Harvest Retirement

Allegation investigated: Staff did not notify resident's family member of resident's change of condition. Staff did not report resident's death to responsible party.

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility to begin the investigation into the complaint allegations listed above. LPA explained the purpose of the visit upon entry. The complaint investigation consisted of interviews and document review. Regarding the allegation: Staff did not notify resident's family member of resident's change of condition. During the investigation 4 of 4 individuals interviewed provided information that contradicts the complaint allegation. During interviews it was discovered that Resident 1 (R1) did not have much involvement from family in regards to the resident’s care needs. It was discovered that R1 did have a sibling but R1’s sibling was not involved in R1’s care at all. According to S3, R1’s sibling came to the facility several years ago to drop off mail for R1, due to a request made by the facility. According to S3, that was the only time the sibling came to the facility. Continued on LIC9099C Unsubstantiated S3 says the facility contacted the sibling after the mail was dropped off and during the conversation with R1’s sibling, the sibling asked to not be contacted by the facility because they had a lot of things going on in their personal life. S3 said, the facility attempted to contact R1’s sibling again after the second contact was made, and the siblings’ telephone number was disconnected. According to Staff 1 (S1) and Staff 2 (S2), R1’s siblings’ telephone number was either disconnected or off since both staff members were hired. One staff members was hired in 2021, and the other was hired in 2024. According to both members of the staff, the number on file for R1’s sibling never worked since they were hired. Regarding the allegation: Staff did not report resident's death to responsible party. During the investigation 3 of 4 individuals interviewed provided information that contradicts the complaint allegation. According to S2, when R1 passed, a call was made to R1's sibling but the phone didn’t ring or anything. According to the staff, the number was off or disconnected because the phone didn't ring or anything. A review of the incident report sent to the department on October 7, 2025, stated R1 does not have any family on file. According to the incident report, R1’s hospice provider was notified of a possible change in condition. The hospice provider showed up to the facility a very short time later and pronounced R1 deceased. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed unsubstantiated. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 22-AS-20260127144048

Allegation investigated: Staff handled resident in a rough manner causing a skin tear Staff locked the resident's door preventing the POA from seeing the resident

Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to follow-up on a complaint received in the Regional Office. LPA was greeted and granted entry and met with Administrator (AD) Rose Enriquez at 1:15pm, and explained the purpose of the visit. LPA obtained the following documents: Facility in-services on Body Mechanics, Transfers, Assists from June 22, 2023, and an in-service provided by Evergreen Hospice Nurse on April 10. 2024. LPA reviewed Resident #1 (R1)'s: Identification and Emergency Information Form, Physician's Report, and Death Report. LPA also obtained hospice documentation for care provided from May 13-24, 2024. R1 passed away on May 21, 2024. (Continued on LIC 9099-C) Unfounded (Continued from LIC 9099) It was alleged that Staff handled resident in a rough manner causing a skin tear. LPA reviewed hospice documents, dated May 18-19, 2024, regarding Resident #1 (R1)'s hospice care provided. A skin tear was documented on R1's left wrist. It was reported to the hospice that Staff handled resident in a rough manner causing a skin tear. Hospice could not confirm nor deny statement and provided wound care to R1. R1 was non-responsive at this time. LPA interviewed two of two witnesses. Two of two witnesses could not confirm, nor deny the allegation. LPA interviewed three of three staff regarding the above allegation and three of three staff denied the allegation. LPA investigated the allegation that Staff locked the resident's door preventing the POA from seeing the resident. LPA interviewed two of two witnesses. Two of two witnesse could not confirm, nor deny the allegation. Three of three staff members were interviewed. Three of three staff members denied the allegation. R1 was a two person assist and that staff, as well as hospice, would close the door for privacy but stated the door was never locked. Resident #1 (R1) was actively passing during this time and staff, POA and visitors were not denied entry. LPA was unable to interview the person who stated the doors were locked and denied entry. Based on LPA's record review and interviews, the allegations that: Staff handled resident in a rough manner causing a skin tear and Staff locked the resident's door preventing the POA from seeing the resident are Unfounded. The allegations are false, could not have happened, and/or is without a reasonable basis. An exit interview was conducted with Administrator (AD) Rose Enriquez, and a copy of this report and LIC 811 were provided to the facility.the state’s words, verbatim · CDSS document, Jan 28, 2026 · control 22-AS-20240522120534

Allegation investigated: Staff does not ensure hygiene needs are being met resulting in resident developing infections. Staff leaves resident soiled for extended periods of time. Staff does not follow resident's dietary plan.

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the investigation into the allegations listed above. LPA met with Administrator Rose Enriquez and explained the reason for the visit. The investigation into the allegation, staff does not follow resident's dietary plan, revealed the following. Resident 1's (R1) physician report dated, May 8, 2024 shows R1 was diagnosed with Alzheimer's disease and type 2 diabetes. R1 was prescribed a low fat and low sodium diet. The Administrator reported that all residents with a prescribed special diet are accommodated. The head chef reported that R1's special diet was accommodated. The head chef reported that the kitchen has a list of all the residents with special diets so all the kitchen staff know who they are. The head chef reported that R1 received a low fat, low sodium diet and had sugar free deserts along with portion control because they were diabetic. The head chef reported that R1 was only served water or tea because they were diabetic. 2 out of 2 kitchen servers reported there is a list showing the residents who are diabetic and require a special diet. Unsubstantiated The Administrator and Assistant Administrator reported the medication was administered but not marked in the Medication Administration Record (MAR). The Administrator reported that R1 was seen regularly by her physician and home health nurse. R1 was seen by her primary care physician (PCP) on July 18, 2024, August 15, 2024, September 19, 2024 and October 17, 2024. The Administrator reported that R1 was never sent out to the hospital during their stay at the facility. 4 out of 4 caregivers reported they did not observe any health related issues with R1 during their stay at the facility. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights. LPA observed the list in the kitchen. 2 out of 2 kitchen servers and the head chef reported that R1 was not served food high in sugar or inappropriate for a diabetic. It was reported that starches, sugary food and food not appropriate for a diabetic were served to R1. It was reported that staff reported to R1's responsible party that R1's glucose level was above 400. No specific dates or times were provided when the inappropriate food was provided or when staff informed the responsible party R1's glucose was above 400. 4 out of 4 caregivers interviewed denied the reports. R1's home health nurse could not corroborate the reports. R1 received home health visits from a nurse daily. LPA reviewed the facility's menu, the facility menu meets title 22 requirements. No incidents were reported involving R1 going to the hospital for any reason. The Administrator reported that R1 was never sent to the hospital while living at the facility. LPA attempted to interview R1 but they did not respond to any questions. None of the evidence gathered supports the allegation, therefore the allegation is unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff does not ensure hygiene needs are being met resulting in resident developing infections, revealed the following. It was reported that R1 had multiple urinary tract infections (UTIs) while at the facility and an infection on the abdomen. The Administrator reported that R1's hygiene needs were met and R1 had never been diagnosed with a UTI. R1's physician ordered a urinalysis on August 13, 2024 and on October 17, 2024. R1 had a doctor's visits on August 15, 2024 and on October 17, 2024. Facility records verified this information. The Administrator reported that R1's responsible party requested that R1 be put on an antibiotics prior to the urinalysis being completed in August and October. A review of R1's medicaiton administration record shows R1 was prescribed antibiotics on August 13, 2024 and October 18, 2024. The results of both tests were inconclusive, suggesting both samples were contaminated. The Administrator reported that since R1 was already prescribed and taking antibiotics at the request of the responsible party, R1's physician did not order new tests. The Administrator reported that R1 moved in with redness on their abdomen and the Clotrimazole 1% topical cream was listed on their original physician's report medication list dated May 8, 2024. A review of R1's physician's report verified this information. R1's MAR for July 2024 shows R1 was prescribed Clotrimazole 1% topical cream from July 5 to August 6, 2024. R1's home health nurse reported R1's hygiene needs were being met by staff and stated R1's possible UTI's and redness on the abdomen could not be attributed to lack of care. R1 received home health visits daily. 4 out of 4 caregivers interviewed reported R1's hygiene needs were always met. R1's responsible party did not respond to LPA's request for an interview. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff leaves resident soiled for extended periods of time, revealed the following. It was reported that R1's briefs were not changed timely and R1 was left in soiled briefs for an extended period of time. No dates or times were provided as to when this incident took place. 4 out of 4 caregivers interviewed denied the allegation and reported that R1's incontinence needs were always met. R1's home health nurse reported that they visited R1 at least 5 days a week and R1 was always clean. R1's home health nurse reported that they did not observe any issues with R1's hygiene. The Administrator reported that R1 was well cared for and they always communicated with the responsible party regarding R1's status. R1's responsible party did not respond to LPA's request for an interview. Based on the evidence gathered the allegation is unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Jan 7, 2026 · control 22-AS-20240823090146

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Jan 16, 2026

To receive or reject medical care or other services. This requirement was not met as evidenced by Resident 1 (R1) was not administered medications on July 18, July 20 and September 18, 2024. This poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 7, 2026

Plan of correction: Licensee agrees to train staff (med-techs) on CCR 87468.1 and on the facility's policy and procedure regarding medication administration. Proof to be provided to LPA by POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Jerome Haley arrived to conduct an unannounced Case Management visit regarding information the facility self reported to the Regional Office. LPA Haley explained the reason for the visit upon entering the facility. 73 residents were present during the visit, of which 27 are resident’s housed in the Memory Care unit. During the visit, LPA was led on a tour of the facility, and a Health and Safety check was conducted. Resident’s were observed in their rooms, the outdoor areas of the facility, and 12 residents were observed in the memory care activity room. LPA requested additional documents for Resident 1 (R1) as documents were already provided. A list of documents for Resident 2 (R2) were requested and will be provided via email by the end of the day. LPA also requested documents for two staff members. Staff 3 and Staff 4. Administrator Enriquez agreed to send the requested documents by the close of business. A resident and staff roster will not be emailed after the visit. No deficiencies are being cited as a result of today’s visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 12, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff and explained the reason for the visit. Structure: The facility is a two story building and serves Assisted Living and Memory Care residents. The facility is licensed for 106 non-ambulatory residents, has a hospice waiver for 30, and a waiver for a secured perimeter. The census was 73 during the annual inspection and residents were observed in their rooms, the different activity rooms, dining areas, and exterior portions of the facility. Bedrooms: All resident bedrooms have the required furnishings: bed, lamp, chair, and storage space. Bathroom(s): Bathrooms are equipped with a working toilet, wash basin, and shower. Hot water measured in the range of 106.5 – 119.6 degrees F. Kitchen: The kitchen is locked and off limits to residents. Kitchen appliances are operational. Refrigerator/freezer log is available for review. Sharps are hanging on a wall near the stove. Food Service: A supply of perishable and non-perishable food items that meet regulation requirements was observed. The facility received two shipments a week from Costco, and two shipments each week from Dairy King. Client & Staff Files: Resident and staff files stored in locked storage cabinets behind the central desk. File Review: Six resident files were reviewed during the inspection and five staff files were reviewed during the visit. Medications/First-Aid Kit: Resident medications are stored in a locked medication room behind the central desk. Medication Review: Six resident medications were reviewed during the inspection. No discrepancies were noted. Medications are being administered as prescribed. Continued on LIC809C Linens & Hygiene Supplies: Additional hygiene items are being stored in a storage room #201. Common Area: There are activity areas on both floors of the facility and a total of three dining rooms. Exterior: There’s plenty of seating in the different outside areas. There's plenty shade and there is a shaded patio area with a table and chairs. There are lock storage bins in the back parking lot used to store commercial kitchen chemicals and commercial kitchen supplies. Bodies of Water: None. Smoke/Carbon Monoxide Detectors: Smoke and carbon monoxide detectors tested operational. Fire Extinguisher: Fire extinguisher was observed mounted on the walls in different areas of the facility. An emergency evacuation drill: Evacuation drill was conducted September 19, 2025. Drills are conducted quarterly. Emergency Phone Numbers, House Rules, Exit Plan & Menu: Facility postings are posted are available for review on the main postings board in the main hallway. Additional Comments: Emergency food and water was observed in a storage room across from the central desk. There’s a laundry room near the central desk and additional linens are stored in the laundry room. The facility receives deliveries of fresh linen once a week. P&I review was conducted for 4 residents; no discrepancies noted. Licensing fees are current. Contact information was reviewed and confirmed during the visit. No deficiencies will be cited as a result of todays visit. An exit interview conducted, and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 30, 2025

Allegation investigated: Facility did not notify responsible party of incident Facility staff tied residents to wheelchairs

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on October 17, 2023. LPA was greeted and granted entry into the facility and met with Administrator (AD) Rose Enriquez. LPA explained the reason for the visit. This Department has investigated the complaint alleging that facility did not notify responsible party of incident. Regarding the allegation the following was revealed: During the course of the investigation LPA reviewed documents including the Unusual Incident/Injury Report (UIIR) dated October 15, 2023, for Resident 1 (R1). Per UIIR, on October 15, 2023, R1's wife and daughter were informed about R1 excessively sweating while walking in the hallway. Per UIIR, R1 was transported to the Hospital. During the course of the interviews with staff, Staff 1 (S1) reported that unusual incidents get reported to the Medication Technician who is in charge of notifying the Responsible Party (RP). During the course of the interviews with residents, R2 reported that if she has an incident that the facility notifies her RP. CONTINUED ON LIC9099-C... Unsubstantiated Per R3, the facility will report any incidents to her daughter on-time. R5 reported that the facility notifies his RP of incidents on-time. During the course of the interviews the Director of Operations reported that families get notified of unusual incidents the same day. Regarding the allegation that facility staff tied residents to wheelchairs, the following was revealed: During the course of the interviews with individuals seven of eight individuals interviewed denied the allegation. During the course of the investigation LPA reviewed documents including the Moulton Family Medical Group lab buddy prescription dated September 6, 2023, for R1. Per AD, the lab buddy was prescribed to prevent falls for R1. During the course of the interviews with residents, R2 reported that she has not witness residents being tied to their wheelchair. R3 stated that he has never seen residents being tied to their wheelchair. Per R4, he has not witness residents being tied to their wheelchair. R5 reported that he has never witness residents being tied to their wheelchair. During the course of the interviews with staff, S1 reported that residents do not get tied to their wheelchair. Per S2, she has never witness residents being tied to their wheelchair during her shifts. During the course of the interviews the Director of Operations reported that she has never witness residents being tied to their wheelchair. Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED. For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations. LPA conducted an exit interview with AD Enriquez, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 22-AS-20231017103829

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Jerome Haley arrived to conduct an unannounced Case Management – Health Checks visit. LPA Haley explained the reason for the visit upon entering the facility. During the visit, LPA was led on a tour of the facility with staff. During the tour, a Health and Safety check was conducted. 73 residents were present at the time of the visit. 50 residents in the Assisted Living (AL) and 23 residents in the Memory Care (MC). Residents were observed in their rooms, and the majority of the resident were in the dining rooms. Residents were finishing up their lunch at the time of the Health and Safety check. LPA requested additional documents for Resident 1 (R1), as well as training documents for five staff members. LPA requested documents be sent via email. A resident and staff roster was provided during the visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 8, 2025

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Jerome Haley arrived to conduct an unannounced Case Management visit regarding information the facility self reported to the Regional Office. LPA Haley explained the reason for the visit upon entering the facility. 69 residents were present at the time of the visit, of which 25 are resident’s housed in the Memory Care unit. During the visit, LPA was led on a tour of the memory care unit with staff. During the tour of the Memory Care unit, a Health and Safety check was conducted. R1 was observed in their room sleeping with the blankets pulled up to the residents’ chin area. Only the resident’s face was exposed. R1 appeared to be resting peacefully and appeared healthy looking in the face. LPA requested relevant documents regarding Resident 1 (R1), Staff 2 (S2), Outside Staff 1 (OS1), and Resident 2 (R2). Documents were also requested for two additional caregivers regarding a previous investigation. LPA requested documents be sent via email. A resident and staff roster was provided during the visit. S1 was advised additional documents may be requested. No deficiencies are being cited as a result of today’s Case Management visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 19, 2025

Allegation investigated: Staff did not seek medical attention for resident in a timely manner.

Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the facility regarding additional information on the complaint allegation listed above. LPA explained the reason for the visit upon entry. On October 22, 2024, the department received subpoenaed medical records from West Anaheim Medical Center (WAMC) regarding Resident 1 (R1). A review of the medical records reveal R1 was diagnosed with a stroke. An Enhanced Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(f). The facility was cited per Title 22, Division 6 of the California Code of Regulations. An amended deficiency is being cited on the attached LIC9099D. An immediate Civil Penalty is being assessed today in the amount of five hundred dollars ($500). An exit interview was conducted, and a copy of this report, a copy of Civil Penalty Assessment Form and appeal rights was provided. Substantiatedthe state’s words, verbatim · CDSS document, Apr 22, 2025 · control 22-AS-20240301162515

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Apr 22, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical...care shall be developed by each facility. The plan shall encourage routine medical care... and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical... needs. This includes transportation which may be limited to the nearest available medical... facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not being met as evidenced by: Based on interviews and record review, R1 had a change in condition observed by staff. Staff failed to get the resident medical attention in a timely manner causing R1 a serious injury. The resident was sent to the hospital to be evaluated a few hours later. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2025

Plan of correction: Administrator Po will read and review regulations section 87465 on Incidental Medical and Dental Care. Upon completion Administrator Po will email LPA Haley a plan of action that outlines the steps that will be taken to prevent this from happening again. Administrator Po will cover Incidental Medical and Dental Care with all staff and send a signed acknowledgement (from all staff) the regulation section was covered and understood. POC will be emailed to LPA Haley by 5:00PM Tuesday, March 12, 2024. POC was completed. No further action necessary.

Allegation investigated: Staff did not meet the residents' care needs resulting in injury.

Licensing Program Analysts (LPA) Jerome Haley made an unannounced visit to begin the investigation into the complaint allegation above. LPA Haley was greeted by staff and explained the reason for the visit upon entry. The complaint investigation consisted of interviews with facility staff, document review, and photo review. Regarding the complaint allegation: Staff did not meet the residents' care needs resulting in injury. During the investigation interviews were conducted with facility staff. 6 staff members denied the allegation and explained that residents are changed every two hours or as needed. LPA requested to review the incontinent care logs and it could not be found; however, Staff 1 (S1) provided an end of shift report which is a care log for the entire shift. On the end of shift report, the incontinent care was noted for each shift. Continued on LIC9099 Substantiated According to S1 and other staff members who were interviewed during the investigation explained that Resident 1 (R1) deals with on and off again rash like irritation to the groin area. Document review revealed that R1 is on hospice and the rash like irritation was being treated with Calomoseptine cream since January 15, 2025. The cream did not appear to be treating the rash and it was reported to the hospice nurse, and on March 14, 2025 Hospice provided an order for a new medication (Nyastatin powder) to treat R1’s rash like irritation on the groin area. During the investigation the department received several photos of different residents that dealing with skin discolorations, rashes, and skin tears. During a phot0 review of R1’s groin area, LPA observed what appeared to be redness on all sides of the groin area with darker red spotting all around the private area. The irritated area appears to be bleeding or was bleeding as blood can be seen on the residents legs and inside the pull up. LPA Haley also received photos of Resident 2 (R2) with red spots on the tail bone area and on a private area on R2. In the photo of R2’s private area the skin appears to be broken. Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 22-AS-20250312162715

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 21, 2025

(a) A plan for incidental medical and dental care shall be developed... The plan shall encourage... and provide for assistance in obtaining such care... (1) The licensee shall arrange... for medical and dental care appropriate to the conditions and needs of residents. This requirement was not being met as evidenced by: Photo evidence showed three different residents dealing with skin irritation. In on photo redness was observed on the resident groin area with darker color red spots and what appeared to be blood in the residents’ pull up.the state’s words, verbatim · CDSS document, Mar 20, 2025

Plan of correction: Assistant Administrator stated residents evaluated by their physician so affected areas of the skin can be evaluated and treated, if needed. Assistant Administrator will provide an update on each resident via email. Further, incontinent training will be scheduled for all staff on March 25, 2025.

Allegation investigated: Staff did not treat residents with respect.

Regarding the complaint allegation: Staff did not treat residents with respect. During the investigation 5 of 7 individuals denied the allegation. Staff 6 (S6) strongly denied any staff yelling at residents’ and said that would not happen in front of them. S6 explained if they heard about this happening, they would try to catch the individual in action. Multiple staff members interviewed during the investigation explained that sometimes the caregivers do speak loudly and are encouraged to lower their voice by Staff 1 (S1). According to Staff 3 (S3) sometimes the staff get together and start to talk and sometimes it can get loud. S3 says, S1 will remind them to lower their voice. Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegation is deemed Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 20, 2025 · control 22-AS-20250312162715

Allegation investigated: Facility did not prevent resident from eloping. Staff did not follow the medication orders as prescribed.

Regarding the complaint allegation: Facility did not prevent resident from eloping. During the investigation it was discovered Resident 3 (R3) could not be located on the morning or March 8, 2025. Facility staff went to the cameras and after reviewing the footage it was discovered the R3 walked out of the facility after signing themself out around 8:00am. R3 indicated that they would be going to the hospital. After the resident did not return later in the day the staff contacted local hospital to see if the resident had been admitted. After being unable to locate R3, S1 contacted local Police and filed a missing persons report. On March 14 Staff 2 (S2) received a call from the Orange County Public Guardian (OCPG) who explained they received a call form someone with the New York Police Department and R3 was located in New York. Document review revealed that R3 does not have dementia or MCI and can leave the facility unassisted. Continued on LIC9099C Unfounded Regarding the complaint allegation: Staff did not follow the medication orders as prescribed. During the investigation it was discovered R2 was being seen by a Home Health Nurse who was treating the irritated areas to R2’s tailbone and private area with barrier cream and off-loading. According to Staff 1 (S1) rotating the resident was important. Staff was advised to rotate the resident at least every two hours. Home Health came to treat the affected area once a week. However, the Home Health Nurse was in the facility daily and would see R2 upon request if needed, according to S1. Based on the information gathered through interviews and document review, the following allegations: Facility did not prevent resident from eloping, and Staff did not follow the medication orders as prescribed are deemed unfounded, meaning the allegations are false, could not have happened and/or are without a reasonable basis. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 22-AS-20250312162715

Allegation investigated: Due to lack of staff, facility did not respond to the resident's call timely.

On March 11, 2025, at 9:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted a subsequent complaint visit to deliver complaint investigation findings. LPA was greeted and granted entry by Assisted Living Waiver Program Director (PD) Rose Enriquez. PD Enriquez made a telephone call to Administrator (AD) Ginger Po who stated they could not meet for today's visit. LPA Kim explained the purpose of the visit to AD Po and AD Po said that PD Enriquez could sign on their behalf. The investigation consisted of the following. On January 22, 2025, LPA Kim conducted initial visit. LPA obtained records and interviewed ten staff (S1-S10) and nine residents (R1-R9). The investigation revealed the following: Allegation: Due to lack of staff, facility did not respond to the resident’s call timely. It is alleged that around 5:45 AM, a resident (R1) was crying out for help because the resident had fallen out of bed and could not reach their pendant. Another resident attempted to find staff to assist R1, however, the resident could not find any staff. Unsubstantiated Based on interviews, eight out of nine residents and ten out of ten staff denied the allegation that due to lack of staff, facility did not respond to the resident’s call timely, while one resident claimed due to a lack of staff, facility staff did not respond to the resident’s call timely. S2 states the Nocturnal (NOC) shift is from 10:30 PM to 7:00 AM with 3 caregivers and 1 medication technician. The facility has three units: Unit 1 (Memory Care) has two staff, Unit 2 (Assisted Living Wing 2) has one staff, and Unit 3 (Assisted Living Wing 1) has one staff. Residents in Unit 1 need two staff members because they need constant attention. One of the staff from Unit 1 are floaters to fill in for residents in Unit 2 and Unit 3 as needed. Unit 1 has 18 residents, Unit 2 has 20 residents, and Unit 3 has 33 residents. S2 states they have enough coverage for the facility because the residents are asleep at this time. S3 states the staff are expected to respond within 5 to 10 minutes of the call light pendant being pressed by the resident. Based on interview, R1 stated they do not recall falling or needing assistance on the night of the incident. R1 also stated that if they needed help, then they would press the pendant. R1 said their pendant has never been broken and that staff would respond right away of pressing the pendant. At the night of the incident around 5:30 AM, S5 stated they were approached by two residents about R1 calling out for help. S5 went to R1’s room and tried to assist R1 off the floor but could not lift them up from the floor. S5 called 911 and emergency services arrived and assisted R1 to bed. Based on record review, Incident Report states staff responded at 5:30 AM and assisted the resident and called 911 at 5:36 AM. The Orange County Fire Authority (OCFA) report confirms that a call was received at 5:36 AM and they arrived at the facility at 5:42 AM Client refused to go to the hospital per Incident Report. Based on LPA’s observation during the visit on January 22, 2025, staff responded timely to a resident’s call through the call button. A caregiver responded to the call and assisted the resident in their room within 2-3 minutes. Based on Information gathered, there is no sufficient evidence to corroborate the above allegation. Based on records review, interviews, and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Exit interview was conducted and a copy of the report was provided to Assisted Living Waiver Program Director Rose Enriquez.the state’s words, verbatim · CDSS document, Mar 11, 2025 · control 22-AS-20250115130302

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Jerome Haley, Jessica Cho, and Samer Haddadin arrived at the facility unannounced for the purpose to conduct the Required 1 Year Annual Inspection. LPAs were greeted and granted entry by Assistant Administrator Rose Enriquez, LVN. LPAs also met with Assistant Administrator Danielle Lucero, and Business Office Manager Edith Marinero. The facility is licensed for 106 and maintains a hospice waiver of 30 residents. As of today, the resident census is 81 of which 2 are receiving hospice care. LPA Haley conducted a tour of the physical plant and observed the following: This is a two-story commercial building comprised of an Assisted Living (AL) Memory Care Unit. LPA Haley inspected all common areas. LPA inspected 8 resident bedrooms which had all the required elements with ample lighting. The residents’ personal bathrooms were checked. Toilets and water faucets worked properly, and the grab bars were secure. Showers were free of mold/mildew, and the non-skid mats were in place. The hot water temperature measured within the range of 105.9 -119.4 degrees Fahrenheit. LPAs inspected the kitchen and the dining area. Facility maintains ample supply of two-day perishables and seven-day non-perishables. LPA observed the emergency food and water. Multiple fire extinguishers were observed on the walls, fully charged, and serviced in February of 2024. The smoke detectors were last tested on July 4, 2024 by Fire Safety Service INC, which was verified on the inspection report. LPA toured the outside grounds. There were sufficient seating and shading for the residents, and the walkways were clear of hazards. A locked storage shed used to store cleaning chemicals was observed outside in the parking lot area. All exit gates were self-closing and self-latching. Continued on LIC809C LPAs observed sufficient PPE and emergency disaster supplies including food/water. Emergency evacuation drills are conducted quarterly, and facility is maintaining a log documenting the drills. The first aid kit contains all necessary elements. LPA observed the required 'See Something, Say Something' (PUB475) poster in the correct size posted in the entry way. Facility maintains a current liability insurance. LPAs Cho and Haddadin reviewed eight residents’ files. No discrepancies noted. LPAs reviewed two staff files. No discrepancies noted. Interviews were conducted with seven out of eight residents as one resident refused. The two staff interviews were not conducted as they had ended their shift. The medications and the Medication Administration Records (MARs) were reviewed for 4 residents. No discrepancies noted. Based on LPAs observations, no deficiencies will be cited as a result of today's visit. A Technical Advisory (TVs) is being issued. An exit interview was conducted with Business Office Manager Edith Marinero, and Assistant Administrator Danielle Lucero, and Assistant Administrator Rose Enriquez. A copy of this report was provided at the end of the visit.the state’s words, verbatim · CDSS document, Sep 11, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff handled resident in a rough manner, resulting in resident sustaining a bruise

Licensing Program Analyst (LPA) Haley made an unannounced visit to the facility to deliver the findings on the complaint allegation made February 6, 2024. LPA Haley was greeted by staff and explained the reason for the visit. Regarding the allegation: Staff handled resident in a rough manner, resulting in resident sustaining a bruise The investigation consisted of interviews and document review. Interviews with 4 of 5 individuals confirmed Resident 1 (R1) sustained bruising to the left arm. Document review and interview confirmation revealed that R1 complained to Staff 4 (S4) about pain to the arm after being showered by Staff 2 (S2). S4 reported the information to Staff 1 (S1). According to S1, it was reported that R1 was on the bed when S2 yanked or pulled R1’s arm because it was time to shower. According to S1, after gathering details on the incident, an in-service training was conducted and an Employee Warning Notice signed and dated by S2 and Staff 3 (S3) was issued to S2 for the employees actions. Continued on LIC9099C Substantiated Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 10, 2024 · control 22-AS-20240206145710

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jun 11, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not being met as evidenced by Staff 2 handling Resident 1 roughly during showers on February 2, 2024 which poses a health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 10, 2024

Plan of correction: Staff 2 was given a written warning and an in-service training was held for staff on agressive behavior. No further action is required. A copy of the written notice provided to Staff 2 was provided and a copy of the and in-service training will be emailed to LPA Haley.

Allegation investigated: Staff did not seek medical attention for resident in a timely manner.

Licensing Program Analyst (LPA) Jerome Haley made unannounced visit to begin the investigation into the complaint received March 1, 2024. LPA Haley was greeted by staff and explained the reason for the visit upon entry. During the visit, LPA Haley conducted staff interviews and collected relevant documents. Regarding the allegation: Staff did not seek medical attention for resident in a timely manner. 2 of 2 staff interviewed confirmed Resident 1 (R1) had a change in condition observed by staff and was not assessed or sent out for an evaluation after the change in condition. Staff interviews revealed sometime during the morning of February 22, 2024, Staff 3 (S3) observed Resident 1 (R1) weak and unable to stay balanced. R1 was given a wheelchair and S3 spoke to Staff 4 (S4) regarding the change in condition. However, R1 was never assessed and never sent out to be evaluated regarding the change in condition. Continued on LIC9099C Substantiated Later in the day around noon, R1 received a visit from family who made some concerning observations including facial drooping and R1 being in a wheelchair. The family member requested R1 be sent to the hospital and that’s when the facility arranged for R1 to be sent to the hospital for a medical evaluation. Staff 1 (S1) admitted R1 should have been evaluated and sent out based on the residents change in condition observed by S3. Based on the evidence gathered through interviews, and document review the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6, Chapter 1. An exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Mar 5, 2024 · control 22-AS-20240301162515

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87565(a)(2) · Plan of correction due date: Mar 12, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical...care shall be developed by each facility. The plan shall encourage routine medical care... and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical... needs. This includes transportation which may be limited to the nearest available medical... facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not being met as evidenced by a resident having a change in condition observed by staff and the staff failing to get the resident medical attention in a timely manner. The resident was sent out to the hospital to be evaluated a few hours later. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 5, 2024

Plan of correction: Administrator Po will read and review regulations section 87465 on Incidental Medical and Dental Care. Upon completion Administrator Po will email LPA Haley a plan of action that outlines the steps that will be taken to prevent this from happening again. Administrator Po will cover Incidental Medical and Dental Care with all staff and send a signed acknowledgement (from all staff) the regulation section was covered and understood. POC will be emailed to LPA Haley by 5:00PM Tuesday, March 12, 2024.

Allegation investigated: Facility staff are not keeping residents clean Facility is not maintaining a comfortable temperature for residents in care

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced initial 10-Day complaint visit to initiate the investigation into the above allegations and to deliver the findings of the investigation. LPA was greeted and granted entry into the facility and met with Director of Operations Rachelle Reyes. LPA explained the reason for the visit. On today’s visit LPA Ramirez conducted file reviews and interviews and obtained copies of pertinent documents. Regarding the allegations, the following was revealed: Seven of eight individuals interviewed denied the allegations. During interviews conducted with residents it was reported that staff assist the residents to stay clean and/or that staff are helpful. Per Resident 1 (R1) he does not need much assistance but that staff assist him with washing his clothes, towels and bedding in order to keep his personal space clean. During interviews conducted with staff, Staff 1 (S1) reported that residents are schedule for three showers per week but that staff will clean and shower the residents as needed. CONTINUED 9099-C... Unfounded Regarding the allegation that facility is not maintaining a comfortable temperature for residents in care, the investigation revealed the following: During the initial visit on 10/26/23 LPA toured the Memory Care Unit and observed that the temperature in the hallway was 78.2 degrees Fahrenheit and the temperature in the dining room was 78 degrees Fahrenheit. Per interviews conducted R1 reported that the temperature is comfortable. During interviews conducted with staff it was reported that the Memory Care Unit temperature is always comfortable for the residents and that it gets adjusted depending on the weather. Therefore, the allegations are deemed UNFOUNDED, meaning the allegations are false, could not have happened and/or are without a reasonable basis. LPA Ramirez conducted an exit interview with Director of Operations Reyes and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 26, 2023 · control 22-AS-20231017103829

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.