Harbor Terrace Retirement Center of San Pedro

Allegation investigated: Staff did not follow doctor’s orders.

On 07/28/26 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent, unannounced, complaint visit at the facility. California Department of Social Services (CDSS) was met by staff one, Holly Rice - Executive Director (S1), and the purpose of the visit was explained.CDSS arrived to deliver updated findings to the facility. The investigation consisted of the following: During today's date, CDSS arrived to deliver updated findings. On 07/09/26 CDSS interviewed Witness one (W1). On 04/23/26 CDSS requested and reviewed facility documents and toured the facility. CDSS interviewed three (3) out of sixty-nine (69) residents and four (4) out of forty-eight (48) staff. The investigation revealed the following: Regarding the allegation “Staff did not follow doctor’s orders.”, it is being alleged that a resident is being allowed to drive themselves, against Dr's orders. On 04/23/26, between 08:15AM and 11:30AM, CDSS interviewed three (3) residents (R1-R3) and four (4) staff (S1-S4). Report continues, please see LIC9099-C. Unsubstantiated Interviews revealed that all three (3) residents (R1-R3) and all four (4) staff (S1-S4) and one (1) witness have denied the allegation has taken place. A resident (R1) has stated, "I’ve got my car down there, so I got my freedom." Record reviews have revealed that Doctors' orders have not restricted R1 from driving their car, according to the latest Physician's report which had been conducted on 07/13/26. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. An exit interview was held with Holly Rice - Executive Director and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Jul 28, 2026 · control 11-AS-20260416163804

Type of visit: Case Management - Deficiencies

On 07/28/26 Licensing Program Analyst (LPA) Mario Leon conducted a case management visit to deliver one (1) deficiency, related to California Department of Social Services (CDSS) observation on 04/23/26. CDSS has observed that one (1) resident (R1) did not have an annually updated Physician's report. There has been one (1) deficiency delivered during today's visit. Please see LIC809-D. An exit interview was held with Holly Rice - Executive Director and a copy of one (1) deficiency, facilities' appeal rights and this report have been provided.the state’s words, verbatim · CDSS document, Jul 28, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(h) · Plan of correction due date: Aug 28, 2026

87463 Reappraisals (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This has not been met as evidenced by: Based on LPA's observation during record review, R1's latest LIC602A was on 04/04/24. Therefore, the licensee did not comply with the section cited above. This violation poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 28, 2026

Plan of correction: LPA and Executive Director have agreed that care staff will go through an in-service reappraisal training, attendee signature required. Administrator will forward all sign-in sheet(s) along with the presentation details on or prior to POC due date, via email at MARIO.LEON@DSS.CA.GOV

Allegation investigated: Staff did not ensure resident personal property was kept safely secured. Staff does not ensure resident is provided with toileting assistance. Staff does not provide resident with adequate assistance when standing.

** This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 07/22/26. **On 07/27/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint investigation visit for the allegations listed above. LPA met with Administrator Holly Rice, explained the purpose of the visit, and was granted entry to the facility. On 07/22/26, the department conducted an unannounced complaint visit to investigate the allegations listed above. The department met with Assistant Administrator, Sandra Marquez, and the purpose of the visit was explained. The department was granted entry to the facility. Continued on LIC9099-C Unsubstantiated The investigation consisted of the following: The department obtained the following documents: staff roster, resident roster, and an Unusual Incident/Injury Report (SIR) dated: 07/13/26. The department conducted a review of resident #1’s (R1’s) file and obtained copies of the following documents: Identification and Emergency Information, Care Services form, Physician’s Report, Personal Rights, Assisted Living Residency Agreement, and Appraisal Needs and Services Plan. The department conducted interviews with staff #1-#5 (S1-S5) and R1-R8. Additionally, the department conducted a tour of the facility. On 07/27/26, the department conducted an interview with R1. The investigation revealed the following: Allegation: Staff did not ensure resident personal property was kept safely secured. It is being alleged that $200 went missing from a residents wallet. It is also being alleged that this is the second time money has been taken from this resident. On 07/22/26, the department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. 5 out of 5 staff said they treat residents with dignity and respect. An interview with S1 revealed that R1's family member reported that $180 was missing from R1 on 07/13/26. S1 stated that they, along with the facility's Executive Director, went to R1's room to assist in searching for the missing money; however, the money was not located. S1 further stated that the family was advised of options to help safeguard R1's money, including installing a camera in R1's room and/or completing an LIC 405 to have facility staff secure and maintain and safekeep R1's funds. On 07/22/26, and 07/27/26, the department conducted interviews with R1-R8. Of those interviewed, 7 out of 8 residents could not corroborate the allegation. 7 out of 8 residents stated they had never experienced any incidents involving missing money or personal belongings. An interview with R1 revealed that they've experienced money missing on two separate occasions. R1 stated that they were unsure who took the money and could not confirm whether a staff member was responsible. On 07/22/26, the department reviewed an Unusual Incident/Injury Report dated 07/13/26. The report documented that on 07/13/26, R1's family member contacted the facility to report that money was missing from R1. According to the report, S1, R1, and the facility's Executive Director, Holly Rice, spoke with R1's family member via speakerphone to discuss the details of the incident. The report stated that R1 had withdrawn $200 in cash on 07/08/26 and discovered on 07/13/26 that $180 was missing. Continued on LIC9099-C The report further stated that S1 and Executive Director Holly Rice assisted R1 in searching R1's personal belongings, including the wallet, walker, clothing, pockets, and apartment; however, the missing cash was not located. The report documented that staff notified R1's family member that the cash could not be found and recommended that R1 maintain a Record of Resident's Safeguarded Cash Resources (LIC 405) in the administrative office to help safeguard R1's funds. The report also indicated that the incident was documented on the facility's theft and loss report. Based on observation, records reviewed, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been unsubstantiated. Allegation: Staff does not ensure resident is provided with toileting assistance. It is being alleged that a staff member refuses to take a resident to the bathroom and instructs the resident to urinate in their diaper instead. On 07/22/26, the department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. 5 out of 5 staff said they treat residents with dignity and respect. On 07/22/26, and 07/27/26, the department conducted interviews with R1-R8. Of those interviewed, 7 out of 8 residents could not corroborate the allegation. 3 out of 8 residents said staff assist them with their toileting needs, while 5 out of 7 residents said they do not require assistance with toileting. 8 out of 8 residents said they are satisfied with the service being provided to them. Based on observation, records reviewed, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been unsubstantiated. Continued on LIC9099-C Allegation: Staff does not provide resident with adequate assistance when standing. It is being alleged that staff will poke at the resident rather than assist them in getting up. On 07/22/26, the department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. 5 out of 5 staff said they treat residents with dignity and respect. On 07/22/26, and 07/27/26, the department conducted interviews with R1-R8. Of those interviewed, 7 out of 8 residents could not corroborate the allegation. 8 out of 8 residents stated that staff treat them with dignity and respect. On 07/22/26, the department conducted a tour of the facility and observed staff interacting with residents during the lunch hour. Staff were observed to be patient, attentive, and respectful in their interactions with residents. Based on observation, records reviewed, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been unsubstantiated. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of this report was provided to Holly Rice.the state’s words, verbatim · CDSS document, Jul 27, 2026 · control 11-AS-20260714093225

Allegation investigated: Staff did not ensure resident personal property was kept safely secured. Staff does not ensure resident is provided with toileting assistance. Staff does not provide resident with adequate assistance when standing.

On 07/22/26, the department conducted an unannounced complaint visit to investigate the allegations listed above. The department met with Assistant Administrator, Sandra Marquez, and the purpose of the visit was explained. The department was granted entry to the facility. The investigation consisted of the following: The department obtained the following documents: staff roster, resident roster, and an Unusual Incident/Injury Report (SIR) dated: 07/13/26. The department conducted a review of resident #1’s (R1’s) file and obtained copies of the following documents: Identification and Emergency Information, Care Services form, Physician’s Report, Personal Rights, Assisted Living Residency Aggreement, and Appraisal Needs and Services Plan. The department conducted interviews with staff #1-#5 (S1-S5) and R1-R8. Additionally, the department conducted a tour of the facility. Continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not ensure resident personal property was kept safely secured. It is being alleged that $200 went missing from a residents wallet. It is also being alleged that this is the second time money has been taken from this resident. On 07/22/26, the department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. 5 out of 5 staff said they treat residents with dignity and respect. An interview with S1 revealed that R1's family member reported that $180 was missing from R1 on 07/13/26. S1 stated that they, along with the facility's Executive Director, went to R1's room to assist in searching for the missing money; however, the money was not located. S1 further stated that the family was advised of options to help safeguard R1's money, including installing a camera in R1's room and/or completing an LIC 405 to have facility staff secure and maintain and safekeep R1's funds. On 07/22/26, the department conducted interviews with R2-R8 and attempted to interview R1; however, R1 was away from the facility at the time of the visit. The department also attempted to contact R1 by telephone but was unsuccessful. Of those interviewed, 7 out of 7 residents could not corroborate the allegation. 7 out of 7 residents stated they had never experienced any incidents involving missing money or personal belongings. On 07/22/26, the department reviewed an Unusual Incident/Injury Report dated 07/13/26. The report documented that on 07/13/26, R1's family member contacted the facility to report that money was missing from R1. According to the report, S1, R1, and the facility's Executive Director, Holly Rice, spoke with R1's family member via speakerphone to discuss the details of the incident. The report stated that R1 had withdrawn $200 in cash on 07/08/26 and discovered on 07/13/26 that $180 was missing. The report further stated that S1 and Executive Director Holly Rice assisted R1 in searching R1's personal belongings, including the wallet, walker, clothing, pockets, and apartment; however, the missing cash was not located. The report documented that staff notified R1's family member that the cash could not be found and recommended that R1 maintain a Record of Resident's Safeguarded Cash Resources (LIC 405) in the administrative office to help safeguard R1's funds. The report also indicated that the incident was documented on the facility's theft and loss report. Continued on LIC9099-C Based on observation, records reviewed, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been unsubstantiated. Allegation: Staff does not ensure resident is provided with toileting assistance. It is being alleged that a staff member refuses to take a resident to the bathroom and instructs the resident to urinate in their diaper instead. On 07/22/26, the department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. 5 out of 5 staff said they treat residents with dignity and respect. On 07/22/26, the department conducted interviews with R2-R8 and attempted to interview R1; however, R1 was away from the facility at the time of the visit. The department also attempted to contact R1 by telephone but was unsuccessful. Of those interviewed, 7 out of 7 residents could not corroborate the allegation. 3 out of 7 residents said staff assist them with their toileting needs, while 4 out of 7 residents said they do not require assistance with toileting. 7 out of 7 residents said they are satisfied with the service being provided to them. Based on observation, records reviewed, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been unsubstantiated. Allegation: Staff does not provide resident with adequate assistance when standing. It is being alleged that staff will poke at the resident rather than assist them in getting up. On 07/22/26, the department conducted interviews with S1-S5. Of those interviewed, 5 out of 5 staff denied the allegation. 5 out of 5 staff said they treat residents with dignity and respect. On 07/22/26, the department conducted interviews with R2-R8 and attempted to interview R1; however, R1 was away from the facility at the time of the visit. The department also attempted to contact R1 by telephone but was unsuccessful. Of those interviewed, 7 out of 7 residents could not corroborate the allegation. 7 out of 7 residents stated that staff treat them with dignity and respect. Continued on LIC9099-C On 07/22/26, the department conducted a tour of the facility and observed staff interacting with residents during the lunch hour. Staff were observed to be patient, attentive, and respectful in their interactions with residents. Based on observation, records reviewed, and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been unsubstantiated. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of this report was provided to Sandra Marquez.the state’s words, verbatim · CDSS document, Jul 22, 2026 · control 11-AS-20260714093225

Type of visit: Required - 1 Year

On 05/12/26, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. California Department of Social Services (CDSS) met with Holly Rice - Executive Director and the purpose of today's visit was explained. The facility is licensed to serve (202) elderly adults ages 60 and above, of which (78) can be non-ambulatory on 1st and 2nd floor and (62) ambulatory on 3rd floor and (62) ambulatory on 4th floor. The facility has an approved hospice waiver for (10). Approved for delayed egress. Currently the facility has (70) residents. The facility is a four-story building situated in a commercial district. It consists of the following: (85) resident bedrooms. Each room has its bathroom within the unit. The facility features an activity room, dining area, kitchen, beauty salon, administrative offices, medication room, computer room, library, and an outside patio area. CDSS and the Executive Director toured the physical plant. There were no bodies of water or obstructions on the premises. CDSS inspected a total of (8) bedrooms and (8) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be clean and operational, grab bars in place with no mold/mildew in showers. There was an average water temperature at 132.6°F, outside of title 22 regulation, and the room temperature was comfortable which ranged from 71.2°F to 74.3°F. Report continues, please see LIC809-C. One deficiency has been cited, please see LIC809-D; a technical violation has been cited, please see LIC9102-AN. Smoke and carbon monoxide detectors were in operable condition.During the visit, CDSS observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 9/3/24. A review of (5) residents' service files and (5) staff personnel files was maintained in order. LPA reviewed (3) Medication Administration Records (MARs) and found no discrepancies. Facilities' liability insurance is current and their annual fees have been paid as of 03/09/26. There has been one (1) deficiency cited during today's visit, please see LIC809-D. An exit interview was held with Holly Rice - Executive Director and a copy of facilities' appeal rights, one deficiency and this report has been provided.the state’s words, verbatim · CDSS document, May 12, 2026

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff did not follow doctor’s orders.

On 04/23/26 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. California Department of Social Services (CDSS) was met by staff one, Holly Rice - Executive Director (S1), and the purpose of the visit was explained. S1 and LPA toured the facility. The investigation consisted of the following: On 04/23/26 CDSS requested and reviewed facility documents and toured the facility. LPA interviewed three (3) out of sixty-nine (69) residents and four (4) out of forty-eight (48) staff. The investigation revealed the following: Regarding the allegation “Staff did not follow doctor’s orders.”, it is being alleged that a resident is being allowed to drive themselves, against Dr's orders. Between 08:15AM and 11:30AM, LPA interviewed three (3) residents (R1-R3) and four (4) staff (S1-S4). Interviews revealed that all three (3) residents (R1-R3) and all four (4) staff (S1-S4) have denied the allegation has taken place. R1 has stated, "I’ve got my car down there, so I got my freedom." Report continues, please see LIC9099-C Unsubstantiated Record reviews have revealed that Doctors' orders have not restricted a resident (R1) from driving their car. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Holly Rice - Executive Director and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Apr 23, 2026 · control 11-AS-20260416163804

Type of visit: Required - 1 Year

On 6/6/2025, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Holly Rice/Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (202) elderly adults ages 60 and above, of which (78) can be non-ambulatory on 1st and 2nd floor and (62) ambulatory on 3rd floor and (62) ambulatory on 4th floor. The facility has an approved hospice waiver for (10). Approved for delayed egress. Currently the facility has (70) residents. The facility is a four-story building situated in a commercial district. It consists of the following: (84) resident bedrooms. Each room has its bathroom within the unit. The facility features an activity room, dining area, kitchen, beauty salon, administrative offices, medication room, computer room, library, and an outside patio area. LPA Iniguez and the Executive Director toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (8) bedrooms and (8) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature measured below 120F°, and the room temperature ranged from 76°F to 78°F. The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings. During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on 9/3/24. A review of (5) residents' service files and (5) staff personnel files was maintained in order. LPA reviewed (3) Medication Administration Records (MARs) and found no discrepancies. LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance will be email to LPA. Facility Annual Fess current. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies during this visit; therefore, no citations were issued. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Holly Rice /Executive Director.the state’s words, verbatim · CDSS document, Jun 6, 2025

Allegation investigated: Staff did not treat resident with dignity or respect. Staff did not ensure that resident was adequately fed. Staff did not offer resident privacy. Staff mismanaged resident's medication. Staff did not safeguard resident's personal items.

On March 7, 2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent, unannounced complaint visit. The Executive Director Holly Rice greeted the (LPA). The (LPA) explained that the purpose of this visit was to investigate the allegations mentioned above. The investigation included interviews, collection of records and tour of the facility. Interviews were conducted with staff members #1 to #6 (S1-S6), resident members #1 to -#7 (R1-R7), and witness #1 to #2 (W1-W2). The Department reviewed several documents, including the Facilty Staff Roster, the Resident Roster, Resident #1 (R1)'s Face Sheet; Identification and Emergency Information; Service Plan; Resident Assessment; Preplacement Appraisal Information; Admissions Agreement; Physicians Report; Resident Manual, Medication Administration Records, and other pertinent records associated with this complaint. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not treat resident with dignity or respect. Allegation #3: Staff did not offer resident privacy. The complaint stated that staff did not treat Resident #1 (R1) with dignity or respect and failed to provide privacy. It is reported (R1) felt disrespected when staff ordered them to leave the dining area for to make room for other group of residents. In addition, it was overheard staff saying, “Let’s go. All you need is a whip.” Furthermore, reports indicated that staff often ignored (R1's) privacy by entering (R1's) room without permission while (R1) was in the restroom. On March 4, 2025, between 9:35 AM and 3:10 PM, the Department interviewed six staff members, identified as Staff #1 through Staff #6, regarding the accusations. Six (6) out of six (6) could not corroborate the claims made against them. They stated that all residents are treated with dignity, respect, and privacy. All staff members have completed training in Workplace Sensitivity courses, which include topics such as Resident Rights, Working with Individuals with Physical Disabilities, Cultural Competence, and the Basics of Depression in older adults, among others. (S1) explained that there is a seating chart for dining. Resident #1 (R1) is in Group A and is served first, followed by Group B. (S1 and S4) mentioned for breakfast, lunch and dinner residents are given 45 minutes. There are 20 tables available for residents, of which four are vacant. (S1 and S4) clearly stated that (R1) has never indicated feeling rushed to complete meals during mealtime. If that is true, special arrangements would be made to let (R1) finish meals at an empty table that is not assigned. Moreover, all six staff members emphasized the importance of giving residents space and privacy. All staff members must knock and announce themselves before entering a resident's room, rather than barging in unannounced. On March 4, 2025, between 10:35 AM and 2:55 PM, the Department interviewed all seven resident members identified as Resident #1 through Resident #7. Six (6) out of the (7) could not valid this claim. The feedback from (R2 to R7) commendably highlights the staff's exemplary qualities of respect, kindness, and graciousness. Their commitment to creating a positive and supportive environment has greatly improved their living conditions. Evaluation Report continues LIC 9099-C (R1) was interviewed and expressed that living at this facility was generally acceptable and that the staff treated (R1) well. However, (R1) stated that staff occasionally forced residents to leave the dining area like "cattle" to prepare for the next group. (R1) could not recall the incident’s details, staff names, or date. Regarding privacy, (R1) stated the importance of having personal space, noting that staff do respect (R1's) privacy by knocking and announcing their presence before entering the room. On March 4, 2025, between 3:30 PM and 4:00 PM, the Department interviewed Welbe Health Care Case Manager identified as Witness #1 who is unable to support this claim. (W1) reported (R1) is actively addressing mental health challenges and is attending supportive weekly therapy to effectively navigate through these obstacles. A review of the facility’s Dining Seating Chart shows that assigned seating has been implemented for Groups A and B. (R1) is part of Group A. Additionally, a review of the Relias Healthcare Workforce staff training confirmed that all staff have completed the mandatory training, including the Workplace Sensitivity courses. Based on the information gathered, there is not enough evidence to support the allegations mentioned above. Allegation #2: Staff did not ensure the resident was adequately fed. The complaint details indicate that the facility staff did not ensure that Resident #1 (R1) received adequate meals. It has been reported that (R1) is often left feeling hungry due to small portion sizes, and when (R1) requests additional servings, the facility staff often provide excuses for not having more food available. Furthermore, when (R1) asks for alternative meal options, the staff fails to fulfill those requests. It is also noted that (R1) is charged $7 for tray service, which staff insist is necessary for (R1). On March 4, 2025, between 9:35 AM and 3:10 PM, the Department interviewed all six staff members, identified as Staff #1 through Staff #6, regarding the accusations. Six (6) out of the six (6) refuted this claim. Staff members #1, #2, and #4 stated that (R1) is offered three meals each day; nonetheless, (R1) only participates in lunch and dinner. Staff members #1 and #4 confirmed that a copy of the daily activities and menu is given to every resident. Evaluation Report continues LIC 9099-C The menu includes options for breakfast, lunch, and dinner, as well as alternative choices for lunch and dinner. Staff #4 (S4) mentioned that meals are nutritious, featuring balanced portions of protein, fruits, vegetables, and grains. (S4) also noted that (R1) is not on a special diet but prefers the BRAT diet, which consists of easily digestible foods. (S4) explained that (R1) frequently adjusts the daily menu, and these requests are always accommodated made before 10 AM. Additionally, (S4) affirmed that there are no concerns regarding portion sizes, assuring that every resident is always welcome to request second helpings. (S4) mentioned that (R1) receives a prepared sack lunch at no cost during weekly outings with Welbe Health. Both (S2) and (S4) reported that residents occasionally request Tray Service, which incurs a fee of $6. (R1) is escorted to the dining area for meals but sometimes prefers to eat in the room, which requires Tray Service and results to a charge. According to (S1) and (S2), (R1) is aware of this fee, as it is outlined in the Resident Manual provided to all residents and discussed during the Resident Council Meetings. On March 4, 2025, between 10:35 AM and 2:55 PM, the Department interviewed all seven resident members, referred to as Resident #1 through Resident #7. Six (6) out of the seven (7) residents could not validate the claim in question. They reported that the meals were sufficient in portion sizes, with alternative options available, and that second helpings can be requested. All residents confirmed their understanding of the Tray Service fee, which is outlined in the Resident Manual, or mentioned that staff would be reminded them about this service fee. (R1) mentioned that the meal portions were small but noted that they could request second helpings if needed. (R1) preferred not to eat breakfast and was aware of the available snacks. (R1) expressed uncertainty about the Tray Service fee, estimating it to be around $5 per tray. Additionally, (R1) indicated to be on a BRAT diet and that the kitchen staff would accommodate (R1's) dietary requests. (W2) reported that (R1), a former resident of the facility, expressed concerns about the quality of the meals, the adequacy of the services, and the comfort of the seating arrangements. (R1) emphasized the need for improved dining options and more attentive assistance from the staff. A reviewed the facility's Resident Manual, dated 12/20/23, which mentions meal tray service on page 3. The List of Alternative Options for Lunch and Dinner, dated 09/2024, and the Facility Menu, dated 03/04/25, displayed that the facility provides alternative meal choices and healthy, balanced meals. The Department checked the food inventory, both non-perishable and perishable, and confirmed it met Title 22 Regulations. Additionally, an inspection of lunch portions found that a bowl of beef vegetable soup, a half crab cake on a roll, coleslaw, and vanilla ice cream for dessert appeared to be sufficient. Evaluation Report continues LIC 9099-C Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Allegation #4: Staff mismanaged resident's medication. It is alleged that Resident #1 (R1) medication is mismanaged by staff. According to the report, (R1’s) were not administered timely. (R1’s) thyroid medications prior to meals but did not administer by staff until around 10 AM. No further details provided for this matter. On March 4, 2025, between 9:35 AM and 10:10 AM, the Department interviewed med-tech staff identified as Staff #5 (S5) who dispute this claim. (S4) reported that (R1) is prescribed seven medications and three PRN (as needed). (R1) is scheduled to receive Levothyroxine 50MG daily at 10:30 AM. Since (R1) skips breakfast, the medication is given before lunchtime. On March 4, 2025, between 10:35 AM and 2:55 PM, the Department interviewed all seven resident members, referred to as Resident #1 through Resident #7. Six (6) out of the seven (7) residents claimed to have no issues with medication management. Four (4) out of the seven (7) claimed to self-medicate and handle their own medications. (R1) reported to received support from staff for medication administration. However, (R1) expressed concerns about experiencing delays in receiving medications on time, although specific details, names, and dates were not provided. In a follow-up statement, (R1) assured that there were no issues regarding (R1’s) management of medications and expressed confidence in the process. The Department conducted a review of (R1’s) Physician Medication Orders dated March 3, 2025, as well as the Medication Administration Records covering the period from January 21, 2025 to March 03, 2025, and Centrally Stored Medication and Destruction Record LIC 622. This assessment confirmed adherence to prescribed medications and PRN (as needed) directives. The records were organized and showed no mistakes. This indicates the facility is keeping accurate records and managing medications carefully. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Evaluation Report continues LIC 9099-C Allegation 5: Staff did not safeguard resident's personal items. The complaint indicated that the staff failed to protect the personal belongings of Resident #1 (R1). The report indicated that the staff disposed of (R1's) cat carrier without (R1's) consent after the cat was euthanized. No additional details regarding this incident were provided. On March 4, 2025, between 9:35 AM and 10:20 AM, the Department interviewed three staff members identified as Staff #1, Staff #2, and Staff #3. Three (3) out of the (3) claimed this accusation is false. (S1-S3) reported (R1) relocated to this facility from Brookdale Ocean House in April 2024. (R1) did not have any valuable items to include in a personal inventory. However, (R1) was viewed as a collector of items and resisted parting with possessions. The facility provided furniture for (R1). (R1) moved in with an elderly cat and had to be euthanized due to poor health. (S1) reported that (R1's) room was serviced several times by Western Exterminator Company due to infestations of fleas and roaches. It was recommended that the cat carriage be disposed of, as it contained fleas that had been detected. (S1) stated that (R1) had been informed and agreed to dispose of the item for (R1’s) well-being and health and safety of all residents in care. On March 4, 2025, between 10:35 AM and 2:55 PM, the Department interviewed all seven resident members, referred to as Resident #1 through Resident #7. Six (6) out of the seven (7) residents reported not having encountered any missing or lost valuables. All residents interviewed asserted that staff members are trustworthy. Furthermore, they emphasized that residents bear the essential responsibility of safeguarding their personal valuables. In an interview, (R1) stated that who had no valuables (R1) moved in. (R1) claimed that no personal items had gone missing or been taken. However, (R1) mentioned that the cat carriage was disposed of and was not unaware of or had given permission for staff to dispose of it. (R1) made conflicting statements when (R1) mentioned that (S1) described the cat carriage as “gross,” despite (R1) claiming not to know about anything regarding the carriage being disposed of. On March 4, 2025, between 1:00 PM and 4:00 PM, the Department interviewed witnesses identified as Witness #1 and Witness #2. (W1) mentioned that (R1) is seeking mental health support to cope with a loss, making acceptance difficult. (W2) noted that (R1), a former resident of the facility, experienced considerable emotional distress when parting with numerous personal belongings collected over the years. Evaluation Report continues LIC 9099-C The Department conducted a review of the pest control service receipts provided by Western Exterminator, dated October 17, 2024, October 25, 2024, and November 6, 2024. This evaluation confirmed that (R1's) room received treatment targeting both flea and roach infestations, ensuring pest management in the living space. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are deemed Unsubstantiated. An exit interview was conducted with Holly Rice, and copies of the reports were provided.the state’s words, verbatim · CDSS document, Mar 7, 2025 · control 11-AS-20250222173003

Type of visit: Required - 1 Year

On 4/23/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Holly Rice /Executive Director. LPA explained the purpose of today’s visit. The facility is licensed to serve (202) elderly adults ages 60 and above, of which (78) non-ambulatory residents on 1st floor and 2nd. (62) ambulatory residents on the 3rd floor and (62) residents on the 4th floor. Facility has an approved hospice waiver for (10). The facility is a four-story structure located in a commercial neighborhood. It consists of the following: (84) resident bedrooms. Each room has a bathroom in the unit. The facility houses an activity room, dining area, kitchen, beauty shop, administrative offices, medication room, computer room, libraries and outside patio area. LPA Iniguez toured the physical plant with Executive Director. There were no bodies of water or obstructions on the premises. A total of (8) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #102, #106, #209, #219, #306, #320, #406 and #422; call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 113.5F° – 115.2F°. The room temperature ranged from 76F° – 78F°. Evaluation Report continues on LIC 809-C LPA Iniguez observed the facility to be claen sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene items were observed. Cleaning supplies, toxins, and sharps objects were stored and not accessible to residents in care. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 01/4/24. Annual fire clearance performed on 8/10/2023. Working landline phones are available on-site. A review of (4) residents' service files (R1-R4) and (4) staff personnel files (S1-S4) were maintained in order. LPA reviewed (4) Medication Administration Records (MARs) and no discrepancies were found. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted throughout the facility. Copy of liability insurance will be email to LPA. Facility Annual Fess are Current. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Holly Rice /Executive Director.the state’s words, verbatim · CDSS document, Apr 23, 2024