3 Out of 3 Witnesses states he/she has no concerns with the care his/her loved one is receiving at the facility. Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be substantiated. California Code of Regulations Title 22 are being cited on the attached LIC 9099 D. An exit interview was conducted with Administrator Marsha Belleza, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 9, 2026 · control 26-AS-20260219165639

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Apr 16, 2026

87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment ... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by; Based on record review and interview, both R2 and R3's needs and services plans have not been updated annually. Both R2 and R3 have neurocognitive impairment. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 9, 2026

Plan of correction: Administrator states she will submit a plan of action on how she will ensure resident care plans are updated annually. Administrator will submit POC by POC due date of 4/16/2026 to CCL via email.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced visit to follow up on deficiencies cited on 10/8/2025, and the licensure of Hanover Guest Home LLC 445203006. LPA met with Administrator Marsha Belleza. LPA stated the purpose of the visit. On 10/8/2025 the facility was cited the following Type A deficiencies: 87111 Continuation of License Under Emergency Conditions (b)(1), POC due 10/9/2025 87405 Administrator - Qualifications and Duties(a), POC due 10/9/2025 Administrator submitted the POC on 10/10/2025. A Letter of Deficiencies Citations Cleared was provided during today's visit. LPA also followed up on the licensure of Hanover Guest Home LLC 445203006. LPA discussed with Administrator to ensure to continue to work with Centralized Application Bureau (CAB) with regard to submitting all requested documentation in a timely manner. LPA advised Administrator to communicate with CAB any issues or concerns she may have during this process. LPA also advised Administrator to communicate any issues or concerns LPA as well.the state’s words, verbatim · CDSS document, Apr 9, 2026

Allegation investigated: Staff did not notify resident's responsible party of an incident.

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced complaint investigation visit and met with Designated Administrator Wendy Sanchez. LPA stated the purpose of the visit. Designated ADM called Administrator (ADM) Marsha Belleza to inform her of LPA Tarin at the facility. LPA Tarin spoke with ADM. ADM stated she was not well and would not be able to be present for the complaint visit. On 1/21/2026 the Department received a complaint with the above allegation. On 1/21/2026 the Department interviewed Witness 1 (W1). W1 states the facility staff did not notify him/her when resident, referred to as R1, fell on 1/17/2026. Page 1 of 2 Unfounded On 1/23/2026 the Department interviewed 3 Staff (S1 to S3). 3 Out of 3 staff state the facility notifies families when his/her loved one has had a fall. S2 states he/she notified R1's responsible party on 1/21/2026 regarding R1 having fallen, and the facility was going to call 911. S2 states she is not aware of R1 having a fall on 1/17/2026. Based upon review of phone call logs made to R1's responsible party on 1/20/2026, 1/21/2026,1/22/2026, the responsible party's phone number was incorrectly listed in the saved contact information. LPA also observed the resident's emergency contact sheet on the kitchen refrigerator to incorrectly list R1's responsible party's phone number. Facility staff updated R1's responsible party's phone number to the correct phone number during visit today. This agency has investigated the complaint alleging staff did not notify resident's responsible party of an incident. We have found that the complaint was UNFOUNDED meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted with Staff Silvia Pintor De Sanchez. Designated Administrator Wendy Sanchez had an appointment and was not present during the exit interview. A copy of this report was provided. No deficiencies were cited during today's visit per California Code of Regulations, Title 22.the state’s words, verbatim · CDSS document, Jan 23, 2026 · control 26-AS-20260121091934

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct a Case Management-Other visit regarding the death of Licensee Ramon Bellezan and to follow up on non-payment of civil penalties. LPA met with Administrator (ADM) Marsha Belleza. LPA stated the purpose of the visit. During visit, LPA and ADM met with LPM Romeo Manzano on a teams meeting. ADM acknowledged receiving the civil penalty letters in the mail. ADM states she was not ignoring the civil penalties, but was unable to pay due to her 'budget' and not having enough residents. ADM stated she will submit a letter requesting a payment plan for the civil penalties to the Department. ADM stated Licensee Ramon Belleza passed away in 2015. Based on facility file review, the facility is a partnership between Licensee Ramon Belleza and ADM's husband. Based on stipulations of the partnership, upon the death of any partner, the partnership is dissolved. The Department was not notified of the Licensee’s death until 10/7/2025. ADM stated she was not aware she was required to report the death to the Department. According to ADM, her husband is not involved with the facility, and has his own business. ADM states her husband was currently out of the state and unable to join the meeting. LPA and LPM informed ADM the facility must be licensed in order to continue to operate. After the meeting, ADM stated she will obtain licensure through the Department. LPA provided ADM with the website for ASCP Centralized Application Bureau. LPA also provided ADM with hard copies of the following documentation to submit for Change of Administrator for Staff Wendy Sanchez: Page 1 of 2 •LIC501 • LIC500 • LIC200 • LIC308 • LIC 9182 ADM also stated she will provide the Department with copies of the control of property, deed to the property and additional documentation regarding the property. ADM was advised to inform residents about the Change of Ownership (CHOW) as she plans to seek licensure for the facility. Deficiencies are being cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with ADM Marsha Belleza, and ADM requested LPA to not read the report. ADM stated she would read the report privately. ADM signed the report and LPA provided ADM with a copy and appeal rights.the state’s words, verbatim · CDSS document, Oct 8, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87111(b)(1) · Plan of correction due date: Oct 9, 2025

87111 Continuation of License Under Emergency Conditions (b) In the event of a licensee's death...(1) notify the Department by the next working day of the licensee’s death This was not met as evidenced by: Based on interview and record review, the ADM did not inform the Department of the death of the Licensee by the next working day. ADM stated the Licensee died in 2015, which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2025

Plan of correction: ADM will submit a statement of understanding of the regulation cited and submit to CCLD by POC due date of 10/9/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(a) · Plan of correction due date: Oct 9, 2025

87405 Administrator - Qualifications and Duties(a) The administrator shall.. permit adequate attention to the management and administration of the facility as specified in this section. This was not met as evidenced by: ADM acknowleges non-payment of civil penalties. ADM states she is unable to pay due to her 'budget' and not having enough residents, which poses an immediate health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 8, 2025

Plan of correction: ADM will submit a letter of understanding of Administrator Qualifications and Duties and submit an updated LIC500 to include the days and times she is at the facility. ADM will submit POC to CCLD by POC due date of 10/9/2025.

Type of visit: POC

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced POC visit for deficiencies cited during the facility annual continuation inspection on 9/3/2025. LPA met with Lead Staff Wendy Sanchez and Staff Silvia Pintor De Sanchez. LPA stated the purpose of the visit. Lead Staff stated Administrator (ADM) Marsha Belleza is currently out of town. The facility was cited the following Type A deficiencies on September 3, 2025: 1569.95(c) Emergency Plans, POC due date September 4, 2025 87458(a) Medical Assessment, POC due date September 4, 2025 87411(c)(1) Personnel Requirements, POC due date September 4, 2025 On 9/4/2025 the ADM inadvertently did not submit all POC documentation per the Plan of Correction (POC). LPA conducted a Case Management visit on 9/10/2025. During visit, ADM stated the additional POC documentation was filed away by lead staff, who was not working. ADM requested an extension to September 12, 2025. LPA and ADM collaborated that the remaining POCs have to be submitted on or before the POC due date. ADM submitted POC documentation by POC extension due date 9/12/2025. A letter of deficiencies citations cleared was provided during visit. No deficiencies cited during today's visit per California Code of Regulations, Title 22. An exit interview was conducted with Staff Silvia Pintor De Sanchez and a signed copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 19, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced POC visit for deficiencies cited during the facility annual continuation inspection on 9/3/2025. LPA met with ADM Marsha Belleza and stated the purpose of the visit. The facility was cited the following Type A deficiencies on September 3, 2025: 1569.95(c) Emergency Plans, POC due date September 4, 2025 87458(a) Medical Assessment, POC due date September 4, 2025 87355(c) Criminal Record Clearance, POC due date September 4, 2025 87411(c)(1) Personnel Requirements, POC due date September 4, 2025 As of today's visit, the ADM inadvertently did not submit all POC documentation per the Plan of Correction (POC). Per ADM the additional POC documentation was filed away by lead staff, who is not working today. LPA cleared 1 deficiency 87355(c) Criminal Record Clearance and a letter of Deficiency Citations Cleared provided to ADM. During visit, ADM requested an extension to September 12, 2025. LPA and ADM collaborated that the remaining POCs have to be submitted on or before the POC due date. If ADM requires additional time, ADM is to communicate with LPA or CCLD. No deficiencies cited per California Code of Regulations Title 22. An exit interview was conducted with ADM and signed copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 10, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case Management - Annual Continuation Visit and met with Administrator (ADM) Marsha Belleza. This annual inspection is a continuation of the annual visit that was conducted on 8/28/2025. LPA stated the purpose of the visit. The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by ADM. The facility emergency drill log was reviewed. The facility is not conducting emergency drills for 2025. A deficiency is being issued, see LIC809-D for more information. LPA toured 4 resident bathrooms and measured water temperatures. 3 out of 4 bathrooms water temperatures were not within range, temperatures ranged from 103.8 F to 122.5 F. A Technical Violation is being issued, see LIC9102 for more information. During review of 3 resident records (R1 to R3), LPA observed 1 out of 3 records did not contain a medical assessment. R1's record did not contain a medical assessment. ADM states she is aware R1 does not have a medical assessment on file. A deficiency is being issued, see LIC809-D for more information. Page 1 of 2 During review of 9 staff records, LPA observed all 9 staff records did not contain training and first aid training. A deficiency is being issued, see LIC809-D for more information. LPA also observed S8 and S9's staff record was missing documentation. Upon further review of staff through the facility Guardian roster, S8 and S9 were not associated to the facility, but had obtained fingerprint background clearance. ADM states she is aware S8 and S9 have not been associated and had difficult accessing the facility Guardian account. ADM states S8 has worked at the facility since 1/7/2025 and S9 has worked at the facility since 8/24/2024. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S8 working in the facility without association. Another civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S9 working in the facility without association. See LIC421BG. LPA provided ADM with a pamphlet for Community Care Licensing Division (CCLD) Technical Support Program (TSP). An exit interview was conducted with Administrator (ADM) Marsha Belleza and signed copy of this report was provided. Appeal rights were also provided during visit. Page 2 of 2 END OF REPORT.the state’s words, verbatim · CDSS document, Sep 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.695(c) · Plan of correction due date: Sep 4, 2025

(c) A facility shall conduct a drill at least quarterly for each shift.... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Based on record review and interview, ADM did not ensure that the facility is conducting emergency drills for 2025, which poses an immediate health, safety and personal rights to persons in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: ADM states the facility will conduct a fire drill by 9/5/2025 and submit documentation of fire drill to include the type of drill, and names of staff participation. ADM will submit POC to CCLD by POC due date 9/4/2025. ADM states she will provide a statement of understanding of the regulation cited, and provide a timelime of when she will obtain her Administrator Certficate. ADM states she will submit the POC to CCLD by POC due date of 9/5/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(c) · Plan of correction due date: Sep 4, 2025

87355 Criminal Record Clearance(c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another. This requirement is not met as evidenced by: Based on interview, observation and record review, the ADM did not ensure S8 and S9 were associated prior to working in the facility which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: ADM stated she will associate S8 and S9 to the facility. ADM stated she will send a written plan of action on how she will ensure staff are associated to the facility. ADM stated she will send this written plan of action to CCLD by POC due date 9/4/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(c)(1) · Plan of correction due date: Sep 4, 2025

87411 Personnel Requirements(c)(1) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training...Staff providing care shall receive appropriate training in first aid. This requirement is not met as evidenced by: Based on interview, observation and record review, ADM did not ensure 9 out of 9 staff received initial or annual training, and first aid training, which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: ADM stated she will schedule annual training and first aid training for 9 out of 9 staff. ADM states she will submit proof of scheduled first aid training to include name of agency providing training, and a schedule of upcoming staff trainings to CCLD by POC due date 9/4/2025

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

87458 Medical Assessment (a) Prior to a person's acceptance as a resident... a medical assessment, signed by a licensed medical professional... made within the last year, to be kept in the resident's record. This was not met as evidenced by Based on record review and interview, R1's record did not contain a medical assessment, which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: ADM states she will contact R1's responsible parties to obtain a medical assessment. ADM will submit proof of communication with R1's responsible parties to CCLD by POC due date 9/4/2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced at 2:30PM to conduct the facility's Required 1-Year annual inspection. LPA met with Staff S1 Wendy Sanchez. S1 stated Administrator Marsha Belleza was unavailable for the inspection visit. LPA Tarin called ADM and left a voicemail regarding the 1-year inspection. LPA toured the facility's interior and exterior with S1 to include the dining room, kitchen, living room, resident bedrooms, and the front and back of facility. All exits and passageways were free and clear of obstruction. LPA toured the kitchen area, and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the thermostat on the 1 kitchen refrigerator refrigerator temperature at 40 F and freezer at 0 F. LPA observed knives and chemicals were locked and inaccessible to residents in care. LPA observed locked medication in the office cabinet and hallway cabinet, inaccessible to residents in care. LPA toured 10 resident bedrooms. 10 resident bedrooms had a bed, clean bedding, adequate lighting and space for personal belongings. Due to time constraints, this annual inspection will need to be continued at a later date. No deficiencies were issued during today's visit. An exit interview was conducted with Staff S1 Wendy Sanchez and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2025

Allegation investigated: Staff did not safeguard resident's personal belongings. Staff did not provide adequate supervision resulting in resident pushing another resident in care. Staff handled resident in a rough manner. Staff did not provide resident's responsible party with resident's documents.

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegation. LPA met with Administrator (ADM) Marsha Belleza. On May 14, 2024, the Department received a complaint alleging Staff did not safeguard resident’s personal belongings. It has been alleged that staff did not safeguard R1’s personal belongings. On May 21, 2024, LPA Monter interviewed R1’s Conservator. (R1C). R1C stated regarding to safeguarding R1’s belongings has been an ongoing issue since 2016. R1C stated he/she has informed the staff. R1C stated he/she buys R1C a new shirt but then when he/she visits, he/she can't find it. R1C stated this is an ongoing issue. Page 1 Out of 5 Unsubstantiated On May 22, 2024, LPA Monter interviewed ADM. LPA requested to review R1’s personal property form. ADM stated the facility does not have R1’s personal property form and did not fill out a personal property form. ADM stated the majority of R1’s cloths are donations. ADM stated R1’s conservator did not inform her when he/she brought new things to the facility. On December 4, 2024, LPA Monter interviewed staff S6. S6 stated he/she has not heard anyone complain that R1 has lost or had his/her clothing taken. S1 stated R1 has not gotten cloths from her responsible party. S1 stated the facility has been providing cloths and shoes to R1. S1 stated R1’s responsible party has never mentioned anything about R1 missing cloths. ON May 21, 2024 and January 31, 2025, LPA interviewed 7 residents, (R1, R2, R3, R4, R6, R8, R9). R1 stated he/she has not had anything lost or stolen. 2 Out of 6 residents (R2 & R6) declined to be interviewed. 5 Out of 7 residents (R1, R3, R4, R8 & R9) stated they have not had any personal property stolen or lost, and facility staff will assist them in finding there property if misplaced. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Staff did not provide adequate supervision resulting in resident pushing another resident in care. On May 14, 2024, the Department received a complaint alleging Staff did not provide adequate supervision resulting in resident pushing another resident in care. It has been alleged that resident R2 pushed R1 in late 2022 or early 2023. On May 22, 2024, LPA Monter interviewed residents R1-R7. 5 Out of 7 residents interviewed (R1, R3-R5, R7) stated residents don’t push each other and don’t fight with each other. Resident R1 stated he/she has not been pushed by anyone. R2 declined to be interviewed. R6 was unable to answer LPA’s questions due to neurocognitive disorder. Page 2 Out of 5 LPA Monter interviewed staff S1-S5 and ADM. 5 Out of 5 staff interviewed stated they have not seen resident R2 push R1. All staff interviewed stated resident R1 has been seen pushing R2. ADM stated state resident R2 does not push R1. ADM stated R1 is the aggressor and pushes R2. On December 4, 2024, LPA Monter interviewed staff S6. S6 stated resident R1 has been seen pushing R2. S6 stated R2 does not push R1. On January 31, 2025, LPA Monter interviewed Staff S2, S3, S7. 3 Out of 3 staff interviewed stated resident R1 and R2's room door is in the dinning area, which has a direct line of sight for staff in the dinning area and kitchen. 3 Out of 3 staff stated redirect R1 and R2 to do activities and if there is a any potential commotion, staff will intervene. LPA interviewed ADM. ADM stated the facility staff aware aware of Resident R1's behaviors. ADM stated R1's bedroom is in the line of sight of staff in the dinning room and kitchen. ADM stated staff will keep Resident R1 and R2 occupied. ADM stated she has instructed staff to keep an eye on them and intervene at any sign of potential conflict between R1 and R2. Based on a facility record review, there are no incident reports regarding the alleged push in late 2022 or early 2023. There are also no incident reports noting any hospitalization's for R1 in late 2022 or early 2023. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Staff did not provide resident's responsible party with resident's documents. On May 14, 2024, the Department received a complaint alleging Staff did not provide resident’s responsible party with resident’s documents. It has been alleged a residents conservator requested a copy of the resident’s previous payment history. Page 3 Out of 5 On May 21, 2024, LPA Monter interviewed R1’s Conservator, R1C. R1C stated he/she requested a copy of R1’s history of payments in the beginning of the year, 2024. R1C stated he/she has not yet received the documentation. On May 22 and December 12, 2024, LPA Monter interviewed ADM. ADM stated she has sent over the history of payments to R1C. ADM stated she did not send this information via certified mail. ADM stated she did send the documents but did not record the exact date she sent them. On December 4, 2024, LPA Monter interviewed staff S6, stated the facility has provided R1’s responsible party with a copy of receipts. S6 stated the facility made copies and sent them via mail to R1’s responsible party via physical mail. S1 stated the facility has asked R1’s responsible party for their actual mailing address, so they can send the receipts thru verified mail, to ensures he/she gets them. S1 stated R1’s responsible party only provide them with the PO Box. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Staff handled resident in a rough manner. On May 14, 2024, the Department received a complaint alleging Staff handled resident in a rough manner. It has been alleged near the end of April 2024, staff S6 grabbed R1’s arms and pulled him/her. On May 21, 2024, LPA Monter interviewed Witness W1. W1 stated R1 had an appointment and needed to get inside the car. W1 stated HM grabbed R1’s arms, pulled him/her to the car. W1 stated staff S3 saw this. W1 stated R1 did not sustain an injury from the pull. On May 22, 2024, LPA Monter interviewed residents R1-R7. 5 Out of 7 residents (R1, R3-R5, R7) interviewed stated the staff are not rough when assisting them and do not pull residents arm in a rough manner. R1 stated the staff are not rough with him/her and staff doesn’t pull on his/her arms. R2 declined to be interviewed. R6 was unable to answer LPA’s questions due to neurocognitive disorder. Page 4 Out of 5 LPA interviewed staff S1-S5 and ADM. 5 Out of 5 staff interviewed stated staff are not rough with residents. 5 Out of 5 staff interviewed they have not seen other staff or the house manager handling the residents in a rough manner. ADM stated she has not seen staff or HM handle the residents in a rough manner. On December 4, 2024, LPA Monter interviewed staff S6. S6 stated he/she has never seen staff handle residents in a rough manner. S6 stated he/she has never handled residents in a rough manner or yanked/pulled residents in a rough manner. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 5 Out of 5. On May 22 and December 12, 2024 LPA Monter interviewed ADM. ADM stated she has been informed by R1’s conservator of moving R1 in another room sometime in March/April 2024. ADM stated the other shared bedrooms residents are also not a good fit for R1 and they can’t move the residents without the resident’s permission. ADM stated R1’s current, roommate, R2 cannot be moved either. ADM stated R2’s responsible party prefers R2 stay in the same bedroom to keep things consist for him/her. ADM stated she has no objection to R1 switching rooms with another resident who stays in a shared bedroom. ADM stated she must respect the residents personal rights and the residents themselves and the families must agree to this change. On December 4, 2024, LPA Monter interviewed staff S6. S6 stated the facility has tried to move R1/R2 to other bedrooms. S6 stated they haven’t had the opportunity, because other families don’t want to either share the bedroom, or have R1/R2 move in. S6 stated the facility has made the attempt, but the resident’s family don’t want to make the change. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Staff does not ensure facility is free of bed bugs. On May 14, 2024, the Department received a complaint alleging Staff does not ensure facility is free of bed bugs. It has been alleged that resident R1’s bed has bed bugs. On May 22, 2024, LPA Manuel Monter interviewed staff S1-S5 and ADM. 5 Out of 5 staff interviewed stated they have not seen bed bugs at the facility. ADM stated the facility has checked R1’s bed and there are no signs of bedbugs. LPA Monter interviewed residents R1-R7. 5 Out of 7 residents (R1, R3-R5, R7) interviewed stated they have not seen bed bugs at the facility. R2 declined to be interviewed. R6 was unable to answer LPA’s questions due to neurocognitive disorder. Page 2 Out of 4 On May 22, 2024, LPA Monter randomly inspected 6 beds for bed bugs, including R1 bed. LPA inspected the beds by asking facility ADM to remove the blankets and bed sheets. LPA then checked the edges of the mattress for any sign of bed bugs. LPA also inspected the edges of the bed frame. LPA found no signs of bed bugs, droppings or blood in the beds inspected. On December 4, 2024, LPA Monter interviewed staff S6. S6 stated the facility does not have bed bugs and it’s a false allegation. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Staff increased residents rent without notice On May 14, 2024, the Department received a complaint alleging Staff increased residents rent without notice. It has been alleged that R1’s rent has been raised without notice. On May 13 and 27, 2024, the Department interviewed R1’s Conservator (R1C). R1C stated he/she was informed via text message, on January 31st 2024, that rent was going up from $2250-$4000. R1C notified facility ADM that he/she could not afford such an increase. R1C stated during their back and forth text between him/her and the ADM, the ADM stated, “if you keep paying on time, I will not charge any additional fee and you don’t owe me anything as long as you move R1 out as soon as possible.” R1C stated he/she replied, “Great! Thank you.” On December 4, 2024, LPA Monter interviewed staff S6. S6 stated the facility did raise R1’s rent and they did notify R1’s responsible party. S6 stated, the issue is R1’s responsible party is still paying the same amount of money. S6 stated they have sent him/her 3 notices but no response and R1’s responsible Party is still sends the same amount of money. Page 3 Out of 4. On December 12, 2024, LPA Monter interviewed ADM. ADM stated she did raise the rent for R1. ADM stated she gave R1’s responsible party a letter with the changes in rent. ADM stated this letter/email was given to R1’s responsible party in the first few months of 2024. ADM stated the changes would have gone into effective May 2024. ADM stated she sent the letter to R1’s PO box. The Department has completed the investigation of the above allegations. Based on interviews conducted and records review, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 4 Out of 4. LPA Monter interviewed staff S1-S5 and ADM. S1 and S2 they have not seen the facility exits locked when they work. Staff S3-S5 stated the facility locks the doors and gate because R2 has a wandering behavior. ADM stated a staff member put the locks because R2 has a wandering behavior at night. ADM acknowledged that this is a form of restraint. Based on interviews and observation of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED. The Department is issuing an immediate civil penalty of $250 a repeat violation for the following deficiencies: 87307 Personal Accommodations and Services (d)(6), which was previously cited on August 27, 2024. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. This report was reviewed with Administrator Marsha Belleza and a copy of the report was provided. Appeal Rights was provided. Page 2 Out of 2. END OF REPORTthe state’s words, verbatim · CDSS document, Jan 31, 2025 · control 26-AS-20240514090217

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(6) · Plan of correction due date: Feb 3, 2025

87307 Personal Accommodations and Services (d)(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on interviews and observation, the facility was locking the exit next to the dinning area, room 9, and front entrance of the facility. ADM stated R2 has an exit seeking behavior. ADM acknowledged this was a form of restraint. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 31, 2025

Plan of correction: ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send the Plan of Correction by POC date, Febuary 3, 2025.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Marcella Tarin and Christine Dolores arrived unannounced to conduct a case management-other visit. LPAs met with Administrator Marsha Belleza. The purpose of the visit was to amend deficiencies from visit date 8/27/2024. LIC809Ds reviewed with Administrator and a copy of the amended deficiencies were provided during visit. Administrator was advised to submit the plan of corrections for deficiencies section cited 1569.695(c) and 87506(a). No deficiencies were cited today per California Code of Regulations Title 22. This report was reviewed with Administrator Marsha Belleza and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 10, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Marcella Tarin and Christine Dolores conducted a required unannounced 1 year visit and met with Administrator Stephanie Means. During the visit LPAs toured the facility inside and out. LPAs toured the kitchen area. LPAs observed a perishable food supply of at least 2 days and a nonperishable food supply of 7 days. LPAs observed the kitchen is supervised by staff which contains sharp objects, chemical disinfectants,and medications. Refrigerator temperatures maintained between 42 and 52 degrees F. Administrator was advised. Freezer temperature maintained at 0 degrees F. LPAs toured 10 resident rooms. LPAs recorded bathroom water temperature 108 degrees Fahrenheit in all 3 resident bathrooms. Hot water temperature next to room #1 maintained at 108 degrees F. The bathroom had functioning lights and available soap and paper towels. LPAs toured the bathrooms in each bedroom and found them to have working lights, available soap and paper towels. LPAs toured 10 resident bedrooms. Each room had working lights, and available bedding and clothing storage areas. LPAs observed 2 resident (Room 4 and Room 7) sliding door exits contained a pole and wooden plank that obstructed the opening of the sliding door. LPAs observed hygiene items on a dresser in Room 1. Based on record review, the Dementia resident is at risk if allowed access to hygiene items. LPAs tested the carbon monoxide detector to be functioning properly. The fire extinguisher last serviced on 1/5/2024. LPAs reviewed 5 resident files. It was observed that 5 residents Appraisal Needs and Services Plan were updated but did not contain signatures from the resident and responsible parties. LPAs observed that 5 Centrally Stored Medication and Destruction Record (CSMDR) were not maintained as multiple resident’s medications were not part of the CSMDR and did not contain a start date. 1 resident file did not contain a Physician’s Report. 2 residents did not contain an order for half-bed rails. See LIC809C. LPAs reviewed 5 staff files. It was observed that 5 staff files did not contain 10 hours of initial and/or 20 hours of annual training on topics covered in Section 87707. 5 out of 5 staff do not have CPR and First Aid certification. LPAs observed 2 staff scheduled during visit did not have CPR and First Aid certification. 5 out of 5 staff obtains fingerprint clearance. Facility has emergency disaster plan. LPAs advised to update the emergency disaster plan. Facility is not conducting emergency drills quarterly. LPAs observed flashlights in resident bedrooms. Facility does not have a written Infection Control Plan. Administrator was advised. Posters observed to include personal rights, ombudsman, facility license. LPAs did not observe the licensing complaint poster. Documents were requested by 8/30/2024 to include Infection Control Plan, updated Emergency Disaster Plan, Liability Insurance, Administrator Certificates. Deficiencies were cited per California Code of Regulations, Title 22. See LIC809Ds. This report was reviewed with Administrator Stephanie Means and a copy of the report and Appeal Rights were providedthe state’s words, verbatim · CDSS document, Aug 27, 2024

Type of visit: Case Management - Other

Licensing Program Analyst Manuel Monter conducted an unannounced case management to amend a case management deficiency page. The LIC809-D was issued on May 22, 2024. LPA observed 3 staff and 10 residents. LPA met with Administrator Marsha Belleza. LPA explained the purpose of the visit. No deficiencies cited during todays visit. This Report was reviewed with Administrator Marsha Belleza. A signed copy was provided.the state’s words, verbatim · CDSS document, Jul 18, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to open a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Administrator Marsha Belleza LPA entered the facility and asked the staff members their names to cross reference the facility personnel report summary (LIS536), dated May 22, 2024. Staff S1 is not associated to the facility. LPA reviewed S1's name in guardian and S1 is not fingerprint cleared. ADM asked S1 to leave the facility as she is not finger print clear. Staff S1 stated she has been working at the facility for 1 month as kitchen staff and caregiver when needed. Staff S2 is not associated with the facility. S2 stated she has been working at the facility for 9 years. While investigating the complaint (26-AS-20240514090217) dated May 14, 2024, LPA requested to review R1 and R2's physicians report. R1's physician's report states R1 has dementia. ADM stated the physicians report that they have is from when R1 moved to the facility back in 2015. ADM stated she has not updated R1's physicians report. R2's Physicians Report, dated June 2, 2020 states R2 has dementia. ADM stated she has not updated R2's physicians report. LPA requested to review R1 and R2's needs and services plan. R1's needs and services plan is dated September 20, 2017. R1's needs and services plan does not address R1's hoarding toilet paper behavior. LPA requested to review R2's needs and services plan. ADM stated she does not have a needs and services plan for R2. During interview with ADM, ADM stated R2 had wandering behavior. Page 1 Out of 2. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S1 working in the facility without receiving a criminal record background clearance. Another civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S2 working and residing in the facility without association. See LIC421BG. This report was reviewed with Administrator Marsha Belleza and a copy of the report and appeal rights were provided. Page 2 Out of 2 END OF REPORT.the state’s words, verbatim · CDSS document, May 22, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: May 29, 2024

87355 Criminal Record Clearance (e)(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) Based on interview, observation and record review S2 works in the facility without association which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: ADM stated she will associate S2 to the facility. ADM stated she will send a written plan of action on how she will ensure staff are associated to the facility. ADM stated she will send this written plan of action by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(5) · Plan of correction due date: May 29, 2024

87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment ... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by; Based on record review and interview, both R1 and R2's physicians reports and needs and services plans have not been updated annually. Both R1 and R2 have dementia. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: ADM stated she will send a written plan of action on how she will ensure residents with dementia have their annual medical assessment and their reappraisal done annually. ADM stated she will send this written plan of action by POC date. ADM stated she will send R1 and R2's the updated physicians reports and needs and services plans, with the responsible party's signature once they have been completed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: May 23, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility. This requirement was not met as evidenced by; Based on interview, observation and record review S1 was working in the facility without obtaining a criminal record background clearance which poses an immediate health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: ADM asked S1 to leave the faciltiy. ADM stated S1 is going to get his/her finger prints done. ADM stated she will send a plan of action on how she will ensure all staff are finger print cleared beofre working at the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d) · Plan of correction due date: May 23, 2024

Administrator Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7).... This requirement is not met as evidenced by: Based on the result of todays visit, the ADM did not conform to applicable laws, rules and regulations. Staff S1 was working at the facility without finger print cleareance. Residents R1 and R2 did not have an updated needs and services plan and physicans report.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: ADM stated she will send a written letter of understanding regarding the regulation. ADM stated she will send the letter of understanding by POC date.